Pleural effusion
Pneumothorax
Ketut Putu Yasa, SpB, SpBTKV
Cardiothoracic and Vascular Surgery Division
Department of Surgery Udayana University / Sanglah
Hospital
DISORDER OF PLEURA
PLEURAL EFFUSION
EXUDATE / TRANSUDATE
EMPYEMA
HEMOTHORAX
CHYLOTHORAX
PNEUMOTHORAX
SOLID DISORDER
- BENIGN : FIBROTHORAX, PLEURAL PLAQUE, DIFFUSE PLEURAL
THICKENING, BENIGN TUMORS
- MALIGNANT: MESOTHELIOMA, LIPOSARCOMA, FIBROSARCOMA
CONTENTS - Thoracic
cavity
Chest wall
Sternum + Ribs + Corpus
Vertebra , Clavicle
Pleural cavity
Lungs, Pleura, Diaphragm
Mediastinum
Heart, Great vessels, Esophagus,
Tracheo-bronchial tree, Thymus,
Nerve and Limphatyc system,
Pleura : Anatomy and Physiology
Visceral Pleura
Cover lungs
Parietal Pleura
Lines inside of thoracic cavity
Pleural Space
POTENTIAL SPACE
Air in Space = PNEUMOTHORAX
Blood in Space = HEMOTHORAX
Fluid in space = PLEURAL EFFUSION
Serous (pleural) fluid within : approximately 10 ml
Lubricates & permits ease of expansion
Negative pressure at -2 to -5 cm H2O
Disorder lead to symptoms as a result of mechanical compression
Normal composition of pleural
fluid
Volume 0,1 0,2 ml / kg (<10 cc)
Cells / mm3 1000 5000
-% mesothel 3-70%
-% Monocytes 30-75%
-% lymphocytes 2-30%
-% granulocytes 10%
Protein 1 2 g/dl
-% albumin 50 70%
Glucose = plasma
LDH < 50% plasma
pH plasma
Schematic diagram of normal filtration and
resorption of fluid in pleural space
Formation & resorption rate
15-20 mL/day
Starling equation
Fluid movement = K [(Pc Pis) (COPc COPis)]
K = filtration coeff
P = hydrostatic pressure
COP = colloid osmotic pressure
= cap permeability to protein / reflection coeff
c = cappilary
is = interstitial or pleural space
Pathogenesis of pleural fluid
accumulation
1. Alteration of pleural permebiality : EXUDATE
2. Alteration of pressure without change in pleural permeability :
TRANSUDATE
Exudate : 1. High level of protein
2. High level of LDH
Transudate : 1. Low level of protein
2. Low level of LDH
Transudate Eksudate
Tes Rivalta (-) (+)
Protein < 3 g/dl > 3 g/dl
Pleural fluid / serum protein ratio * < 0,5 0,5
Berat jenis < 1016 > 1016
LDH < 200 IU > 200 IU
Pleural fluid / serum LDH ratio * < 0,6 0,6
Type of cellular > 50 % > 50 %
Limfosit MN Limfosit PMN
Number of cellular normal
increase
pH > 7,3 < 7,3
Glukosa = glukosa darah < glukosa darah (< 40)
ETIOLOGY OF PLEURAL EFFUSION
Pleural eff as clinical manifestation of
other disorders :
Meigs syndrome
TRIAS : Pleural effusion,
Ascites,
Benign ovarial tumor (fibroma)
Hypothyroidsm
Asbestos exposure
Primary disorder of lymphatic channel
Clinical Features of Pleural Effusion
May or may not have symptoms
Symptoms depends on size of effusion and the underlying process
- Pleuritic chest pain or local tenderness
- Underlying disease as the cause of pleural effusion
- Dyspnea
Physical exam :
Dullness in percussion
Decreased breath sound at the level of effusion
Egophony at upper level of effusion
Pleural friction rub
Diagnosis
Imaging : chest x-ray, USG, CT scan thorax
Pleural taping / punksi / thoracocentesis ( ICS 6,7,8 midaxilar line)
Pleural biopsy (for TBC and Malignancy)
Thoracoccopy /VATS ( evaluating pleural malignant implant)
Chest X-ray and prediction of fluid
-Position : PA, Lat
-Small effblunting of costophrenic
angle ( at least 300ml)
-Large effhomogenous opacity
-Loculation eff lateral decubitus foto ,
can detect 50 ml of fluid
->500 ml, usually detectable clinical sign
MANAGEMENT OF PLEURAL EFFUSION
1. Identification
Transudate vs exudate
Malignant pleural effusion
Fluid should routinely be sent for
1. chemical analysis
2. cytology
3. microbiology stains and culture
2. Treatment
- Causative / underlying process treatment
- Complete removal of effusion
1. thoracocentesis
2. tube thoracostomy (standard)
3. open drainage / VATS with decortication (if loculation or
extensive fibrosis and adhesion)
4. pleurodesis ( if recurrent or malignancy)
5. pleurectomy (if all above failed)
6. pleuroperitoneal shunt ( if all above failed )
Malignant Pleural Effusion
Definition : malignant cells in pleural fluid or pleural tissue
Pathogenesis :
Direct extension and Haematogenous invasion of tumor to pleura
Lymphatic channel and lymphnode blocked impaired lymphatic
clearance of protein and fluid
Inflamatory response to pleural tumor invasion microvascular permeabelity
Pleural fluid characteristics :
Serous(lymphatic obstruction) , serosanguineous, hemorrhagic
(direct pleural involvement)
Exudate
Management :
Investigation source of malignancy
Treatment of primary tumor
Drainage : tube thoracostomy + pleurodesis (w/ talc, tetracycline)
Malignant Neoplasms Associated with
Pleural Effusion
Malignancy Total
Lung 35 %
Breast 23 %
Adenocarcinoma , unknown 12 %
primary 10 %
Lymphoma 6%
Reproductive tract 5%
Gastrointestinal tract 3%
Genitourinaray tract 3%
Primary unknown 5%
Others
Alur Diagnosis Efusi Pleura Ganas
Efusi Pleura Punksi
Transudat Eksudat
Gangguan Jantung Pleuritis Keganasan
Gangguan Ginjal Pleuritis TB Tu primer di Paru (+)
Gangguan Metaboliasme Pleuritis Non-TB Atau Tu Primer Paru Pernah (+)
Penyakit sistemik lain Gangguan Immonologi Riwayat Tu Ganas di luar paru
Sitologi Cairan Pleura
Histologi Biopsi Pleura
Sitologi (-) Sitologi /Histologi (+)
Histologi (-) Efusi Pleura ganas
Lanjutkan prosedur lain
Tu di Paru (+) Tu di Paru (-) Tu di Paru (-)
Torakoskopi bila semua hasil (-) Tu diluar Paru (+) Tu diluar Paru (-)
T 4 dalam TNM Metastasis (reaksi Dianggap Tu Primernya
Tu Paru sistemikTu Primer) Tu Paru (T 4 dalam TNM)
Penatalaksanaan Diagnosis Efusi Pleura
Ganas
EFUSI PLEURA GANAS (EPG)
T 4 pada Tu Paru Metastasis di paru
(Tu Primer di paru)
Diagnostik Tu paru (+) Staging belum ditegakkan Punksi / WSD
Jenis (+) Punksi / WSD Untuk mengurangi keluhan
TNM (+) Untuk mengurangi keluhan
Tu Primer Tu Primer tidak
Cairan masif / Cairan tidak Masif Cairan Masif/ diketahui diketahui
produktif Produktif
Penatalaksanaan Punksi Berulang
Punksi / WSD Penatalaksanaan**
berdsarkan Pleurodesis * Pleurodesis, dekortikasi
sesuai dengan
Pleurodesis Jenis, Staging dan PS Shunting pleuro-abdominal
tumor primernya
Teruskan prosedur
Penatalaksanaan diagnostik
berdasarkan Teruskan prosedur
Jenis, Staging diagnostik
dan PS Penatalaksanaan berdasarkan
Jenis, Staging dan PS
Bila tumor primer di paru
Atau di luar paru (-)
Maka dianggap tu Primer
di paru
Penatalaksanaan Diagnosis Efusi Pleura
Ganas
EFUSI PLEURA GANAS (EPG)
T 4 pada Tu Paru Metastasis di paru
(Tu Primer di paru)
Diagnostik Tu paru (+) Staging belum ditegakkan Punksi / WSD
Jenis (+) Punksi / WSD Untuk mengurangi keluhan
TNM (+) Untuk mengurangi keluhan
Tu Primer Tu Primer tidak
Cairan masif / Cairan tidak Masif Cairan Masif/ diketahui diketahui
produktif Produktif
Penatalaksanaan Punksi Berulang
Punksi / WSD Penatalaksanaan**
berdsarkan Pleurodesis * Pleurodesis, dekortikasi
sesuai dengan
Pleurodesis Jenis, Staging dan PS Shunting pleuro-abdominal
tumor primernya
Teruskan prosedur
Penatalaksanaan diagnostik
berdasarkan Teruskan prosedur
Jenis, Staging diagnostik
dan PS Penatalaksanaan berdasarkan
Jenis, Staging dan PS
Bila tumor primer di paru
Atau di luar paru (-)
Maka dianggap tu Primer
di paru
PLEURODESIS
PLEURO = PLEURA,
DESIS = PENGIKATAN
TINDAKAN PENYATUAN PLEURA
VISCERAL DAN PARIETAL,
MENGHILANGKAN PLEURAL SPACE
TUJUAN DAN INDIKASI
PLEURODESIS
TUJUAN : MELEKATKAN PLEURA VISCERAL DAN
PARIETAL
INDIKASI :
PNEUMOTHORAX BERULANG
PNEUMOTHORAX DENGAN LESI LUAS
EFUSI PLEURA GANAS
CHYLOTHORAX
KONTRA INDIKASI & METODE
PLEURODESIS
KONTRA INDIKASI :
TIDAK ADA
ADA YG MENYEBUTKAN :
OBSTRUKSI ENDOBRONKIAL DAN
TRAPPED LUNG
METODE :
CHEMICAL ( talc, tetracycline,
bleomycine )
SURGICAL
RADIOTHERAPI
EMPYEMA THORACIS
Def : Pus in pleural space
E/ : 1. Pneumonia extend to pleural surface parapneumonic
eff
pus + bacteria
2. Secondary infection within pleural space ( trauma,
surgery )
3 stages of disease
Stage I (preempyema /exudative phase /para pneumonic effusion):
exudative fluid
Stage II ( fibrinopurulent phase ) :
pleural fluid becomes grossly purulent
Stage III (chronic or organisation phase):
lung is imprisoned within a thick fibrotic peel and
functionlesss
Patogenesis of Thoracic Empyema
Contamination From a source contiguous to the pleural space (50
60%)
Lung (parapneumonic empyema)
Mediastinum (esophagus or nodes)
Deep cervical
Chest wall and spine
Subphrenic abscesses
Direct inoculation of the pleural space (30 40 %)
Minor thoracic interventions
Postoperative infections
Penetrating chest injuries
Hematogenous infection of the pleural space (1%)
Prosentase jenis bakteri penyebab empiema
nontuberkulosis
Jenis Kuman Bryant & Salmon Brook & Frazier
( n = 217 kasus ) ( n = 197 kasus )
Staphylococcus aureus 18 27
Staphylococcus epidermidis 8 1
Streptococcus pneumoniae 8 32
Streptococcus lain 26 10
E Colli 9 8
Klebsiella sp 6 7
Proteus sp 5 2
Pseudomonas sp 12 4
Bakteri aerob lain (Enterobacter 5
5
Haeomophilus)
Isolat murni bakteri aerob 12 4
Peptostreptococcus sp 13 20
Streptococcus anaerob 10 9
Clostridium sp 5 4
Bacteroides sp 30 20
Fusobacterium sp 13 16
Actinomyces sp 2 1
Eubacterium sp 4 2
Propionibacterium 3 4
Veillonella sp 4 2
Isolat murni bakteri anaerob 23 13
EMPYEMA THORACIS
Diagnosis
-Acute illness, fever, local tenderness,
-Decreased breath soud, dulness in percusion
-Chest x-ray showing homogenous opacity, inverted D-
shaped density on lateral film.
The principles of management
1. Complete drainage ( tube thoracostomy, open drainage )
2. Obliteration ( decortication, plumbage )
3. Eradication of infection ( culture, antibiotic )
4. Nutrition support
Management of Empyema
Four basic principles
1. Drainage / evacuation of fluid
2. Obliteration of pleural space
3. Infection treatment / eradication
4. Associated treatment / nutritional support
Goal of drainage
1. Lung expansion > 50%
2. Free Space < 50%
3. Drainage < 50 ml / day
PNEUMOTHORAX
Incidence : 6-7 per 100.000 men, 1-2 per 100.000 women, bilateral
<10%, recurrences 42% within 2 yrs, after 2nd episode increase to
>50%
Pathophysiology :
Ranging from none to development of acute cardiovascular collaps
Size determinant clinical effect
Tension pneumothorax (one-way valve mechanism)
Important risk factor for tension is PEEP ventilation
Spontaneous resorbtion
Diagnosis :
acute pleuritic chest pain, dyspnea
+/- tension ( Dx/ Tension : resp. distress, CV collaps, trachea deviation)
Decreased breath sound , hypersonor
Chest x-ray erect PA and Lateral is best view, for small pnthorax is
expiration PA (curve or pleural line, radiolucent and no vascular marking)
CT Scan if suspect secondary pnthorax
Classification of pneumothorax
Spontaneous
Primary
Subpleural bleb rupture
Secondary
Bullous disease including COPD
Cystic fibrosis
Esophagus rupture
Marfans syndrome
Eosinophilic granuloma
Pneumocystis carinii AIDS
Metastatic cancer
Pneumonia with lung abscess
Lung cancer
Asthma secondary to mucous plugg
Lymphangioleiomyomatosis
Catamenial
Neonatal
Acquired
Iatrogenic
Barotrauma
Traumatic
TREATMENT OPTION OF PNEUMOTHORAX
OBSERVATION
Asymptomatic, small spontaneous pnthorax (<20%),
healthy patient, all patient should be hospitalized for 24-48
hrs, and serial foto thorax no progression
ASPIRATION
Asymptomatic, small pnthorax, dont repeated if reccurence
TUBE THORACOSTOMY -WSD
Standard of treatment
Chest tube insertion with passive or active drainage (active
facilitates full expansion of the lung)
SURGERY
Large pnthorax, persistent (>3 days) and reccurence
pnthorax
Type of surgery :
Pleurodesis prevent recurrence (mechanical aberasion or parietal
pleurectomy ) , chemical pleurodesi only selected case ,
Torakotomi or VATS (wedge resection)
Tension pneumothorax
Is a life threatening emergency
Diagnose should be clinically, not
radiologic
Management of Tension
Pneumothorax
- Is a life threatening
emergency
Confirmation
Auscultaton & Percussion
(diagnose should be clinically,
not radiologic)
Pleural Decompression
2nd intercostal space in mid-
clavicular line
TOP OF RIB
Consider multiple
decompression sites if patient
remains symptomatic
Large over the needle
catheter: 14 G
Create a one-way-valve:
Glove tip or Heimlich valve
Indications for surgery
in primary spontaneous pneumothorax
First episode Second episode
- Prolonged air leak - Ipsilateral recurrence
- Non re-expansion - Contralateral
- Bilateral pnthorax recurrence after a
- Occupational hazard first pnthorax
( flight personel, divers
- Isolated area
- Tension pnthorax
- Associated large bulla
- Individual indication
