1. Clinical Approach to
PLEURAL EFFUSIONS

2. PLEURAL SPACE The pleura consists of 2 layers 1 – parietal pleura
2 – visceral pleura
The space between the 2 layers is called the pleural space
Normal width of the pleural space is
10-20 mm

3. Pleura

4. envelope all surfaces of the lungs, including the interlobar fissures.
Pleura
Visceral pleura
envelope all surfaces of the lungs, including the interlobar fissures.
Parietal pleura
cover the inner surface of the thoracic cavity, including the diaphragm, and ribs.
At the Hilum
where pulmonary vessels, bronchi, and nerves enter the lung tissue, the parietal pleura is continuous with the visceral pleura.

5. Normally the pleural space contains: 3.5 to 7.0 ml of clear liquid
PLEURAL EFFUSION
Normally the pleural space contains:
3.5 to 7.0 ml of clear liquid
low protein content
small number of mononuclear cells
Pleural effusion: presence of large amount of fluid in the pleural space irrespective of the underlying causes

6. PLEURAL FLUID FORMATION AND ABSORTION
PLEURAL SPACE
INTERCOSTAL MICROVESSELS
BRONCHIAL MICROVESSELS
VEIN
VEIN
ARTERY
ARTERY ?
LYMPHATICS TO MEDIASTINAL NODES
PLEURAL FLUID
STOMA
PLEURAL SPACE
PARIETAL PLEURAL
VISCERAL PLEURAL

7. MOVEMENTS OF FLUID IS BASED ON STARLING’S LOW
L . A [ (PCAP – PPl) – (CAP – Pl) ]
L: Filtration coefficient
A: Surface area
Cap: Capillary
Pl: Pleural

8. PLEURAL FLUID FORMATION AND ABSORTION
The rate of fluid formation is 0.02 ml/kg/hour.
The rate of fluid clearance is 0.2 ml/kg/hour.

9. PLEURAL FLUID FORMATION AND ABSORTION
PLEURAL SPACE
INTERCOSTAL MICROVESSELS
BRONCHIAL MICROVESSELS
VEIN
VEIN
ARTERY
ARTERY ?
LYMPHATICS TO MEDIASTINAL NODES
PLEURAL FLUID
STOMA
PLEURAL SPACE
PARIETAL PLEURAL
VISCERAL PLEURAL

10. Development of Pleural Effusion
pulmonary capillary pressure (CHF)
capillary permeability (Pneumonia)
plasma oncotic pressure (hypoalbuminemia)
pleural membrane permeability (malignancy)
lymphatic obstruction (malignancy)
diaphragmatic defect (hepatic hydrothorax)
thoracic duct rupture (chylothorax)

11. Symptoms * key symptom -------> shortness of breath
Fluid filling the pleural space makes it hard for the lungs to fully expand, causing the patient to take many breaths so as to get enough oxygen.
* If parietal pleura is irritated > mild pain or a sharp stabbing
pleuritic type of pain.
** Some patients will have a dry cough.

12. Symptoms Occasionally ------> no symptoms at all.
* This is more likely when the effusion results from:
recent abdominal surgery, cancer, or tuberculosis.
* Tapping on the chest will show stony dullness, and decrease breath sound

13. Diagosisn of pleural effustion
x ray
The fluid itself can be seen at the bottom of the lung or lungs, hiding the normal lung structure.
If heart failure is present,
the x-ray shadow of the heart will be enlarged.
Ultrasound may disclose a small effusion that caused no abnormal findings during chest examination.
C.T. scan is very helpful if the lungs themselves are diseased.
Diagosisn of pleural effustion

15. Management of Pleural effusion

17. Indication for Pleural Fluid Analysis
PLEURAL EFFUSION
Indication for Pleural Fluid Analysis
Diagnostic ( detect underlying diagnosis)
Therapeutic (relief shortness of breath)

18. DIAGNOSTIC THORACENTESIS
PLEURAL EFFUSION
DIAGNOSTIC THORACENTESIS
CONTRAINDICATIONS
Bleeding tendency
Thrombocytopenia (decrease platelets less u3/dl )
Prolonged PT or PTT greater than twice normal,
A very small volume of pleural fluid

19. Color of Fluid Color of Fluid Suggested Diagnosis
Pale yellow (straw) Transudate, some exudates
Red (bloody) Malignancy or embolism or TB
Turbid Infected effusion
Pus Empyema
White (milky) Chylothorax or cholesterol effusion

20. Transudates vs Exudates
LIGHT’S CRITERIA*
1. Pleural Protein divided by serum protein >0.5
2. Pleural fluid LDH divided by Serum LDH >0.6
3. Pleural fluid LDH > 2/3 the upper limit of normal for
the serum LDH.

21. Constrictive Pericarditis Pulmonary Infarction Hypothyroidism
Causes of Transudates and Exudates
Tronsudote
Exudate
Left Heart Failure
Bacterial Pneumonia
Carcinoma Bronchus
Hypoproteinaemia
Constrictive Pericarditis
Pulmonary Infarction
Hypothyroidism
Cirrhosis
Connective-tissue Disease
Tuberculosis

22. CELL COUNT PLEURAL EFFUSION
Transudate < 1000 but 20% > 1000 and rarely > 10,000/mm3
Exudate > 1000/mm3
Limited value (unless > 50,000/mm3  emphyema)

23. PF LYMPHOCYTE-PREDOMINANT EXUDATES (>80%)
PLEURAL EFFUSION
PF LYMPHOCYTE-PREDOMINANT EXUDATES (>80%)
Causes TB
Lymphoma
`Chronic lymphocytic leukaemia

24. BIOCHEMISTY PLEURAL EFFUSION
Glucose < 3.3 mmol/L or 1/2 serum glucose (simultaneous)
- Rheumatoid pleurisy (85%)
- Empyema (80%)
- Malignancy (40%)

25. The mechanism responsible for pleural fluid low glucose include;
PLEURAL EFFUSION
The mechanism responsible for pleural fluid low glucose include;
Decreased transport of glucose from blood to pleural fluid
Increased utilization of glucose by constituents of pleural fluid, such as neutrophils, bacteria (empyema), and malignant cells

26. BIOCHEMISTY PLEURAL EFFUSION Pleural fluid pH:
- Normal pleural fluid pH is > 7.6
- Transudates – pH
- Exudates – pH is
Should always be measured in a blood gas machine
Parapneumonic - pH < 7.0 predicts “complicated effusion” that is unlikely to resolve without chest tube drainage.
Malignant effusion with a pH < 7.3 is associated with poor survival.
If pH < 6.0 think of ruptured esophagus

27. PLEURAL EFFUSION
The mechanism responsible for pleural fluid acidosis (pH <7.30) include;
Increased acid production by pleural fluid cells and bacteria
Decreased hydrogen ion efflux from the pleural space, due to pleuritis, tumor, or pleural fibrosis.

28. PLEURAL EFFUSION
DIAGNOSES ASSOCIATED WITH PLEURAL FLUID ACIDOSIS (pH <7.30) AND LOW GLUCOSE CONCENTRATION (PF/SERUM <0.5)
Diagnosis Usual pH (Incidence) Usual Glucose
Concentration
(mg/dL)
Empyema (-100%) <40
Malignancy (33%)
Tuberculous pleurisy (20%)

29. positive in about 60% of patients with malignant effusion
PLEURAL EFFUSION
CYTOLOGY
positive in about 60% of patients with malignant effusion

30. PLEURAL EFFUSION Patients with Abnormal Chest Radiograph
Suspect pleural disease
Blunting of costophrenic angle?
YES
Lateral decubitus chest radiographs
Yes No
Diagnostic thoracentesis
Fluid thickness > 10mm
Observe

32. PLEURAL EFFUSION SUMMARY Yes No Diagnostic thoracentesis
Any of the following met?
PF/serum protein >0.5
PF/serum LDH >0.6
PF LDH >2/3 upper normal Serum limit
Yes No
Exudate
Transudate
Appearance of plueral fluid, pH & glucose, cytology and differential cell count of pleural fluid
Treat CHF, cirrhosis, or nephrosis

33. Treatment
Best Way
direct treatment at what is causing it, rather than treating the effusion itself

34. pneumothorax
Peneumothorax is the accumulation of air in the pleural space. It may occur spontaneously or following trauma
Disorder
Cause
Collection
Haemothorax
Hydrothorax
Chylothorax
Pneumothorax
Blood
Proteinaceous Fluid
Lymph
Air
Chest trauma; rupture of aortic
aneurysm
Congestive cardiac failure
Neoplastic infiltration; trauma
Spontaneous; traumatic

35. Spontaneous Results from rupture of a pleural bleb
Pleural bleb being a congenital defect of the alveolar wall connective tissue.
Patients are typically tall, thin, young males.
M:F ratio 6:1.
Usually apical affecting both lungs with equal frequency.

36. Spontaneous
Secondary causes occur in patients with underlying disease :
COPD, TB, pneumonia, bronchial carcinoma, sarcoidosis and cystic fibrosis.

37. Spontaneous
Patients present with sudden onset of unilateral pleuritic pain and increasing breathlessness.
The main aim of treatment is to get the patient back to active life as soon as possible.

38. Investigations
Chest radiography may show an area devoid of lung markings.
May be more clearly seen on the expiratory film

39. Management Small pneumothorax: no treatment, but review in 7-10 days.
Moderate pneumothorax: admit for simple aspiration.

40. The End