• S- Khaled 85 year old Saudi male . he complained of dyspnea for
one weak and coughing with sputum. He has DM from 30 years,
HTN, stroke for 7 month and Parkinson disease.
• O- taking history and physical examination
• E- pleural effusion or pneumothorax or inspiration pneumonia.
• P- CXR, cbc, echo
• E- thoracentesis, tube thoracotomy and
• L- pleural effusion
5. PLEURAL SPACE
The pleura consists of 2 layers
1 – parietal pleura
2 – visceral pleura
The space between the 2 layers is called the pleural
Normally the pleural space contains:
• 3.5 to 7.0 ml of clear liquid
• low protein content
• small number of mononuclear cells
6. • Definition.
Defined as an excess quantity of fluid in the pleural space caused either by ↑
pleural fluid formation or ↓ removal by the lymphatic system. The fluid may be
transudative or exudative.
1. Transudative effusion: ↑ production of pleural fluid due to ↑ hydrostatic or ↓
oncotic pressures. Found in CHF, pulmonary embolism, cirrhosis, and
2. Exudative effusion: ↑ production due to abnormal capillary permeability or ↓
lymphatic clearance of fluid. Found in malignancy, pneumonia, TB, pulmonary
embolism, pancreatitis, esophageal rupture, collagen vascular disease, and
3. In healthy patients, the pleural cavity contains a small volume of lubricating
serous fluid, formed primarily by transudation from the parietal pleura and
absorbed primarily by the capillaries and lymphatics. The balance between
formation and removal of this fluid may be compromised by any disorder that
increases the pulmonary or systemic venous pressure, lowers the plasma
oncotic pressure, increases capillary permeability, or obstructs the lymphatic
• patients may experience dyspnea with large effusions. They may also complain
Of pleuritic pain and have symptoms of pneumonia such as productive Cough,
fever, and signs of consolidation.
• on exam, dullness to percussion, decreased fremitus, and ↓ breath sounds May
be found on the affected side. Patients may show symptoms of their Underlying
disease process (cancer, pneumonia, CHF, cirrhosis).
• CXR: on upright PA and lateral films, blunting of costophrenic angles may be
present with effusions > 250 ml. Decubitus films can differentiate Pleural fluid
from pleural scarring and can help determine if the fluid is Loculated .
• obtain fluid via thoracentesis and send for protein, glucose, LDH, cell Count,
gram stain, and culture. Also obtain PH, fungal and mycobacterial Cultures, and
cytology. In appropriate settings, look for pleural fluid Amylase, triglycerides,
cholesterol, and hematocrit. Grossly purulent fluid Represents empyema.
• hemothorax: a pleural hematocrit-to-peripheral hematocrit ratio > 0.5.
• pancreatitis, pancreatic pseudocyst, adenocarcinoma of lung, or esophageal
Rupture: ↑ pleural fluid amylase.
• malignancy: cytology is only 50%–60% sensitive for detection.
• pleural biopsy can help diagnose TB or cancer.
• Transudative effusion: treat the underlying cause, and consider therapeutic
Thoracentesis if symptomatic. No further workup is required.
• exudative effusion:
• parapneumonic: give appropriate antibiotics for infections; insert a Chest tube
for drainage if complicated (eg, if ph < 7.2 or glucose < 60
• Mg/dl) or if empyema is present.
• malignant: treat the underlying malignancy; repeat thoracentesis or Chest tube
insertion for symptom relief. Pleurodesis can ↓ reaccumulation Of fluid.
• hemothorax: rapid drainage via a large-bore chest tube to prevent fibrothorax.
• tuberculous: usually resolves with treatment of TB.
Color of Fluid Suggested Diagnosis
Pale yellow (straw) Transudate, some exudates
Red (bloody) Malignancy or embolism or TB
Turbid Infected effusion
White (milky) Chylothorax or cholesterol effusion
Color of Fluid
15. Peneumothorax is the accumulation of air in the pleural space. It may occur
spontaneously or following trauma
Chest trauma; rupture of aortic
Congestive cardiac failure
Neoplastic infiltration; trauma
16. Results from rupture of a pleural bleb
Pleural bleb being a congenital defect of the alveolar wall
Patients are typically tall, thin, young males.
M:f ratio 6:1.
Usually apical affecting both lungs with equal frequency.
17. Secondary causes occur in patients with underlying disease :
COPD, TB, pneumonia, bronchial carcinoma, sarcoidosis and
18. Patients present with sudden onset of unilateral pleuritic pain and increasing
The main aim of treatment is to get the patient back to active life as soon as
19. Chest radiography may show an area devoid of lung markings.
May be more clearly seen on the expiratory film
20. Small pneumothorax: no treatment, but review in 7-10 days.
Moderate pneumothorax: admit for simple aspiration.