A Simple Guide to Pleural effusion

A Simple Guide to Pleural effusion
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What is Pleural effusion?
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Pleural effusion is excess fluid collection in the pleural space between the parietal and visceral layers of the pleural cavity.

Excessive fluid can limit the expansion of the lungs and cause breathing difficulty.

What the types of Pleural effusions and their causes?
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There are 4 types of pleural effusion which can occur in the pleural space:

1.Serous fluid (hydrothorax)

This is essentially passive collection of extracellular fluid with a specific gravity of <1.015 and protein < 2-3g/dl.

It is translucent in color.

It occur as part of :
a.generalized edema

b.left heart failure

c.liver cirrhosis giving rise to hydrothorax

2.Pus (pyothorax or empyema)

This consists of inflammatory or neoplastic fluid with high protein content.

It is usually yellow or orange in color.

There may be cells or pus or bacteria.

Causes include:
a.bacterial and viral infections such as pneumonia

b.tuberculosis

c.intra-abdominal abscess

d.autoimmune diseases like SLE, rheumatoid arthritis

e.neoplasm(cancer of the lung)

3.Blood (hemothorax)

The exudate is typically blood stained.

Causes are:
a.pulmonary embolism and infarction

b.neoplasm especially with secondaries to lungs

4.Chyle (chylothorax)

Here the exudate arise from the leakage of thoracic duct.

It is milky in appearance.

Causes are:
a.Trauma including chest and heart surgery

b.filariasis in the tropics

What are the symptoms and signs of Pleural effusion?
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Symptoms:
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1.Breathless

2.Side Chest pain

3.dry cough

Signs:
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1.Dullness to percussion

2.Faint or absent breath sounds

3.Decreased movement of the chest

4.Decreased vocal resonance

5.Fremitus

6.pleural friction rub

How do you made a Diagnosis of Pleural effusion?
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Pleural effusion is usually diagnosed on:
1.medical history and physical exam,

2.chest x-ray.
Chest films with the patient lying on their side are more accurate and can show fluid level as low as 50 ml of fluid.

Upright chest films can show fluid level of at least 300ml of pleural effusion

In large effusion there may be tracheal deviation away from the effusion.

3.CT scan of chest showing left sided pleural effusion.

Effusion fluid often settles at the lowest space due to gravity;

4.Pleural tap or thoracentesis.

A needle is inserted through the back of the chest wall in sixth, seventh or eight intercostal space in midaxillary line, into the pleural space.
The fluid may then be evaluated for the following:

Chemical composition including
protein,
lactate dehydrogenase (LDH),
albumin,
amylase,
pH and
glucose

Gram stain and culture to identify possible bacterial infections

Cell count and differential white cell count

Cytology to identify cancer cells

Cytology to identify some infective organisms

Other tests :
lipids,
fungal culture,
viral culture,
specific immunoglobulins

5.Thoracoscopy
If cytology does not show cancer but cancer is still suspected, then a thoracoscopy, or needle biopsy of the pleura may be done to exclude cancer.

What is the Treatment of Pleural Effusion?
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1.Pleural Aspiration is done for relief of chest discomfortand breathlessness.

The Chest Drainage Device is usually connected to an underwater seal below the level of the chest.

Air or pleural fluid is allowed to escape from the pleural space but nothing is allowed to return to the pleural cavity.

Larger effusions may need insertion of an intercostal drain .

2.Treatment depends on the underlying cause of the pleural effusion.

a.Therapeutic aspiration may be sufficient in some cases of trauma and leakage.

b.Installation of antibiotics( eg.bleomycin, tetracycline/doxycycline) in pleural cavity

c.Installation of chemotherapy drugs for cancer into the pleural cavity.

d.treatment of filariasis cases with anti-parasitic drugs

e.surgical pleurodesis- here the parietal and visceral pleural surfaces are made to adhere to each other to prevent accumulation of fluid.

What is the Prognosis of Pleural Effusion?
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Recovery of patient from the pleural effusion after appropriate treatment of the underlying disease is the rule.

Recurrence from returning cancer or infections may be common.

A Simple Guide to Pneumothorax

A Simple Guide to Pneumothorax
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What is Pneumothorax?
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Pneumothorax is a medical emergency caused by collection of air in the pleural space between the perietal and visceral pleura.

What are the types of pneumothorax?
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Tension pneumothorax:
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This ia a medical emergency as air builds up in the pleural space with each breath.
The rising intrathoracic pressure pushes the mediastinum away from the affected lung to the other compressing intrathoracic vessels and causing collapse of the lung.
Tension pneumothorax are life threatening.

Non-tension pneumothorax:
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A non-tension pneumothorax is less serious because there is no increasing pressure of air in the thoracic region and hence no increasing pressure on the intrathoracic organs.

Hemopneumothorax:
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When blood accumulates in the thoracic cavity (hemothorax), there is even more increased pressure in the pleural cavity. This is called a hemopneumothorax and also be life threatening.

What is the causes of pneumothorax?
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It is most commonly due to:

Spontaneous pneumothorax
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This is due to the rupture of superficial air sacs following severe coughing or strenous exercise in:

1.tall young males and in Marfan syndrome

2.Tuberculosis

3.Bronchial obstruction

4.Cancer

Non-spontaneous pneumothorax
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1.penetrating chest wound

2.surgical trauma

3.pleural effusion tap

What are the Signs and symptoms of Pneumothorax?
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Symptoms:
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1.Sudden onset of chest pain, back

2.shortness of breath,

3.dry coughs,

4.cyanosis (turning blue)

5.coma

Signs:
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1.Pale or cyanotic

2.Percussion show resonance at normal lung while none at the pneumothorax lung area

3.Auscultation reveals breath sounds on the normal side but none at the pneumothoracic lung

4.There may be a characteristic clicking sound with respiration.

5.In penetrating chest wounds, there is a typical "sucking" sound of air flowing through the puncture hole .

6.The flopping sound of the punctured lung can sometimes be heard

How is the Diagnosis of Pneumothorax made?
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Physical examination:
a. absence of audible breath sounds through a stethoscope

b. hyperresonance (higher pitched sounds than normal) to percussion of the chest wall is suggestive of the diagnosis.

c.Two coins when tapped on the affected side results in a tinkling resonant sound

Chest X-ray reveals a typical pattern of complete lung collapse with air space surrounding the lung edge.

Medistinal shifts can be seen on inspiratory and expiratory films

CT scan and MRI can revealed a clearer picture of the pneumothorax and even the bubbles on the lung surface which may burst and cause a pneumothorax.

What is the complication of Pneumothorax?
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Respiratory failure with circulatory collapse

What is the treatment of Pneumothorax?
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All pneumothorax patients are to be admitted to hospital for treatment.

1. Small spontaneous pneumothorax
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A small spontaneous pneumothorax can be left alone to reabsorb on its own.

The patient is monitored in hospital and given oxygen until the pneumothorax has disappeared.

2.Tension Pneumothorax
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Tension Pneumothorax is a medical emergency.

Any perimedic or doctor attending to the patient should insert a needle immediately into the pleural cavity to allow the air to escape.

Tube drainage can also be done if available. If the tube is not available, immediate evacuation to the hospital should be done for advanced medical care.

The tube should be inserted with underwater seal and suction of the air out of the pleural cavity done using a simple one way valve or vacuum and a water valve device, depending on severity.

The lung should re-expand in the thoracic cavity nad the result is monitored by frequent x-rays

Where rarely the chest tube does not help healing of the lung , surgery may be done to staple the lung closed.


Penetrating wounds:
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A chest drain is inserted first before any treatment of the wounds is done.

Supprtive treatment:
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Oxygen therapy
Rest
Antibiotics for infections
Painkillers for pain


Recurrent pneumothorax
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1.pleurodesis may be required in recurrent pneumothorax.

2.bullectomy (the removal or stapling of bullae).

3.Chemical pleurodesis uses chemical irritant that leads to adhesion of the lung to the parietal pleura.

4.Mechanical pleurodesis The inside chest wall is roughened so the lung attaches to the peural wall with scar tissues

5.pleurectomy is the removal of the parietal pleura which can be performed using keyhole surgery

What is the prognosis of Pneumothorax?
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It is usually good following treatment.

However treatment is always needed to address the cause of the underlying diseases causing the pneumothorax.