1. Para Pneumonic Effusion BY Professor Of Pediatrics, Head of Allergy & Clinical Immunology Unit - Mansoura University Egypt

2. Out line 1) Pleural Space 1) Pleural Space 2) Stages of Para pneumonia effusion. 2) Stages of Para pneumonia effusion. 3) Value of pleural fluid analysis. 3) Value of pleural fluid analysis. 4) Diagnosis of Para pneumonia effusion. 4) Diagnosis of Para pneumonia effusion. 5) Treatment of Para pneumonia effusion. 5) Treatment of Para pneumonia effusion.

3. Pleural Space   It is space between visceral and parietal pleura.   It is nearly liquid free. This character is maintained by: 1- Hydrostatic capillary pressure 2- Plasma oncotic pressure

4. Stages of Para Pneumonia Effusion  It passes in 3 stages according to neutrophilic load. 1- Uncomplicated Para pneumonia effusion  It occurs during first 72 hours.  It is neutrophilic in nature.  PH > 7.3 – glucose > 60 mg/dl. Continue

5. Stages of Para Pneumonia Effusion 2) Complicated (fibrino purulent ) stage  Increased neutrophilic load, resulting in anaerobic glucose metabolism glucose CO 2 + lactic acid ↓< PH with ↓ glucose. glucose CO 2 + lactic acid ↓< PH with ↓ glucose.  Lyses of neutrophil results in fibrin deposition, loculation and adhesion. Continue

6. Stages of Para Pneumonia Effusion 3) Empyema More neutrophils, severe acidosis, more deposition of fibrin. Sequel of effusion Complete resolution Loculation and adhesion Causative organism Anaerobes Staphylococcus aureus Gram-negative bacilli.

7. Diagnosis of Para Pneumonic Effusion Diagnostic criteria: 1) 1)Stony dullness on percussion is cardinal with. 2) 2)Auscultatory finding: Bronchial breathing Egophony Diminshed or absent breath sounds. Continue

8. Diagnosis of Para Pneumonic Effusion 3) Pleural fluid analysis: It clarifies the type of fluid ( trasudate, exudate, blood…..) It indicates if there is infection or not by gram stain and differential cell count ( Neutrophil indicates infection, lymphocytes indicates TB or malignancy. It gives us criteria for chest tube drainage or not.

9. Criteria for Chest Tube Drainage. 1) Neither the pleural fluid Neutrophil nor protein content has proven to be a predictor of drainage. 2) Pleural fluid glucose or PH are a good predictor for drainage: Pleural fluid glucose ≥ 60 mg / dL or a PH ≥ 7.3 → antibiotic alone. Glucose < 40 mg / dL or a PH < 7.1 → drainage is necessary with antibiotics Patients with intermediate glucose concentration or PH needs evaluation How.?   Rising LDH → on going→ inflammation Continue

10. Criteria for Chest Tube Drainage. This rising in LDH obtained on repeated thoracentesis this mean failure of antbiotics and drainage is necessarily. D) PH reading are subjective to errors; exposing the fluid to air can lead to rapid rise in PH as the volatile CO 2 escape. For this reason glucose value may be more reliable.

11. Treatment of Para Pneumonia Effusion 1) Antibiotic looking for anaerobes 2) Chest tube drainage 3) Failure of chest tube drainage Intra pleural fibrinolytic therapy thoracoscopy 4) Failure of thoracoscopy or fibrinolytic agents shift to : Open thoracoscopy Decortications.

12. Treatment of Parapneumonic Effusion NO Yes PH > 7.3 PH 7.1-7.3 Chest Tube drainage Observation Repeat Resolution Failureto Thoracentesis resolve or Antibiotics only located ↑LDH Observe Fbrinolytic or chest tube drainage tharacoscopy if they fail Decortication or open Thoracostomy PH< 7.1, Grossly purulent or positive gram stain