1 / 32

Diseases of the pleura

Pleural Effusions. Mechanisms of accumulation:1-Increase in entry rate normal entry rate(0.01mL/kg/hr;around 16.8mL/day for a 70kg patient).2-Decrease in exit rate exit rate can increase to 0.28mL/kg/hr. Pleural Effusions Increased Fluid Entry. 1-Increase in microvascular pressure.2-Decr

hercules
Télécharger la présentation

Diseases of the pleura

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Diseases of the pleura J. Tavares,MD,FACP,FCCP,FAASM

    2. Pleural Effusions Mechanisms of accumulation: 1-Increase in entry rate normal entry rate(0.01mL/kg/hr;around 16.8mL/day for a 70kg patient). 2-Decrease in exit rate exit rate can increase to 0.28mL/kg/hr

    3. Pleural Effusions Increased Fluid Entry 1-Increase in microvascular pressure. 2-Decrease in pleural pressure(atelectasis) 3-Decrease in plasma oncotic pressure 4-Increase in permeability

    5. Pleural Effusions Decreased Fluid Exit 1-Interference with the ability of the lymphatics to contract a)-inflammation b)-hypothyroidism c)-malignancy 2-Inhibition of lymphatic function a)-phrenic nerve paralysis,atelectasis,granulomas,etc

    6. Pleural Effusions Evaluation 1-History: Typically asymptomatic: BAPE Hypoalbuminemia Nephrotic syndrome Rheumatoid effusion Urinothorax Yellow nail syndrome Trapped lung

    7. Pleural effusions Evaluation 1-History Typically symptomatic Bacterial pneumonia carcinomatous effusion CHF Lupus pleuritis Mesothelioma Pulmonary embolism

    8. Pleural Effusion Evaluation 2-Physical examination normal if fluid volume is less than 250mL Around 500mL: dullness to percussion, decreased fremitus and decreased intensity of the sounds. >1000mL:egophony(E to A change) at the upper level of the effusion.

    9. Pleural Effusion Evaluation 3-Radiology Isolated pleural effusion: a)TB,Lupus,Metastatic cancer b)Massive effusion with contralateral shift(carcinoma,usually a nonlung primary) c)Massive without contralateral shift(lung cancer of the ipsilateral main stem or mesothelioma)

    13. Pleural Effusion Evaluation 4-Pleural fluid analysis Virtually all patients with newly discovered pleural effusions should have thoracenthesis. Exception: typical CHF patient(but,if fever,pleuritic chest pain,unilateral effusion or left effusion greater than right:TAP)

    14. Pleural Effusion Evaluation 4-Pleural fluid analysis( ? How useful) a-definitive diagnosis: 25% patients b-presumptive diagnosis:additional 50% pts c-excludes other causes:15% of patients.

    19. Pleural Effusion Evaluation 4-Pleural fluid analysis a)Observation hemothorax milky(chylothorax,cholesterol,empyema) black(aspergillus niger) yellow-greenish(rheumatoid) brown(amoebic liver)

    20. Pleural Effusion Evaluation 4-Pleural fluid analysis b)Total protein and LDH fluid prot/serum prot>0.5 fluid LDH/serum LDH>0.67 Sensitivity of 98% and specificity of 74% LDH>1000:empyema,rheumatoid,paragonimiasis Total protein>7.0:waldenstrom macrogl,MM

    21. Pleural Effusion Evaluation 4-Pleural fluid analysis c)pH<7.30: empyema,rheumatoid pleurisy d)-glucose fluid/serum<0.5 e)-Triglycerides/Cholesterol TG>110mg/dL: likely chylothorax f)Adenosine deaminase:>50U/L in TB

    22. Pleural Effusion Management Malignant pleural effusions median survival after recognition: 4 months A-repeated thoracenthesis B-Long term pleural catheter C-Pleurodesis D-Pleurectomy E-Shunt

    25. Pleural Effusion Management Trapped Lung a)Observation b)Thoracenthesis if symptomatic c)Decortication

    28. Pneumothorax Management A-Primary spontaneous pneumothorax 7.4/100,000/yr in men in the US(37UK) 1.2 /100,000/yr in women in the US(15.4UK Risk factors:smoking,Marfan,Family Hx,homocystinuria,thoracic endometriosis. Smoking:in 505 patients with PSP,91% were smokers.

    29. Pneumothorax Management A-Primary spontaneous pneumothorax <2 to 3 cm(20%):02 supplement/observation >3cm or symptomatic:needle aspiration. failed aspiration: chest tube and consider thoracoscopy. Unstable patients:Chest tube insertion.

    30. Pneumothorax Management Supplemental oxygen: Normal resorption is 1.25%/hr 100% oxygen: 12.5%/hr VATS pleurodesis

    31. Pneumothorax Management B-Secondary spontaneous pneumothorax All patients shoul be hospitalized <2cm and stable: observe >2cm or unstable:chest tube

    32. Pneumothorax Management C-Air travel Boyle’s law:volume inversely proportional to pressure. Recommendations: 1-No fly if current pneumothorax or congenital pulmonary cysts 2-avoid flying during COPD exacerbations 3-iatrogenic pneumothorax in normal lungs:ok to fly 4 to 6 weeks after resolution of PTX 4-may be contraindicated: spont.PTX,bullous emphysema.

More Related