PLEURAL EFFUSIONS

Anatomy of pleural membrane

and pleural space 1234

 Pleural membrane consists of parietal

pleura and visceral pleura
 A space situated between parietal and
visceral pleura is called pleural space
 It is normally filled with 5 - 10 milliter
of serous fluid
Anatomy of pleural membrane
and pleural space 1234
Parietal pleura
Receiving its blood supply from the
systemic circulation and containing
sensory nerve ending
Anatomy of pleural membrane
and pleural space 1234

Visceral pleura
Receiving its blood supply from the low
pressure pulmonary circulation and
containing no sensory nerve fibers
 Mechanism of formation-resorption
of pleural fluid
Parietal Visceral
pleura pleura
Hydrostatic Pressure of pleural
pressure(30) 11
space (5)

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

5+8+30-34=9 34-(5+8+11)=10
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 )
 Two kinds of pleural effusions
Transudates and exudates
Transudate Exudate
 Cause non-inflammatory flammatory,tumor
 Apperance light yellow yellow, purulent
 Specific gravity <1.018 >1.018
 Coagulability unable able
 Revalta test negative positive
 Protein content <30g/L >30g/L
 ΘP. To serum Pre < 0.5 > 0.5
 LDH < 200 I U/ L > 200 I U / L
 Θ P. To s < 0.6 > 0.6
 Cell count < 100×10 6/ L > 500×10 6 / L
 Differential cell Lymphocyte Different
Common causes of pleural effusions
Transudates
1. Generalized salt and water retention, e.g.,
congestive heart failure, nephrotic syndrome,
hypoalbuminemia
2. Ascites, e.g.,
cirrhosis, meigs' syndrome, peritoneal dialysis
3. Vascular obstruction, e.g.,
superior vena cava obstruction
4. Tumor
Exudates
l. Infectious diseases, e.g.,
TB, bacterial pneumonias, and other
infectious diseases.
2. Tumor
3. Pulmonary infarction
4. Rheumatic diseases
Haemorrhagic effusion
l. Trauma
2. Tumor
3. Pulmonary infarction
4. TB
5. Spontaneous pneumothorax
Chylous effusion
1. Trauma
2. Tumor
3. TB
4. Thrombosis of the left subclavian vein
Empyema
l. TB
2. Pulmonary infection
3. Trauma
4. Esophageal rupture
Bilateral effusion
1. Generalized salt and water retention
e.g., congestive heart failure
nephrotic syndrome
2. Ascites
3. Pulmonary infarction
4. Lupus erythematosus
e.g., rheumatoid arthritis
5. Tumor
6. TB
 T B ( Tuberculosis ) is the most
common cause of pleural effusion ,
especially in young people
 Malignant pleural effusion is frequently
met in aged people today
 Pleural transudation is most commonly
caused by congestive heart failure
Diagnostic procedures 12345

History(primary diseases)
clinical signs

physical examinations
 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)
Diagnostic procedures 12345
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
Pleural effusion
Diagnostic procedures 12345

Ultrasonic examination
To localize a small pleural effusion and
determine the correct site for performance
of a thoracentesis
Diagnostic procedures 12345
Thoracentesis
To aspirate the effusion for laboratory
examination:
Appearance, Specific gravity, Protein content,
Cell counts, Glucose, LDH lipid content,
Rheumatoid factor (RF),
Adenisine deaminase (ADA),
Lupus pleuritis (LE) cells,
Gram stain and culture,
Cytologic examination, etc.
Diagnostic procedures 12345

Pleural biopsy
To obtain a specimen for histologic
examination and culture
胸腔积液诊断思路
有无胸腔积液 ?
胸穿抽液

漏出液 ? 渗出液 ?
分析病因

针对病因治疗
 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 dys
pnea from a large effusion
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
Clinical Manifestations
 Generalized symptoms of toxicity of TB:
Fever, high sweat, fatigue and weight loss, etc.
 Those of pleural effusion:
Pleuritic pain, short breath and dyspnea, etc.
 Pleural fluid is exudative and usually
reveals lymphocytosis
 Rarely pleural fluid is blood stained
 The PPD or OT test usually positive
 Diagnosis

 Based on mentioned findings and some

examinations of pleural fluids,
and culture of material obtained at biopsy
of the pleura and pleural fluids.
 except for pleural effusions caused by
other causes.
Treatment

(1) Standard antituberculous regimens

( usually short course of antituberculous
chemotherapy is used )
(2) Administration of corticosteroid
during the first several weeks of
treatment
(3) Thoracentesis
 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.
Treatment of acute empyema

(1) Control of infection

systemic and local
(2) Repeated thoracentesis or
drainage of the empyema
(3) Chronic empyema is primarily
treated operatively

(4) Operative therapy is also indicated

in the empyema with associated
bronchopleural fistula or with the
ipsilateral ruined lung.
Treatment of malignant pleural
effusion

 Use systemic anti-tumor medicines

 Local treatments
 临床病例
 病史 :
 主诉 : 发热、乏力、消瘦一月伴咳嗽气急一天
 现病史：患者于一月前无明显诱因下出现发热
，体温高峰 38-39℃ ，以午后始发热为主，同
时伴乏力消瘦，一直未予以诊治，于入院前一
天出现明显咳嗽和气急，外院胸部 X 线显示右
侧胸部大片密度增高影，纵隔向右侧移位。遂
收入院。
 既往无其他慢性疾病史。
 体格检查
 一般情况：精神差，消瘦，
 T ： 38.3℃, P80 次 / 分 ,R20 次 / 分 ,BP90/60mmHg
 胸部体征：望诊：右侧呼吸运动减弱，右侧饱满
　　　　　　触诊：气管向左侧移位，右侧呼吸活动　　　　　
　　　　　　　　　　　　　　度减弱，触觉语颤减弱
　　　　　　叩诊：呈实音
　　　　　　听诊：右侧呼吸音消失