Pleural Collections

Dr Debasree Guha
 Any collection between two layers of pleura
(parietal and visceral), that may be-
- Fluid( Transudate/Exudate)
- Air
- Pus
- Blood
- Chyle
 Pleural Effusion
Presence of fluid
Causes-
- TB
- Bacterial infection PneumoniaSynpneumonic
effusion.
- Collagen vascular disease- SLE, RA.
- Malignancy- Primary/metastatic.
- Acute pancreatitis/ sub diaphragmatic abscess.
- Ureamia.
 Hydrothorax
Systemic diseases collection of transudate
fluid.
CCF, Nephrotic Syndrome, Chronic Liver
Disease.
Usually bilateral.
Most of the time associated with fluid
collection in other part of the body( ascites)
and oedema.
 Symptoms
Mild Collection- Asymptomatic
- Chest pain/ heaviness.
- Cough.
Moderate to severe collection- Varying
degree of respiratory distress.
Fever.
Symptoms of primary disease.
 Signs
Inspection-
- Signs of respiratory distress
- Bulging of affected side
- Restricted respiratory movement
Palpation-
- Shifting of mediastinum to opposite side
- Diminished vocal fremitus
 Signs
Percussion-
- Stony dullness of affected side
Auscultation-
- Diminished / Absent breath sounds
- Diminished vocal resonance
- Pleural rub.
Signs of bacterial pneumonia may be present.
 Investigation
Chest X-ray P-A view-
Mild- Obliteration of costo-phrenic angle.
Mod- Severe-
- Homogenous opacity
- Shifting of mediastinum
to opposite side
- Upper level deviated
laterally.
 Investigation
Pleural Fluid Analysis- Thoracocentesis
Transudate Exudate

Appearance Clear Straw color

Cells No cells Lymphocyte/PMN
Protein < 3 gm/dl > 3gm/dl
Pleural fluid : serum protein < 0.5 > 0.5
LDH < 200 IU/dl > 200 IU/dl
pH > 7.2 < 7.2
Sugar > 40 mg/dl < 40 mg/dl
 Special/Supportive
Manteaux test, Pleural fluid ADA.
Serum Amylase, lipase.
Blood Count, Blood Culture.
ANA, RA factor.
 Treatment
Mild Collection- Treatment of the cause
e.g-Pneumonia with syn-pneumonic effusion
Moderate to Severe collection-
-Removal of fluid during diagnostic Thoraco-
centesis.
- < 1 litre.
 Closed tube Thoracostomy, water seal
drainage
Site: 1-2 space below
Upper level of fluid at
mid Axillary line.
 Empyema
Presence of pus.
Usually as spread of infection from
surrounding sites- Pneumonia, Lung abcess,
liver abscess, sub-diaphramatic abscess.
Organisms- Staph aureus (Most common)
-Pneumococcus
- H.influenzae
- Klebsiella pneuminae.
 Symptoms & Signs
Similar to pleural effusion
But patient is more toxic, high grade fever.
Signs-
- Same as pleural effusion
- Edema of chest wall
- Pus collection beneath the skinlocalised
swelling Empyema Necessitatis
- Percussion- Tenderness
 Complications
Broncho-pleural Fistula.
Pyo-pericardium
Peritonitis.
Lung abscess.
Septicemia.
Organization of puss Fibrothorax
Restrictive lung disease
 Investigation
Chest X-ray P-A view- Same as pleural effusion.
USG Chest- can differentiate between fluid &
puss, loculations.
Analysis of puss-
- Exudate character + Turbid & puss cells
- Gram stains & puss culture
- Blood counts and blood culture.
 Treatment
Continuous intercostal water-seal tube
drainage.
Appropriate antibiotic therapy-
- Empirical- Cloxacillin+ 3rd gen Cephalosporin
- Duration- 1-2 weeks, 3-4wks(Staph)
Multiple Loculation- Tube drainage+ Open/
video thoracoscopy
- Debridement/Decortication
 Pneumothorax
Presence of air
Causes- 1. Primary- Tall, teen aged boy, smoker
2. Secondary- Asthma with over-distended
alveoli
- Rupture of pneumatocele, lung abcess, cyst,
sub-pleural bleb
3. Traumatic
4. Iatrogenic- Tracheotomy/ Thracocentesis etc
 Types-
1. Closed- Ruptured pleura seals spontaneously
2. Open- Does not close spontaneously
inspiratory in and expiratory out of air.
3. Tension- Ruptured pleura acts as a valve
allows inspiratory air to go in but not the
expiratory air to go out.
 Symptoms
Respiratory distress
Chest pain.
Tension Pneumothorax- Acute onset severe
respiratory distress.
- Cold clammy extremities due to
compression on heart.
 Signs
Inspection-
- Signs of respiratory distress.
- Bulging and less movement of affected side.
Palpation-
- Shifting of mediastinum to opposite side.
- Diminished vocal fremitus.
Percussion- Hyper resonant
Auscultation- Diminished/ absent breath sound.
 Investigation
Chest X-ray P-A view in erect posture-
- Absent Broncho-vascular
markings.
- Mediastinal shifting to
contralateral side
- Collapsed lung border
 Treatment
Small one(<5% lung collapse)-
- Usually absorbed spontaneously.
Large one(> 5% lung collapse)
- Closed thoracostomy and intercostal tube
drainage under water seal management.
Tension pneumothorax- Needle insertion at
2nd intercostal space at mid-clavicular line.
Supportive management
 Hydro/Pyo-pneumothorax
Presence of both fluid/puss and air.
Etiology-Rupture of lung abscess.
- Iatrogenic- during drainage of
puss/fluid.
Symptoms are same as pleural effusion
/Empyema.
 Signs
Inspection & Palpation- Same
Percussion- Two positions- i) Supine & ii) Sitting

Hyper
resonant

Dull

Sitting Supine
 Investigation
Chest X-ray P-A view Erect posture-
- Increased blackening
& absent broncho- vascular
marking in upper part.
- Opacity in lower part.
- Horizontal level in between.
Pleural fluid analysis.
 Treatment
Closed Thoracotomy with Tube drainage-
Two drains are needed.
Pyo-pneumothorax- parenteral antibiotic
therapy.
 Haemothorax
Trauma- Blunt/ Penetrating/ Iatrogenic.
Inflammation- TB, Empyema.
Congenital lesion- PDA, Pulmonary arterio-
venous malformation
Bleeding diathesis.
Intrathoracic Neoplasm.
 Clinical Features- Same as effusion.
Diagnosis- By thoracocentesis.
Treatment- Tube Thoracostomy.
- Surgical Intervention
- Blood Transfusion.