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احمد عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
1
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Objective :
To show the definition, types, causes and management of P
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Causes
I.Transudative pleural effusions
1. Heart failure
2. Cirrhosis
3. Nephrotic syndrome
4. Hypoalbuminemia
5. Fluid retention/overload
II.Exudative pleural effusions
A. Neoplastic diseases
B. Infectious diseases
1. Bacterial infections
2. Tuberculosis
C. Pulmonary embolization
D. Gastrointestinal disease
1. Pancreatic disease
2. Subphrenic abscess
3. Intrahepatic absces
E. Heart disease
1. Post-CABG surgery
2. Post cardiac injury (Dressler) syndrome
F.Obstetric and gynecologic disease
1. Meigs syndrome
2. Endometriosis
G. Collagen-vascular disease
1. Rheumatoid pleurisy
2. Systemic lupus erythematosus
H. Drug induced pleural effusion
1. Methysergide
2. Amiodarone
I. Miscellaneous diseases and conditions
1. Asbestose exposure
2. Sarcoidosis
J. Hemothorax
K.Chylothorax
Meigs' syndrome is the combination of pleural effusion and ovarian fibroma
.أ
م
.
د
.
احمد عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
2
Clinical features
Pleural effusions can be asymptomatic but can produce dyspnea, cough and chest pain.
The classic signs of pleural effusion are:-
Stony dullness to percussion
Absent tactile and vocal fremitus
Diminished breath sounds
Mediastinal displacement
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Bilateral pleural effusions are due to congestive heart failure in over 80% of patients. If
the clinical history suggests this diagnosis, a trial of diuresis may be indicated. Up to
75% of effusions due to congestive heart failure resolve within 48 hours with diuresis
alone.
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A patient presenting with cough, fever, leukocytosis, and unilateral infiltrate and
effusion is likely to have a parapneumonic process. If the effusion is small and the
patient responds to antibiotics, a diagnostic thoracentesis may be unnecessary.
However, a patient who has an obvious pneumonia and a large pleural effusion that is
purulent and foul-smelling has an empyema. Aggressive drainage with chest tubes is
required, possibly with surgical intervention.
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Pulmonary embolism should be suspected in a patient with a pleural effusion occurring
in association with pleuritic chest pain, hemoptysis, or dyspnea out of proportion to the
size of the effusion.
Investigations
Chest X-ray
A concave meniscus in the costophrenic angle on an upright chest x-ray suggests the
presence of at least 250-300 mL of pleural fluid.
Thoracocentesis
Needle aspiration is sometimes necessary to establish the presence of an effusion and to
differentiate it from other thoracic conditions.
Transudates
Are protein-poor ultrafiltrates of plasma that occur because of alterations in the
systemic hydrostatic pressures or colloid osmotic pressures.
Exudates
Are protein rich pleural fluid collections that occur because of inflammation or invasion
of the pleura by tumors (increased permeability of the pleura to proteins and decreased
lymphatic clearance). Grossly they are often turbid, bloody, or purulent.
.أ
م
.
د
.
احمد عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
3
1. White blood cell count and differential
2. Gram's stains and cultures
3. Pleural fluid glucose
4. Pleural fluid amylase
5. Cytologic examination of pleural fluid
6. Pleural fluid pH
7. Lactic acid dehydrogenase
8. Rheumatoid factor
9. Lipid analysis
Biopsy by needle or trephine
Yields a specific diagnosis in fewer than half the cases in which it is attempted.
Thoracotomy
A small thoracotomy may be necessary to allow the surgeon to inspect the visceral and
the parietal pleura, as well as the lung, and to select the most promising areas for
biopsy.
Video-assisted thoracoscopy
It also provides excellent visualization of the thoracic cavity and its contents and is
preferred by many surgeons for biopsy.
Benign pleural effusion
Treatment
- Treatment of the underlying disease, such as congestive heart failure.
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If recurrence occurs:
Medical management of the underlying cause should be maximized with or without
thoracocentesis.
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If recurrence occurs despite these efforts:
Tube thoracostomy + chemical pleurodesis.
- VATS or thoracotomy with mechanical pleurodesis is reserved for only resistant
effusions.
Malignant Pleural Effusion
Treatment
- The standard therapy is tube thoracostomy followed by chemical pleurodesis and
treatment of the underlying disease.
.أ
م
.
د
.
احمد عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
4
Other options include :-
- A permanent pleural drainage catheter (Hickman, Groshong) can facilitate
repeated thoracocentesis
- Pleuroperitoneal shunts
- VATS or thoracotomy with mechanical pleurodesis is reserved for only resistant
effusions and who have a reasonably long life expectancy
Thoracentesis in malignant pleural effusion can be appropriate if:
The patient is minimally symptomatic
Symptomatic but expected to have a prompt response to other therapy
Is receiving chemotherapy and chest tube insertion is contraindicated
(neutropenia)
Is not a candidate for a more aggressive approach because of comorbid
disease or stage of malignancy.