EFUSI PLEURA

RIANA SARI
BALAI BESAR KESEHATAN PARU
MASYARAKAT (BBKPM)
SURAKARTA
 ANATOMI PLEURA

 Selaput pleura terdiri atas pleura viseral dan

pleura parietalis
 Rongga antara pleura parietal dg pleura
viseral rongga/ kavum pleura
 Normal terisi 5-10 ml cairan serous
ANATOMI PLEURA
Pleura parietalis
Menerima suply darah dari sirkulasi sistemik
terdapat akhiran serabut saraf sensoris

Pleura viseralis
Menerima suply darah dari sirkulasi pulmoner
bertekanan rendah dan tidak terdapat serabut
saraf sensoris
 DEFINISI
 PLEURITIS :
peradangan pada
pleura
 EFUSI PLEURA :
Akumulasi cairan
di rongga/ kavum
pleura
 Ada 2 jenis :
transudat &
eksudat
The mechanisms that lead to
accumulation of pleural fluid
l. Increased hydrostatic pressure in microvascular
circulation (congestive heart failure)
2. Decreased oncotic pressure in microvascular
circulation (severe hypoalbuminemia )
3. Increased permeability of the microvascular
circulation (pneumonia)
4. Impaired lymphatic drainage from the pleural
space (malignant effusion)
5. Movement of fluid from peritoneal space ( ascites )
6. thoracic duct rupture (chylothorax)
 Pathophysiology of Pleural Effusion

capillary pressure
or capillary permeability=
plasma proteins Exudate

Formation of excess fluid= Accumulation of pus

Transudate in the pleural space=Empyema

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 Two kinds of pleural effusions
Transudates and exudates
Transudate Exudate
• Cause non-inflammatory Inflammatory,tumor
• Apperance light yellow yellow, purulent
• Specific gravity <1.018 >1.018
• Coagulability unable able
• Rivalta test negative positive
• Protein content <30g/L >30g/L
ΘPL. To serum < 0.5 > 0.5
• LDH < 200 I U/ L > 200 I U / L
Θ PL. To s < 0.6 > 0.6
• Cell count < 100×10 6/ L > 500×10 6 / L
• Differential cell Lymphocyte Different
 Light’s Criteria
Pleural fluid is exudate if one or more:
 Pleural fluid protein : serum protein > 0.5
 Pleural fluid LDH : serum LDH > 0.6
 Pleural fluid LDH > 2/3 upper limit normal
serum LDH
 Transudate
• Non-inflammatory
• Trans means movement of
fluid due to changes in
pressure gradients
• What do you remember
about oncotic pressure and
serum albumin levels???
• What is hydrostatic pressure?
1/21/2018
vs Exudate
• Inflammatory in nature
• Exudate means there is a
release of fluid.
• Exudative pleural effusion are
due to changes in capillary
permeability.
• The capillaries are inflammed
and are not as selective and
allow fluid to leak into the
pleural space.
9
 • Let’s try to classify Transudative or
Exudative Pleural Effusion….
• Etiology of Pleural Effusions:
– Congestive Heart Failure
– Liver Disease
– Renal Disease
– Lupus, Rheumatoid Arthritis
– Pneumonia
– TB
– Lung Cancer
– Trauma
– ARDS

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Diagnostic procedures

•History(primary diseases)
•clinical signs
•physical examinations
Clinical Manifestations
of Pleural Effusion

• Dyspnea
• Pleurisy
• Decreased breath
sounds
• Decreased chest wall
movement

1/21/2018
 clinical signs
 pleural pain,
 dyspnea,
 tachypnea,
 mild outward bulging of the intercostal spaces,
 decreased tactile fremitus,
 dullness or flatness,
 decreased transmission of breath and vocal
sounds in the area of the effusion,
 and occasionally pleural friction sound in its
early stage (dry pleurisy)
 Examination
Inspection
Tachypneic,, Bulging of affected side, Reduced chest
expansion
and movement
Palpation
Displacement of trachea and apex to the opposite side,
Decreased
vocal fremitus,
Percussion
Stony dull percussion
Auscultation
Absent or diminshed breath sounds, Reduced vocal
resonance, Crackles above effusion
 Diagnostic procedures
Chest X-ray
examination
Blunting of the
normally sharp
costophyrenic angle

a concave shadow with

its highest margin along
the pleural surface

shift of the mediastinum

and the trachus toward the
normal side
Location of effusion-amount of fluid
– 75 mL-subpulmonic space without spillover, can obliterate
the posterior costophrenic sulcus,
– 175 mL is necessary to obscure the lateral costophrenic
sulcus on an upright chest radiograph
– 500 mL will obscure the diaphragmatic contour on an
upright chest radiograph;
– 1000 ml of effusion reaches the level of the fourth anterior
rib,
– On decubitus radiographs and CT scans, less than 10 mL,
and possibly as little as 2 mL, can be identified
Chest x ray vs CT Scan
Diagnostic procedures

Ultrasonic examination
To localize a small pleural effusion and
determine the correct site for performance
of a thoracentesis
Thoracentesis
To aspirate the effusion for therapeutic & laboratory
examination
Pleural biopsy
To obtain a specimen for histologic
examination and culture
USG Chest
 Tuberculous pleural effusion

• TB remains the most common cause of

pleural effusion in young people
• Etiology: tubercle bacillus
• Pathogenesis: host hypersensitivity to
tubercular protein in pleural tubercles
• Delayed hypersensitivity
• ATA & corticosteroid
Parapneumonic Effusion
 Most common cause of exudative pleural
effusion
 Treated conservatively
 Chest tube intubation indicated in case of
following
– Gross pus in pleural space
– Pleural fluid gram stain and culture
– Pleural fluid glucose less than 60
– PH less than 7.2
 Malignant Effusions
• Clinical features suggestive of malignacy:
Symptoms> 1mo, absence of fever, blood-tinged fluid, chest CT
suggesting malignancy
• Lung >breast > lymphoma/leukemia
• metastatic adenocarcinoma positive cytology 70%
• Lymphoma 25-50%
• Mesothelioma 10%
• Squamous Cell Carcinoma 20%
• Sarcoma within pleura 25%
• Pleural fluid: bloody, lymphocytic, decreased or nl glucose and pH,
cytology
 Treatment
Treatment for many pleural effusions, whether
transudates or exudates is primarily for the
underlying pulmonary or systemic disease:
 aspiration of fluid is usually indicated
to establish the diagnosis
 It is also therapeutically used to relieve
dyspnea from a large effusion
 Treatment
• Transudative Effusion: focus on the systemic cause
• Exudative Effusion: dependent on the exact sub-type
• Consider Chest Thoracostomy
• Gross Pus / Empyema
• pH < 7.2
• Hemothorax
• Complicated Parapneumonic Processes
• Malignant Effusions…but remember the role of
pleurodesis!
 Thoracentesis
• Also indicated in a patient with CHF if any of the
following are present.
 A unilateral effusion, particularly if it is left-sided,
 Bilateral effusions, but are of disparate sizes
 There is evidence of pleurisy or fever
 The cardiac silhouette appears normal on CXR
 If no response to diuresis in 48-72 hrs.
 The alveolar-arterial oxygen gradient is widened out
of proportion to the clinical setting
 Thoracentesis.,
Contraindications
None obsulute.
Relative include
• Patient on anticoagulation or with bleeding diathesis
• Very small volume of fluid.
• Patients are mechanical ventilation though not at
increased risk for pneumothorax are at high risk for
tension pneumothorax or persistent airleak.
• Active skin infection at the port of entry.
EMPYEMA
 DEFINITION

Pleural empyema
or
thoracic empyema

The inflamatory process in a preformed

anatomical space defined by the visceral
and parietal pleura
 Empyema
 Thick purulent fluid with more than 100,000
cells per cubic millimeter or fluid with PH
values less than or equal to 7. 20 should
be treated as a presumptive empyema
 The general objectives of therapy of empyema
are the elimination of both the systemic and
local infection.
ETIOLOGY OF PLEURAL EMPYEMA
Etiology %
Purulent pneumonia 50
Lung abscess rupture 1-3
Sepsis 1-3
Pulmonary tuberculosis 1
Mycotic lung infection 1
Trauma 3-5
Pulmonary, esophageal and mediastinal 25
surgery
Subphrenic abscess 8-11
Bronchial fistula causing spontaneous <1
pneumothorax
Complications of parasitic invasion <1
Others 1
 PLEURAL EMPYEMA
(empyema pleurae)

MICROBILOGY - BACTERIOLOGIC AGENTS:

Most common bacteriologic agents :
 pneumococus
 staphylococus
 streptococus
 haemophilus influenzae
 Gram-negative bacteria (pseudomonas, klebsiella,
enterobacteriace,escherichia coli)
 anaerobic bacteria
 mixed bacterial flora
 PLEURAL EMPYEMA
(empyema pleurae)
PATHOPHYSIOLOGY – ways of infection :

DIRECT INFECTION
through the chest wall as a result of
injury, thoracocentesis or surgical management (postoperative
pleural empyemas constitute approximately 25% of pleural
empyema cases)
CONTACT INFECTION
infection spreads from underlying
infected pulmonary parenchyma, lung abscess, bronchiectases,
subphrenic or perinephric abscess.
HEMATOGENOUS SPREAD
LYMPHOGENOUS SPREAD
 PATHOPHYSIOLOGY
PHASES OF PLEURAL EMPYEMA FORMATION
Serous phase (exudative empyema
clear, straw-colored effusion (pH>7.3, glucose
concentration [GLU]>60 mg%, lactate
dehydrogenase activity [LDH] < 500 U/L )

Fibrinopurulent phase (fibrinopurulent

empyema):
effusion contains large numbers of bacteria
polymorphonuclear granulocytes, intensification
of clinical signs and symptoms of inflammation,
deposition of fibrin on both the visceral and
parietal pleura ( pH < 7,1, GLU < 40mg%,
LDH > 1000 U/L)
 PATHOPHYSIOLOGY

Organizing empyema phase

(organizing empyema)
(fibrothorax)
nonelastic, fibrinopurulent coat that imprisons the
lung appears.
An empyema capsule contains pus.
PLEURAL EMPYEMA PHASES
 CLASSIFICATION OF PLEURAL
EMPYEMAS
Etiological classification:
 specific (tuberculosis)
 non-specific – non-specific bacterial infection
 mixed
 mycotic
Size criterion:
 non-localized empyemas – the whole pleural
cavity is involved
 localized (encapsulated) empyemas - (
unilocular or multilocular)
 CLASSIFICATION OF PLEURAL
EMPYEMAS
Duration and pathologic criterion :
 acute empyema
 chronic empyema
Jatrogenic empyemas:
 empyemas with preserved
pulmonary parenchyma
 empyemas after lung resection
(pneumonectomy)
 CLINICAL PRESENTATION

ACUTE PHASE CHRONIC PHASE

hectic fever subfebrile body
shivering
dyspnea
temperature
toxemia cachexia
chest pain low body mass
tachypnoë paroxysmal cough
asthenia
lack of appetite dyspnea
weight loss contraction of
chest wall inflammation intercostal spaces
(sometimes)
leucocytosis
scoliosis
anemia chest pain
expectoration of attenuation of
purulent sputum respiratory murmur
( if bronchial fistula
coexists) dullness of sound
DIAGNOSIS
 characteristic clinical presentation
 features of hydrothorax
in physical examination
 chest X-ray
 pleural ultrasonography
 computed tomography
 diagnostic thoracocentesis
( macroscopic features of liquid, positive bacterial cultures, glucose
concentration< 40 mg/dl, pH<7,0, LDH > 1000 U/L)
 flexible bronchoscopy (useful in a case of bronchial fistula)
 needle pleural biopsy
 diagnostic videothoracoscopy
 diagnostic thoracotomy
 TREATMENT
The goals of treatment in pateints with pleural
empyema are :

1. to save life
2. to elimintae the empyema
3. to reexpand the trapped lung
4. to restore the mobility of the chest wall and
diaphragm
5. to return respiratory functionto normal
6. to eliminate complications and chronicity
7. to reduce the duration of hospital stay
 Treatment of pleura empyeme
Thoracocentesis

Clear liquid Not clear or purulent effusion

pH>7.20 pH<7.20 Not loculated Loculated

No intervention Reccurent thoracocentesis Drainage Drainage

Pleural lavage Pleural lavage
Fibrinolytics

Failure
VATS
Surgery

Hamm et al, ERJ 1997

 COMPLICATION
 atelectasis and respiratory insufficiency
 bronchopleural fistula
 pleurocutaneous fistula
 pleuroesophageal fistula
 sepsis
 peritonitis
 metastatic abscesses
 purulent inflammation of the chest wall
 progressive respiratory insufficiency
 PROGNOSIS
• Mortality in patients with pleural empyema ranges from
1% to 19%.
• A reason for death in an acute phase of empyema is
sepsis or other complications of generalized infection
• Late deaths are caused by toxemia, respiratory
insufficiency or multiorgan failure.
• In patients with concomitant diseases such as diabetes
mellitus, malnutrition, systemic diseases, malignancy and
alcoholism mortality reaches 40%.
 JELAS...?
ADA PERTANYAAN..?
MEKANISME FORMASI – RESORBSI CAIRAN
PLEURA
Parietal Visceral
pleura pleura
Hydrostatic Pressure of pleural 11
pressure(30) space (5)

Permeability
of systemic Permeability of pleural 34
circulation(34) fluid (8)

5+8+30-34=9 34-(5+8+11)=10