Pleural effusion and Empyema

Transcription

1 Pleural effusion and Empyema DR BINOD KUMAR SINGH Associate Professor, PMCH, Patna CIAP Executive board member NNF State president,bihar IAP State secretary,bihar NNF State secretary,bihar Fellow of Indian Academy of Pediatrics (FIAP) Chief consultant Shiv Shishu Hospital Address:K-208, P.C Colony.Hanuman Nagar, Patna Web site :

2 Dry or plastic pleurisy Pleurisy is inflammation of pleura and it may be accompanied by an effusion.

3 Etiology Bacterial pneumonia tuberculosis Heart failure Rheumatologic causes Metastatic intrathoracic malignancy Aspiration pneumonitis Uremia Connective tissue disorder Pancreatitis Subdiaphragmatic abscess

4 Pathology and pathogenesis It usually involves visceral pleura with small amounts of yellow serous fluid In case of tuberculosis the adhesions develop rapidly and pleura is often thickened.

5 Clinical manifestations Pain is most common symptom and exaggerated by deep breathing, coughing and straining and is dull ache. Pain with breathing is responsible for grunting and guarding of respiration. Leathery, rough and inspiratory and expiratory friction rub may be audible.

6 Laboratory finding Chest radiograph show diffuse haziness at pleural surface or a dense, sharply demarcated shadow. Ultrasonography- useful in differentiating it from loculated effusion CT scan can diagnose mininal effusion.

7 Treatment Therapy should be aimed at underlying disease In pneumonia neither immobilization of chest with adhesive plaster nor cough suppressant is indicated. Analgesic agents may be helpful. Strapping of chest- to restrict expansion to relief pain only if pneumonia is not present.

8 Serofibrinous or serosanguineous Pleurisy Serofibrinous pleurisy is defined as -- fibrinous exudate on the pleural surface and exudative effusion of serous fluid into pleural cavity.

9 Etiology Bacterial pneumonia Tuberculosis Connective tissue disorders Primary or metastatic neoplasm

10 Pathogenesis -Normally, only 4-12ml of fluid is present in pleural space. -Pleural inflammation increases the permeability of pleural surface with increased proteinaceous fluid formation.

11 Clinical manifestations Patient may be asymptomatic in case of small effusion. Symptoms--Cough, dyspnea, retractions, tachypnea, orthopnea or cyanosis. On inspection --there will be decrease movements of chest, fullness of intercostal space. Palpation: Mediastinal shifting, decrease chest expansion and decrease tactile fremitus. Percussion: Dullness Auscultation: decrease or absent breath sounds and resonance

12 Investigations Chest radiography show homogenous density obliterating normal marking of underlying lung. Small effusions may cause obliteration of costophrenic and cardiophrenic angles or widening of intercostal space Ultrasonography in case of small and loculated effusion Examination of fluid for cells, sugar, proteins, gram staining, culture, LDH, ph.

13 Right sided pleural effusion

14 Difference between transudate and exudate

15 Light criteria for exudate Pleural fluid total protein/ serum protein >0.5 Pleural total protein > 3g/dl. Pleural fluid LDH/serum LDH > 0.6 Pleural fluid LDH > 200 IU/l. Pleural fluid LDH level > 2/3 of upper normal level of serum LDH

16 Treatment Treat the underlying cause In case of large effusion, drainage is done Maximum amount of fluid to be removed is 1 litre. Indication of chest tube drainage are ph < 7.20 Pleural fluid glucose < 50mg/dl

17 Empyema Empyema is accumulation of pus in pleural space Etiology Pneumonia caused by Streptococcus pneumoniae and Staph aureus. Group A streptococcus, Gram negative organisms, Tuberculosis, Fungi and malignancy

18 Pathology Exudative stage Rapid accumulation of inflammatory fluid and is of fibrinous exudate. Fibrinopurulent stage Fibrinous septa form and cause loculation and thickening of pleura Rarely pus dissect into chest wall leads to empyema necessitansi Organization stage (fibrothorax) Fibroblast proliferation between pleural layers

19 Clinical manifestations Primary signs & symptoms of pneumonia. Most patients are febrile, develop increased work of breathing or respiratory distress, and often appear more ill. Clinical manifestations are more or less likely pleural effusion type.

20 Cough, dyspnea, retractions, tachypne, orthopnea or cyanosis. On inspection there will be decrease movements of chest, fullness of intercostal space. Palpation: Mediastinal shifting, decrease chest expansion and decrease tactile fremitus. Percussion: Dullness Auscultation: decrease or absent breath sounds and resonance

21 Investigations Similar to other effusion radiologically. Pleural fluid analysis is must to differentiate. Characteristic of pus : -Bacteria are present on Gram staining. -ph is < >100,000 neutrophils/µl. Pleural fluid culture & PCR analysis to identify organism.

22 Empyema right side

23 CT chest with effusion USG chest with pleural effusion

24 Treatment Systemic antibiotics. Depends on culture & sensitivity report. Closed tube drainage. VATS Open decortication.

25 Indication of VATS In the child who remains febrile and dyspneic >72 hr after initiation of therapy with intravenous antibiotics and thoracotomy tube drainage

26 Pneumothorax Pneumothorax is the accumulation of extrapulmonary air within the chest. Most commonly from leakage of air from within the lung. Pneumothorax can be primary or secondary and can be spontaneous, traumatic, iatrogenic or cataminial.

27 Etiology and epidemiology Primary spontaneous pneumothorax occur without trauma or underlying lung injury. Familial cases of spontaneous pneumothorax occur and have been associated with mutations of folliculin gene. Patients with collagen synthesis defects are prone to develop pneumothorax.

28 Secondary pneumothorax: as a complication of an underlying lung disease like in ----pneumonia, -secondary to pulmonary abscess, -gangrene, -infarct, - rupture of cyst, - emphysematous blebs, - foreign body. External chest trauma, crack cocaine and marijuana abuse are associated with pneumothorax.

29 Iatrogenic pneumothorax as a complication of transthoracic needle aspiration, tracheotomy, subclavian line placement, thoracentesis, after mechanical and noninvasive ventilation, high flow nasal cannula. Catamenial pneumothorax- is an unusual condition related to menses, is associated with diaphragmatic defects and pleural blebs.

30 Pathogenesis In normal people, the pressure in pleural space is negative during the entire respiratory cycle. Two opposite forces result in negative pressure in pleural space. Inherent outward pull of the chest wall and inherent elastic recoil of the lung. The negative pressure will be disappeared if any communication develops.

31 When a communication develops between an alveolus or other intrapulmonary air space and pleural space, air will flow into the pleural space until there is no longer a pressure difference or until the communication is sealed.

32 Clinical features Symptoms Abrupt onset. Severity depends on : Extent of lung collapse. Amount of pre-existing lung disease. Pain severity of pain does not reflect extent of collapse. Dyspnea. Cyanosis Symptoms and sign difficult to recognise in infants.

33 Signs Respiratory distress, retractions. Decrease chest movements during the respiration. Tactile fremitus is absent. The percussion note is hyperresonant. The breath sounds are reduced or absent on the affected side. The trachea may be shifted toward the contralateral side if the pneumothorax is large.

34 Diagnosis and differentials -The diagnosis of pneumothorax is usually established by radiographic examination. -Tension pneumothorax includes shifting of mediastinal away from side of air leak. -Computer tomography may identify underlying pathology such as blebs.

35 Right sided pleural effusion

36 Localized or generalized emphysema An extensive emphysematous bleb Large pulmonary cavities Cystic formations Diaphragmatic hernia Compensatory overexpansion with contralateral atelectasis.

37 Treatment Oxygen administration Analgesic treatment for pleural pain Needle aspiration on emergency basis for tension pneumothorax. Tube thoracotomy. Both needle aspiration and tube thoracotomy are equally effective.

38 Indication of chest tube drainage Recurrent pneumothorax. Secondary pneumothorax. > 5 % of collapse. Closed thoracotomy and drainage of trapped air through a catheter, the external opening of which is kept under dependent position under water.

39 Chemical pleurodesis Indications Persistant air leak and repeated pneumothorax Bilateral pneumothoraces Complicated with bullae Lung dysfunction, not tolerate to operation Sclerosing agents Tetracycline, Minocycline, Doxycline, Talc Erythromycin The instillation of sclerosing agents into the pleural space should lead to an aseptic inflammation with dense adhesions.

40 Video assisted thoracoscopic surgery Preferred therapy for blebectomy Pleural stripping Pleural brushing And instillation of sclerosing agents. But there is risk of recurrence after video assisted thoracoscopic surgery.

41 Foreign body aspiration Foreign body (FB) aspiration into the airway is one of the dramatic pediatric emergencies. Incoordination of swallowing leads to aspiration. Depending on size, shape and nature, the aspirated FB lodges in the larynx, trachea or bronchial system. Children younger then 3 years of age accounts for 73 % of cases.

42 Food items are the commonest (65-85%) FB encountered like toffee, chocolate and lozenges draw water from mucosa, swell and produce progressive obstruction.

43 Certain anatomical and cognitive constraint predispose the child for aspiration: (a) Oral phase i.e. tendency to take everything into mouth (b) Poor mastication (c) Inadequate control of deglutition (d) Crying /laughing while eating (e) Certain parental behaviour patterns like thumping or spanking while feeding, feeding a crying child, etc. Loss of co-ordination during swallowing results in aspiration of foreign bodies into the airway. In 90% of such occasions FB are coughed out by strong cough reflex, in only 10% it gets lodged in the airway.

44 Clinical Manifestations Three stages have been recognized in the symptoms of FB aspiration: 1. Initial events- immediately after aspiration, the child develops violent cough, stridor, respiratory distress and/ or wheezing. 2. Asymptomatic interval : The foreign body get lodged, reflexes fatigued. It's during this phase that FB aspiration is either forgotten or neglected. This stage may last from hours to weeks.

45 3. Complications in the form of secondary effects of airway obstruction erosions and secondary infection. Only 25% of patients present within 24 hours of aspiration.

46 Clinical features depend on site and duration since aspiration of foreign body 1. Commonly the FB may lodge in the bronchial tree (80-90%). In children right and left side are involved equally. The clinical presentation of bronchial foreign bodies depends on the severity of obstruction The common modes of presentation of bronchial FB are: (a) (b) (c) Acute respiratory distress; Recurrent respiratory symptoms; Chronic respiratory illness.

47 Usually the child recovers from acute phase and presents later in one of the following ways The clinical and radiologic features include obstructive emphysema. Recurrent Pneumonia, non-resolving pneumonia. Recurrent wheeze, recurrent hemoptysis, lung abscess, or bronchiectasis

48 2. In 10-20% cases, the FB can lodge in the larynx or trachea. These patients usually present with acute life threatening upper airway obstruction characterized by stridor, choking hoarseness, cough, dyspnea.

49 Investigations 1. Chest X-ray(CXR): 80% of laryngeal & tracheal FB and 15-28% of bronchial FB can have normal CXR. Obstructive emphysema, segmental or lobar collapse and pneumonia are useful diagnostic findings. A radiopaque FB is seen in only 10-25%patients.

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52 2. CT scan: for radiolucent foreign body 3. Bronchoscopy : when there is high index of suspicion, but the images study is negative then bronchoscopy should be performed.

53 Children above 1 year (Heimlich maneuver): 6-10 abdominal thrusts, visualize pharynx-- if FB is seen, extract. If failed, give rescue breathing, then repeat the above procedure.

54 Bronchoscopy Once stabilized the child is kept nil orally. Oxygen should be administered in cases with respiratory distress. Dehydration, dyselectrolytemia and acid-base disturbances should be corrected before bronchoscopy. Rigid bronchoscopes preferred

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