Medical Archive

Pleural effusion

Etiology

Transudate: 2° to ?PCWP or ?oncotic pressure
Exudate: 2° to ?pleural vascular permeability

Diagnostic approach

• Chest X-ray
• Thoracocentesis for new effusions > 1cm in decubitus
  • Except with bilateral effusions and other clinical evidence of CHF ? trial of a diuretic is warranted

Light’s criteria

+?? ????, protein ??? 3.1 ???? transudate? ??.

Transudate

?? ??? ????? ??? ??
CHF (m/c), liver cirrhosis, nephrosis

Exudate

?? ??? ??. ????-m/c, ????, ??? ??

Differential diagnosis by pleural fluid

• WBC count w/ differential
  • ??? – ???? ??
  • ??? – Tb or ?? ??
  • ??? – ???, ???
• ADA
  • >40IU/L + lymphocyte ? ? TB
  • ???? ????? ?????.
• Glucose 
  • <60: Malignancy, bacteria, rheumatoid pleuritis
  • <30: empyema or rheumatic effusion
  • Low d/t high metabolic activity of leukocytes and bacteria within the pleural fluid.
• ?Amylase
  • Esophageal rupture, pnacreatitis, malignancy

Effusion due to heart failure

Hepatic hydrothorax

Parapneumonic effusion

Uncomplicated

?????? ?? ??. 1cm ?? shifting? ??? centesis

Complicated

• Antibiotics + ?? tube thoracostomy ??? ??.
  • Loculated
  • PF pH<7.2
  • PF glucose <60
  • Gram+ or culture +
  • Gross empyema
• Drain ? ??? Intrapleural uro/streptokinase?, ?? thoracoscopy? adhesion ??
• ??? ? ??? decortication ???.
• ?? ?? f/u: LPG (LDH, pH, glucose)

Effusion secondary to malignancy

• Etiology
  • Lung cancer > breast cancer, lymphoma
  • The three tumors cause ~75% of all malignant pleural effusions.
• Diagnosis
  • Cytology (60%),
  • ?? ??? ????? thoracoscopy. CHF?? ?? Unilateral
• Treatment
  • ?? Thoracostomy + sclerotic agent (Talc, bleomycin, picibanil)
  • Small indwelling catheter
  • Pleurodesis(?????) – ????? ??, ?? ?? ??. ?? ??? ??!

Mesothelioma

??? asbestos ??? ??. ??? ??.
Pleural thickening, ?? ??? ???. ???????…

• Histology
  • Cuboidal or flattened cells (epithelium-like)
    • Joined by desmosomes, contain abundant tonofilaments, and are studded with very long microvilli.
  • Spindle cells (stromal-like)
• Diagnosis
  • ????
  • Immunohistochemistry
    • Pancytokeratin: ???? type?? ?? – ?? ??? ?? ??
    • Calretinin, CK5/6, WT1, D2-40: epithelium-like type

Effusion Secondary to Pulmonary Embolization

Tuberculous Pleuritis

Lymphocyte dominant + ADA>40IU/L
Pulmonary Tb? ??? ??

Effusion Secondary to Viral Infection

Chylothorax

Thoracic duct ?? ? ?? 5%, mediastinal tumor 50%, ?? ?? 20%
Dyspnea, CXR? pleural effusion?; milky fluid, TG>110, chylomicron +
# Pseudochylothorax: pleural fluid? ?? ??? ????? ??? ????? ??? (TG ??)

chest tube drain + octreotide (TOC)
Pleuroperitoneal shunt (2nd)
??? Tube drainage? ????, ???? ????? ??!

Hemothorax

PF Hct > 50% serum Hct
Trauma (m/c) – ?? hemo-pneumothorax ??
Lung ca., mesothelioma, pul. Embolism
Immediate tube thoracostomy
?? Ix ?? 1,000mL or 100mL/hr, 4hr??, ?? ???? ?? ?? ??? ??? ?? (?? ??? ??/??? risk?)

Miscellaneous Causes of Pleural Effusion

Empyema

End stage. ???? ?? ?? thoracostomy? ??? ??. +?? ?????.

Fibrothorax

??, ??, ?? exudate ? ? ??/?? ??? ?? ? ??? ??
Decortication: pleural thickening? ??? ??, ???? ?? ? ??. (??? ????? ??? ???? ?????)

# Procedures

<Schwartz’s> C19 Chest Wall, Lung, Mediastinum, and Pleura

Pneumothorax

Primary spontaneous pneumothorax

Subpleural emphysematous bleb rupture
???(90%) abrupt chest pain, dyspnea
??? shift, hyperresonance, ???? vocal fremitus ?, visceral pleural line

Secondary pneumothorax

?? ?? ? ??? ?? ?? (COPD – m/c)
??? chest tube insertion. ???? ?? pleurodesis ?????.

Traumatic pneumothorax

??? chest tube insertion. Hemopneumothorax ? 2? ?? (?? ?? / ?? ??)
Iatrogenic: FNA, centesis, IV cath ?? ??. – O2 & simple aspiration
????? ????? tension pneumothorax ?? ?? ?? ?????? ?.

Observation, O2	??? ?? ??? 20%??, ???? ?? ?? 1-2?? ?? ??. 100% O2 ??? 4? ??
Needle aspiration	Primary spontaneous, iatrogenic? ??? ???.
Tube thoracostomy	Unstable, large 1°, 2°, traumatic Ventilator induced/large iatrogenic, ??? ?? ?? ?? ?
Video-assisted  thoracoscopic surgery (VATS)	Chronic, recurrent >3, persistent
Thoracotomy	Emergent: penetrating chest injury who are hemodynamically unstable

Open pneumothorax

??? ?? + ??? ??
Bubbling of blood is seen with each respiration at the wound site.
Tension?? ????, ???? ?? ?? ???? ???? ??.

• Management
  • Simple partially occlusive dressings taped at 3 out of 4 sides of the lesion
  • Followed by thoracostomy
  • Observe for development of tension pneumothorax.

Tension pneumothorax

• Plueral pressure? ?????  ??? (ventilator, CPR, trauma)
• Clinical features
  • Respiratory distress, shock, neck vein distension, tracheal deviation, ?? ??
• Management
  • Large bore needle aspiration (2nd ICS, mid-clavicular line)
    + O2 + tube drain
  • Tube thoracostomy is required for definitive management.

Reexpansion pulmonary edema

Pneumothorax? pleural edema? ??? ?? ??? ????? ??? pulmonary edema. (Reperfusion injury)

??: ????