DR M ABDUR RAHIM M.D.

,
ASST. PROFESSOR OF MEDICINE

PLEURITIC DISEASES

 Pleurisy Pleural Effusion Pneumo Thorax

Pleurisy
Pleuritic pain resulting from any disease process involving the Pleura. Clinical Features : Sharp Pain that is aggravated by deep breathing or coughing. On examination : Rib movement is restricted Pleural Rub may be present

 Some times audible only in deep Inspiration or near the Pericardium (Pleuro-Pericadial Rub) Loss of Pleural Rub & Diminution in chest painIndicate eithery recovery or development of a Pleural Effusion Investigation : Chest X-Ray PA View

Management : Primary cause to be treated Symptomatic treatment To allow the patient to breathe normally and cough efficiently Analgesic with Paracetamol, Cocodamol or NSAID is sufficient Some patients require Opiates To be used with Caution

PLEURAL EFFUSION
Accumulation of Serous fluid within Pleural Space is termed as Pleural Effusion Pus Empyema

Blood Haemo Thorax Chyle Chylo Thorax

Mechanism :
Fluid accumulates as a result of either increased Hydrostatic Pressure of Decreased Osmotic Pressure ( Transudative Effusion ). OR From increased Microvascular Pressure due to disease of the pleural surface itself or injury in the adjacent lung ( Exudative Effusion ).

Clinical Features : Pleurisy precede the development of an effusion. Onset may be insidious. Breathlessness Only symptom related to effusion, severity depends on size & rate of accumulation.

Investigations : Imaging : CXR-PA View Ultra sonography CT

 CHEST X-RAY PA VIEW

Ultrasonography : More accurate for determining the volume of oral fluid. Fecilitates skin marking for safe needle aspiration

Pleural Aspiration & Biopsy : Colour Texture Appearance Presence of Blood- Pulmonary Infraction Malignancy Truamatic Tap

Biochemical Analysis : Differntiate Transudate from Exudate

 Gram Stain Para Pneumonic Effusion. Cytologic Examination Biopsy : Video-assisted Thoracoscopy

Management : Aspiration of Pleural Fluid Treatment of underlying cause.

Pneumothorax
Air in pleural space which occur spontaneously or result from Iatrogenic injury or Trauma to the Lung or Chest Wall

Clinical Features : Sudden onset unilateral pleuritic chest pain Breathlessness Severe in Underlying Chest disease. Small Pneumothorax- Normal Large Pneumothorax (>15% of Hemi thorax)Decreased or Absent Breath sounds Resonant Percussion note.

Types of Spontaneous Pneoumothorax

Communication between the Airway and the Pleural space acts as a one way Valve. Air enter Pleural Space during Inspiration but doesnot escape on Expiration. Intra Pleural pressure rises above atmospheric level.

 The pressure causes Mediastinal shift to opposite side Compression of opposite normal lung Impairment of systemic venous return causing Cardiovascular compromise Rapidly progressive breathlessness Clinically Tachycardia, Hypotension, Cyanosis and Tracheal Shift opposite to silent hemi thorax

 Communication between the airway and pleural space seals of as the lung deflates and doesnot reopen. Mean pleural pressure remains ve, reabsorption of air and re expansion of lung occur over a few days or weeks

 Communication fails to seal and air continues to pass freely between Bronchial tree and pleural space Commonly seen following rupture of an Emphysematous bulla, Tuberculous cavity or lung absess into the pleural space.

Investigation : Chest X-Ray Sharply defined edge of the deflated lung with complete translucency between this and chest wall. CT

Management : Primary Pneumothorax- Lung edge < 2 cm from chestwall-resolves without intervention. Moderate or Large Spontaneous primary PneumothoraxPercutaneous needle aspiration of air

 Chronic Underlying Lung Disease, Secondary Pneumothorax causing Respiratory DistressIntercostal tube drainage Intercostal Drains are inserted in the 4th, 5th or 6th ICS in mid axilary line, connected to an underwater seal or oneway Heimlich Valve Drain removed 24 hrs after lung has fully reinflated and bubbling stopped

 Continued Bubbling after 5-7 days Surgery Recurrent spontaneous Pneumothorax- 25% Surgical Pleurodesis is recomended

Empyema
Collection of pus in Pleural space Pus may be thin as serous fluid or thick as impossible to aspirate. Microscopically, Neutrophil Leucocytes are present in large numbers. May involve the whole pleural space or only part of it (Loculated) and is usually Unilateral.

Aetiology : Secondary to infection in a lung (bacterial pnuemonias and TB) Other causes of sub absces Trauma or Surgery Esophegeal Rupture phrenic

Pathology : Thick Shaggy, inflammatory exudate Pus under considerable pressure Pus may rupture into a Bronchus (Bronocho Pleural Fistula) or track through the Chestwall to form Subcutatneous absces or Sinus (Empyema necessitans)

Clinical Features : Suspected in patient with pulmonary infection with persisting Pyrexia despite treatment

Investigations : Radiological Examinations As of Pleural Effusion Horizontal Fluid levelPyopneumothorax Ultrasound and CT Aspiration of fluid Thick and turbid- Empyema

 Other Features suggesting Empyema Fluid Glucose < 60 mg/dL LDH > 1000 units/Lt Fluid pH < 7 Pleural Biopsy, Histology and Culture To differentiate TB and NonTuberculous disease.

Management : Treatment of Non-Tuberculous Empyema Intercostal tube drain connected to underwater-seal Antibiotic Treatment- 2 4 weeks I.V Co-Amoxiclav or I.V Cefuroxime with Metronidazole Surgical Decortication

 Treatment of Tuberculous Empyema Intercostal tube drainage Anti Tuberculosis treatment Complications calcificaton Fibrothorax Pleural