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 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)

Two kinds of pleural effusions

Transudates and exudates
Transudate

Cause
non-inflammatory
Inflammatory,tumor
Apperance
light yellow
purulent
Specific gravity
<1.018
Coagulability
unable
Rivalta test
negative
Protein content
<30g/L
PL. To serum
< 0.5
LDH
< 200 I U/ L
PL. To s
< 0.6
Cell count
< 10010 6/ L
Differential cell
Lymphocyte

Exudate
yellow,
>1.018
able
positive
>30g/L
> 0.5
> 200 I U / L
> 0.6
> 50010 6 / L
Different

Lights 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

Common causes of pleural

effusions
TRANSUDAT
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
1.
2.
3.
4.
5.

Trauma
Tumor
Pulmonary infarction
TB
Spontaneous pneumothorax

Chylous effusion
1.
2.
3.
4.

Trauma
Tumor
TB
Thrombosis
of
the
left
subclavian vein

Empyema
1. TB
2.
3.
4.

Pulmonary infection
Trauma
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

Diagnostic procedures

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)

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

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

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

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

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

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

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

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

JELAS...?
ADA PERTANYAAN..?

MEKANISME FORMASI RESORBSI

CAIRAN PLEURA
Parietal
Visceral
pleura
Hydrostat
ic
pressure(
30)
Permeabili
ty
of
systemic
circulation
(34)

pleura

Pressure of
pleural
space (5)

11

Permeability of
pleural
fluid (8)

34

5+8+3034=9

34(5+8+11)=