DEFINITION

PLEURAL EFFUSION Abnormal collection of fluid in pleural space resulting from production , absorption. Normally contains fluid ; balance between 1.hydrostatic & oncotic forces (visceral & parietal pleural vessels) 2.extensive lymphatic drainage. **PE results from disruption of this balance. **PE classified as TRANSUDATE & EXUDATE. (refer table 1)

EMPYEMA Pus collection in pleural space. -maybe localized or involve entire pleural space. 1.Direct inoculation; penetrating injury / surgery 2. Contamination; -bronchopulmonary Infection. -Rupture of lung abscess, mediastinal abscess. -Transdiaphragmatic spread from subphrenic abscess. 3. Hematogenous spread (from distant sites) AEROBIC ANAEROBIC Gram +ve Bacteroids (strep, staph) Gram ve (coliforms, proteus, H.influenza) 1. Chest pain, purulent sputum, fever. 2. Dullness, air entry.

MESOTHELIOMA Tumor arising from mesothelial surfaces (pleura, peritoneum or pericardium).

ETIOLOGY

Types of PM: Localized -arises from mesothelial lining. -well-defined, encapsulated. -NOT ass. with ASBESTOS. -maybe BENIGN or MALIGNANT. -asymptomatic OR symptomatic (chest pain, cough) -Rx: surgical resection. Diffuse Always malignant, ass with ASBESTOS exposure.

CLINICAL PICTURE

INVESTIGATION

Small : ASYMPTOMATIC Large : dyspnea, cough, chest pain & low output syndrome if under tension. - breath sound & dullness to percussion. 1.Lab : ESR, CBC 2. CXR : Blunting of costophrenic angle (early sign) indicates accumulation more than 400 ml of fluid. 3. CT scanning & Ultrasound

1. Laboratory: Leucocytosis, high sedimentation rate. 2. Imaging : CXR : PE CT : Pleural collection, lung abscess, loculations, thickness of pleural peel,

1. Dyspnea 2. Chest wall pain 3. Weight loss 4. Weakness 5. Anorexia 6. Fever 1.Radiography (CXR, CT, MRI & PET scan): PE, Pleural thickening, mediastinal LN, distant metastases in advanced tumor. 2. Thoracocentesis. 3. Pleural needle biopsy. 4. Thoracoscopy & pleural biopsy.

TREATMENT

-assess PE, underlying lung, ass. Intrathoracic pathology. -localize fluid prior to thoracocentesis. -Plan biopsy or surgery. 4. Thoracocentesis: GROSS APPEARANCE: Bloody effusions malignancy after traumatic tap, with pulmonary embolus or TB. Milky fluid chylothorax Pus empyema ASPIRATE : 1.Microbiology 2. Cytology 3. Biochemistry -Total protein -LDH -Glucose -pH -Amylase -Triglycerides 4. Pleural biopsy -US guided percutaneous -CT guided percutaneous -VATS -Open (mini-thoracotomy) 1.Transudates & some exudates : RESOLVE 2.Moderate & massive effusions : Drainage with thoracocentesis or IC tube to an underwater seal. 3. Malignant PE : -pleurodesis

coexisting thoracic disease. US : pleural collections. 3. Thoracocentesis; Pus is examined for -Gross appearance. -Microbiology. Biochemistry; protein, glucose.

5. Open pleural biopsy. Pathologic types : Epithelial, sarcomatoid, mixed. Should be differentiated from metastatic adenocarcinoma with EM & Immunohistochemistry.

Causes of failure of empyema drainage Non-dependent drainage Tube inserted too far Tube too small Peel too thick dt late drainage Bronchoplueral fistula Presence of FB

1.General : Treat underlying cause, ass. Medical conditions(DM), physiotherapy, fluids & nutrition. 2. Antibiotics : systemic Ab 3. Surgery : a)Closed IC tube drainage : REMOVED when?

1. Radiation: palliate symptomatic chest wall or mediastinal involvement. 2. Chemotherapy : Response is disappointing. 3. Immunotherapy: Promising response with Interferon 4. Surgery:

-surgery -Home management of indwelling pleural catheter.

<100 ml, sterile, lung re-expands. -Instillation of fibrinolytic enzymes (streptokinase, urokinase) ; helps drainage of thick pus. b) Open IC tube drainage. c) Rib resection. d) Decortication. e) Thoracoplasty. 3 stages; 1. Exudative. 2. Fibrinopurulent. 3. Organization. Untreated empyema: 1.Pulmonary fibrosis & chest wall deformities. 2. Spontaneous drainage of pus through chest wall & bronchial tree. 3. Local spread of infection to pericardium or mediastinum. 4. Distant infection ( osteomyelitis) 5. Amyloidosis.

Thoracoscopy & talc pleurodesis Pleurectomy & decortication Extrapleural pneumonectomy : En-bloc resection of pleura, lung, ipsilateral hemidiaphragm, pericardium. MORTALITY is HIGH. Combined modality therapy (Radio & chemo)

Pathogenesis

Complications

TRANSUDATE (imbalance in oncotic & hydrostatic pressure) Congestive Heart Failure Hepatic Failure Renal Failure Hypoalbuminemia

EXUDATE (result of inflammation of pleura or decreased lymphatic drainage Infections (bacterial, TB, fungal, parasitic, viral) Collagen vascular disease (rheumatoid, SLE) Malignancy Pulmonary Embolus Hemothorax Chylothorax Pseudochylothorax Abdominal disease Drug induced

Miscellaneous Idiopathic

DEFINITION

HEMOTHORAX Accumulation of blood in pleural space.

ETIOLOGY

1.Trauma (most common: chest trauma) -blunt/penetrating ++rib fractures -source of bleeding : ITA, IC vessel, lung, bronchial, pulmonary, heart & great v. 2. Iatrogenic -post-operative -thoracocentesis -needle lung biopsy 3. Spontaneous pneumothorax Tear of vascular adhesions. 4.Bloody effusion -Pulmonary embolus -Neoplasm -TB

CHYLOTHORAX Abnormal collection of thoracic duct lymphatic fluid (chyle) in pleural space. - TG, and chylomicron. - Usually right sided. Pseudochylothorax: cholesterol but no TG or chylomicrons. 1. Congenital -birth trauma or TD abnormalities. 2. Traumatic -Blunt: Spinal hyperextension -Penetrating: Above T5(left), Below T5(right) 3. Operative -during of aortic arch, SCA, esophagus, especially transhiatal esophagectomy. 4. Neoplastic -Intrinsic or extrinsic TD obstruction 2ry to malignancy(lymphoma) duct rupture -direct invasionwith lung & esophageal cancer. ++ benign tumors (lymphangioma & mediastinal hygroma) 5. Infections

PNEUMOTHORAX Air in the pleural space.

1. Spontaneous a) Primary : Ruptured apical bleb dt localized form of onterstitial empysema. b) Secondary : ++ -COPD -CF -Infection; TB, mycotic, parasitic, cavitating nonspecific bacterial. -Tumors; Rupture of ischaemic primary / metastatoc lung carcinoma, lymphoma, sarcoma -Catamenial; ++menstruation (focal pleural endometriosis) -Miscellaneous ; ++ CT & AID 2. Traumatic -Iatrogenic : lung biopsy, central line

CLINICAL PICTURE

-obstruction TB lympadenitis, filariasis, ascending lymphangitis. 6. Miscellaneous -spontaneous (violent cough, vomit) -venous thrombosis (SVC, Lt SC, JV) -idiopathic Post-operative: Milky chest tube drainage Non-operative: Dyspnea, physical & radiological evidence of PE 1.index of suspicion following trauma. 2.Physical signs of pleural fluid & pallor. 3.CXR: evidences of pleural collection 4. Thoracocentesis is DIAGNOSTIC. 1. Thoracocentesis &pleural fluid analysis -Gram stain : Lymphocytosis, no bact. -Sudan stain : Fat globules -Fat content>plasma -Lipid analysis : C/TG <1 -lipoprotein electrophoresis : chylomicrons. 2. Radionucleide scanning : 99Tc antimony sulfide colloidlevel of TD obstruction & site of leakage. 3. Lympahangiography : site of obstruction & leakage. 4. CT scanning: define ++pathology. Aim : - Drain pleural space - Lung expansion - Reduce volume of TD leakage

insertion, barotrauma. -Penetrating or blunt chest trauma : Disruption of TB tree, pulmonary parenchymal, esophageal perforation, open pneumothorax. -Asymptomatic -Symptomatic : dyspnea, chest pain, dry cough, severe RD with hypoxia, hypercarbia & acidosis. Signs: breath sound & hyperresonance.

DIAGNOSIS

INVESTIGATION

1. CXR : Expiratory films accentuates small pneumothorax 2. CT : -diff lung cysts & bullae in presence of subcutaneous emphysema. -quantitates degree of penumothorax

TREATMENT

1.General; maintain airway, IV access, define blood group.. 2.ICT : 5th & 6th space MAL 3.Thoracotomy is indicated if:

1.Observation -asymptomatic & small pneumothorax 2. ICTD

-initial ICTD >1500ml blood OR >1000ml +hypotension -ICTD >300ml/hour for 3 hours. -drainage is inadequate with persistent collection on CXR. -manage associated intrathoracic injuries or pathology. -Evacuation of clotted hemothorax. After 4-6 weeks, clot organization requires DECORTICATION.

- Treat underlying cause. 1.Conservative: (within 2 weeks; 50 % close spontaneously) -ICTD -NPO -TPN with correction of fluid & electrolyte imbalance. 2. Operative Indication surgical : daily drainage of 1000ml (adults) OR 100ml/year of age (children) . 7 days -Right thoracotomy & mass ligation of TD above Rt hemidiaphragm in azygoesophageal recess. -Direct ligation at site of leak. -Anastomosis of TD to azygous vein, fibrin glue, radiotherapy, pleurodesis with talc.

-underwater seal & suction 3. Pleurodesis 4. Surgery (Open or VATS) -to resect bullae or blebs, close BP fistula, & obliterate pleural space to prevent recurrence. Indications of Surgery : Prolonged air leak Failure of lung to re-expand Tension pneumothorax Single large bullae Bilateral pneumothorax Hemopneumothorax Recurrent pneumothorax.

COMPLICATION

1.Persistent air leak 2. Recurrence 3. Tension pneumothorax 4. Hemothorax 5. Pneumomediastinum