eff pleura & pneu kuliah kbk sm v
TRANSCRIPT
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Pulmonology & Respiratory Medicine DepartementBrawijaya University/Saiful Anwar Hospital
Malang
PLEURAL EFFUSION
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DEFINITION
Pleural effusions, the result of the
accumulation of fluid in the pleural space
Normally, pleural fluid in pleural cavity amount 1-20 ml.
Pleural fluid in pleural cavity is constant. There is
equlibrium between production and absorsption bypleural viceralis.
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CAUSES OF A PLEURAL EFFUSION
Pleural Effusion can be caused by severalmechanisms: increased permeability of the pleural membrane
increased pulmonary capillarpressure
decreased negative intrapleural pressure decreased oncotic pressure
Obstructed lymphatic flow
Pleural effusion indicate the presence of disease which may be
Pulmonary, pleural or extrapulmonary 3
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CLASSIFIED OF PLEURAL EFFUSION
Transudative Exudative
Lights criteria
Most accurate way of
differentiating
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Lights criteria criteria a
The pleural fluid is an exudate if one or more of
the following criteria are met:
Pleural fluid protein divided by serum protein >0.5
Pleural fluid LDH divided by serum LDH >0.6
Pleural fluid LDH more than two-thirds the upper limits
of normal serum LDH
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CAUSES OF TRANSUDATIVE PL.EFFUSION
Very common causes Left ventricular failure
Liver cirrhosis
Hypoalbuminaemia
Peritoneal dialysis
Less common causes Hypothyroidism Nephrotic syndrome
Mitral stenosis
Pulmonary embolism
Rare causes
Constrictive pericarditis Urinothorax
Superior vena cava obstruction
Ovarian hyperstimulation Meigs syndrome
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CAUSES OF EXUDATIVE PL.EFFUSION
Common causes
Malignancy
Parapneumonic effusions
Less common causes
Pulmonary infarction Rheumatoid arthritis
Autoimmune diseases
Benign asbestos effusion
Pancreatitis
Post-myocardial infarction syndrome Rare causes
Yellow nail syndrome
Drugs
Fungal infections
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DIAGNOSTIC (1) History taking and physical examination
Fluid < 300 cc, The symptom is disappear
The fluid >300 cc, The symptom are decreasing movement
of hemithoraks, stem fremitus and breath sound decrease,or disappear.
Pleural fluid > 1000 cc can cause the chest more convexthan contralateral, auscultation egophoni
The fluid >2000 cc push the mediastinum to the normalsite
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DIAGNOSTIC (2) Plain radiography
PA and lateral chest radiographs should be performed
Ultrasound findings Ultrasound guided pleural aspiration should be used as
a safe and accurate method of obtaining fluid if
the effusion is small or loculated.
Fibrinous septations are better visualised onultrasound
CT Scan
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DIAGNOSTIC (2) A diagnostic pleural fluid sample should be gathered
with a fine bore (21G) needle and a 50 ml syringe. The
sample should be placed in both sterile vials and
blood cultur bottles and analysed for protein,
lactatdehydrogenase (LDH, to clarify borderline,
protein values), pH, Gram stain, AFB stain, cytology,
and microbiological culture.
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DIFFERENTIAL DIAGNOSIS Lung Tumor
Swarte/Tickening of pleuraAtelectasis inferior lobe
High level potition of diaphragma
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COMPLICATION Complication of pleural effusion depend on
underlying desease :
Empiema
Swarte
Respiratory failure
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Management
The management of pleural effusion depend onmanagement of underlying desease andthoracocentesis.
Thoracocentesis indication:
Release of Shortnes of breath that caused by fluidaccumulation
Diagnosis with examine the pleural fluid
Thoracocentesis pleural fluid in the firsttime not more than 1000 cc, can resultlung edema with symptom cough anddyspnea.
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continued..
Lack of thoracocentesis:
Thorakosentesis can cause lost of protein
Infection (empyema)
Pneumothoraks
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EMPYEMA (1)
Definition: Presence of pus in the pleural space
Causes: Direct extension of a pulmonary parenchymal infection
into pleural space
Post surgical infection
Trauma From abdominal infection (ex: subdiaphragmatic
abscess)
Complication of thoracosinthesis or pleural biopsy
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About half of the empyema isolatesconsist of only anaerobic bacteria and
the other half of mixed anaerobic andaerobic organism.
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EMPYEMA (2) Symtoms
Usually non specific 80% : dyspnea and fever
70% : cough and chest pain
Constitusional complaint : weight loss, fatigue, malaise
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THERAPY
Appropriate antibiotic therapy
Initial choice of antibiotic depends on clinical settingand should be guideed by the result of the gram stain ofpleural fluid and sputum
Adequate pleural drainage
Chest tube placement (WSD) Thoracosintesis
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HEMOTHORAX Definition:
Presence of significant amount of blood in the pleuralspace
Causes:
Most comman: trauma (penetrating or penetrating)
Occasionally iatrogenic prosedure Uncomman: malignancy, during unticoagulant therapy
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CHYLOTHORAX True chylous effusions result from disruption of the
thoracic duct or its tributaries. This leads to thepresence of chyle in the pleural space
Chylothorax must be distinguished frompseudochylothorax or cholesterol pleurisy which
results from the accumulation of cholesterol crystals ina long standing pleural effusion
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CAUSES OF CHYLOTHORAX AND
PSEUDOCHYLOTHORAX
Chylothorax Pseudochylothorax
Neoplasm: lymphoma,metastatic carcinoma
Trauma: operative,penetrating injuries
Miscellaneous: tuberculosis,sarcoidosis,
lymphangioleiomyomatosis,cirrhosis, obstruction ofcentral veins, amyloidosis
Tuberculosis
Rheumatoid arthritis
Poorly treated empyema
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MALIGNANT PLEURAL EFFUSION Malignant pleural effusion is a condition in which
cancer causes an abnormal amount of fluid to collect
between the thin layers of tissue (pleura) lining theoutside of the lung and the wall of the chest cavity. Lungcancer and breast cancer account for about 50-65% ofmalignant pleural effusions[1]. Other common causes
include mesotheliomaand lymphoma.
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http://en.wikipedia.org/wiki/Cancerhttp://en.wikipedia.org/wiki/Pleurahttp://en.wikipedia.org/wiki/Chest_cavityhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Breast_cancerhttp://en.wikipedia.org/wiki/Malignant_pleural_effusionhttp://en.wikipedia.org/wiki/Mesotheliomahttp://en.wikipedia.org/wiki/Lymphomahttp://en.wikipedia.org/wiki/Lymphomahttp://en.wikipedia.org/wiki/Mesotheliomahttp://en.wikipedia.org/wiki/Malignant_pleural_effusionhttp://en.wikipedia.org/wiki/Malignant_pleural_effusionhttp://en.wikipedia.org/wiki/Malignant_pleural_effusionhttp://en.wikipedia.org/wiki/Breast_cancerhttp://en.wikipedia.org/wiki/Breast_cancerhttp://en.wikipedia.org/wiki/Breast_cancerhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Chest_cavityhttp://en.wikipedia.org/wiki/Chest_cavityhttp://en.wikipedia.org/wiki/Chest_cavityhttp://en.wikipedia.org/wiki/Pleurahttp://en.wikipedia.org/wiki/Cancer -
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Pulmonology & Respiratory Medicine Departement
Brawijaya University/Saiful Anwar Hospital
Malang
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PNEUMOTHORAX
Pneumothorax is defined as air in the pleuralspace.
Classification: Based on occurrence:
Arrtificial
Traumatic
Spontaneous
Based on kind of fistel: Open pneumothorax
Close pneumothorax
Ventile pneumothorax
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SPONTANEOUS PNEUMOTHORAX
Primary pneumothorax
arise in otherwise healthy people without any lungdisease.
subpleural blebs and bullae are likely to play a role in thepathogenesis since they are found in up to 90% of casesof primary pneumothorax at thoracoscopy orthoracotomy and in up to 80% of cases on CT scanning
Secondary pneumothotax
pneumothoraces arise in subjects with underlying lungdisease
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SECONDARY PNEUMOTHORAX
More serious than spontaneous primary pneumothorax,because it further decrease the pulmonaryfunction of apatient whose reserve is already diminished
The preseent of the underlying disease makes themanagement pneumothorax more dificcult.
Causes:
COPD >> Lung tumor
Tuberculosis
Other pulmonary infection
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DIAGNOSTIC TUMOR
COLLAPS TREATMENT IN
LUNG TUBERCULOSIS
Adakalanyadisertai deng
-Pneumoperitoneum
-phrenikus tripsi
( n phrenikus dilumpuhka
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OPEN PNEUMOTHORAX
Is pneumothorax that there is connection between pleuralcavity and bronchus
Expiration +2 30 minutes +2Inspiration -2 -2
NORMAL:Expiration -4 -9 cm H2O
Inspiration -8 -12 cm H2O
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CLOSED PNEUMOTHORAX pneumothorax that there is no connection between
pleural cavity and bronchus
Expiration -4 30 minutes -4
Inspiration -12 -12
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VENTIL PNEUMOTHORAX
Tension pneumothorax occurs because the opening thatallows air to enter the pleural space functions like a valve,and with every breath more air enters and cannot escape.
Severe hypoxia follows, with a resultant drop in bloodpressure and level of consciousness
Expiration +2 30 min -4 30 min +10
Inspiration -12 -12 +6
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DIAGNOSIS VENTIL PNEUMOTHORAX (1)
Symptoms and signs of tension pneumothorax mayinclude the following:
Chest pain (90%)
Dyspnea (80%)
Anxiety
Acute epigastric pain (a rare finding)
Fatigue
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DIAGNOSIS VENTIL PNEUMOTHORAX (2)
Physical
Respiratory distress or respiratory arrest unilaterally
Tachycardia
Hypotension
Pulsus paradoxus
Increasing of JVP
Trachea, cardiac deviation
Cardiac arrest associated with asystole or pulselesselectrical activity
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DIAGNOSIS VENTIL PNEUMOTHORAX (3)
Physical Pneumothorax ventil Dextra
Inspection Static D>S, deviation of trachea,
Widening ICSDinamic D
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DIAGNOSIS VENTIL PNEUMOTHORAX (4)
Work up
Lab: BGA
Chest radiography
USG
CT Scan
Proef puncture
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DIFFERENTIAL DIAGNOSIS
PNEUMOTHORAX
Emphysematous lungAsthma bronchiale
Giant bullae
Acute Myocard Infarction
Hernia diaphragmatica
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COMPLICATION OF
PNEUMOTHORAX
Pleural effusion
Emphysema subcutis
Syock cardiogenic
Respiratory distress
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PNEUMOTHORAX SPONTANEA
VENTIL
SAAT EKSPIRASI TEKANAN SEMAKIN MENINGKAT
MATI OLEH KARENA:
MEDIASTINUM TERDORONG KE SISI YANG SEHAT
GAGAL KARDIOVASKULER DAN GAGAL NAPAS
INSPIRA
SI
EKSPIRASI
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1. pneumothorax traumatica
2 th t
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PNEUMOTHORAX
PENDORONGAN MEDIASTINUM
HEMITHORAX CEMBUNG & GERAK RESPIRASI TERTINGGAL
PARU KOLAPS & MEDIASTINUM TERDESAK UDARA KEARAH SISI YANG SEHATdjois
1
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2. pneumothorax spontanea
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PNEUMOTHORAX VENTIL
djois
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CHEST X-RAY PNEUMOTHORAX
Picture 2. Right-sided pneumothorax due to stab wound
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CHEST X-RAY PNEUMOTHORAX (LANJUTAN)
Picture 3. A true pneumothorax line.Note that the visceral pleural line is observedclearly, with the absence of vascular marking beyond the pleural line.
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http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/radio/images/Large/1005Slide5.JPG&template=izoom2 -
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Estimate lung collaps
Light Index
PNX% = 100 1 -
lung 3
hemithorax3
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TREATMENT OF PNEUMOTHORAX
Primary spontaneous pneumothorax Observation
Recommanded that only asymtomatic patient with
pneumothorax less than 15 % Oxigen suplementation
Gas absorbtion will exceed
Simple aspiration
Tube thoracostomy Thoracoscopy VATS
Pleurodesis
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TREATMENT OF PNEUMOTHORAX (2)
Secondary spontaneous pneumothorax Oxigen suplementation
The initial treatment for nearly every that patient shouldbe tube thoracostomy
Simple aspiration should not be performed because itfrequently is ineffective and does not decrease thelikehood of a reccurence
Tube thoracostomy
Thoracoscopy VATS Pleurodesis
Treatment the underlying diseses
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a- semprit 5ml / 10ml dengan
jarum infus yang besar
b- kondom / sarung tangan karet
yang lama, ujungnya dipotong
serong
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ALAT KONTRA
VENTIL
WSD
W
ater
S
ealed
D
rainage )
UDARA DALAM
CAVUM PLEURAE
KELUAR
UDARA LUAR TIDAK
DAPAT MASUK
KEDALAM CAVUM
PLEURAE
WSD
+10cmH2OTIP :
+20 cmH2O
djois
udara
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INSERTED THORAX CATHETER Indication:
Pneumothorax > 20% of lung volume/ventil.
Malignant Pleural effusion Empyema
Hematothorax > 300cc
Chilothorax
Post operatif thoracotomy The patient use ventilator/respirator
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Lokasi:
ICS VII/VIII P.A.L
IC II/III M.C.L: Cara Monaldi
ICS IV/V M.A.L: Cara Buelau
Persiapan Alat: Klem desinf, duk
Kasa, duk berlubang
Madrin, kanul
Gunting, pinset
Jarum jahit, benang
Spuit, anestesi
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REPLACEMENT THORAX CATHETER Indication:
THE LUNG has inflated. The. Catheter has diklem 24
hour.
Empyema: pus (-) fluid
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PLEURODESIS Pleurodesis is a medical procedure in which the
pleural space is artificially obliterated.It involves theadhesion of the two pleura
Chemical Surgical
Indication:
recurrent pneumothorax recurrent pleural effusion/ Malignant pleural effusion
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http://en.wikipedia.org/wiki/Pleural_cavityhttp://en.wikipedia.org/wiki/Pleural_cavityhttp://en.wikipedia.org/wiki/Pleural_cavityhttp://en.wikipedia.org/wiki/Pleural_cavity -
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CHEMICAL PLEURODESIS
Chemicals such as:
bleomycin
tetracycline
povidon iodine
Slurry of talc
Introduce into the pleural space through a chest drain.
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