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DR M ABDUR RAHIM M.D.

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ASST. PROFESSOR OF MEDICINE

PLEURITIC DISEASES

• Pleurisy • Pleural Effusion • Pneumo Thorax

Pleurisy
• Pleuritic pain resulting from any disease process involving the Pleura. • Clinical Features :  Sharp Pain that is aggravated by deep breathing or coughing. • On examination :  Rib movement is restricted  Pleural Rub may be present

• Some times audible only in deep Inspiration or near the Pericardium (Pleuro-Pericadial Rub) • Loss of Pleural Rub & Diminution in chest painIndicate eithery recovery or development of a Pleural Effusion Investigation : • Chest X-Ray PA View .

Cocodamol or NSAID is sufficient • Some patients require Opiates • To be used with Caution .Management :  Primary cause to be treated  Symptomatic treatment • To allow the patient to breathe normally and cough efficiently • Analgesic with Paracetamol.

PLEURAL EFFUSION • Accumulation of Serous fluid within Pleural Space is termed as Pleural Effusion • Pus – Empyema • Blood – Haemo Thorax • Chyle – Chylo Thorax .

.Mechanism : • Fluid accumulates as a result of either increased Hydrostatic Pressure of Decreased Osmotic Pressure ( Transudative Effusion ). OR • From increased Microvascular Pressure due to disease of the pleural surface itself or injury in the adjacent lung ( Exudative Effusion ).

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Clinical Features : • Pleurisy precede the development of an effusion. • Breathlessness – Only symptom related to effusion. • Onset may be insidious. . severity depends on size & rate of accumulation.

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Investigations : • Imaging : CXR-PA View Ultra sonography CT .

• CHEST X-RAY PA VIEW .

Ultrasonography : • More accurate for determining the volume of oral fluid. • Fecilitates skin marking for safe needle aspiration .

Pleural Aspiration & Biopsy : • Colour • Texture • Appearance • Presence of Blood.Pulmonary Infraction Malignancy Truamatic Tap .

Biochemical Analysis : • Differntiate Transudate from Exudate .

• Cytologic Examination • Biopsy : Video-assisted Thoracoscopy .• Gram Stain – Para Pneumonic Effusion.

Management : • Aspiration of Pleural Fluid • Treatment of underlying cause. .

Pneumothorax • Air in pleural space which occur spontaneously or result from Iatrogenic injury or Trauma to the Lung or Chest Wall .

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Normal Large Pneumothorax (>15% of Hemi thorax)Decreased or Absent Breath sounds Resonant Percussion note. Small Pneumothorax. .• • • • Clinical Features : Sudden onset unilateral pleuritic chest pain Breathlessness – Severe in Underlying Chest disease.

• Air enter Pleural Space during Inspiration but doesnot escape on Expiration.Types of Spontaneous Pneoumothorax • Communication between the Airway and the Pleural space acts as a one way Valve. • Intra Pleural pressure rises above atmospheric level. .

Hypotension. Cyanosis and Tracheal Shift opposite to silent hemi thorax .• The pressure causes Mediastinal shift to opposite side Compression of opposite normal lung Impairment of systemic venous return causing Cardiovascular compromise Rapidly progressive breathlessness • Clinically Tachycardia.

• Mean pleural pressure remains –ve.• Communication between the airway and pleural space seals of as the lung deflates and doesnot reopen. reabsorption of air and re expansion of lung occur over a few days or weeks .

Tuberculous cavity or lung absess into the pleural space.• Communication fails to seal and air continues to pass freely between Bronchial tree and pleural space • Commonly seen following rupture of an Emphysematous bulla. .

Investigation : • Chest X-Ray – Sharply defined edge of the deflated lung with complete translucency between this and chest wall. • CT .

• Moderate or Large Spontaneous primary PneumothoraxPercutaneous needle aspiration of air .Lung edge < 2 cm from chestwall-resolves without intervention.Management : • Primary Pneumothorax.

Secondary Pneumothorax causing Respiratory DistressIntercostal tube drainage • Intercostal Drains are inserted in the 4th.• Chronic Underlying Lung Disease. 5th or 6th ICS in mid axilary line. connected to an underwater seal or oneway Heimlich Valve • Drain removed 24 hrs after lung has fully reinflated and bubbling stopped .

25% Surgical Pleurodesis is recomended .• Continued Bubbling after 5-7 days – Surgery • Recurrent spontaneous Pneumothorax.

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• Microscopically. .Empyema • Collection of pus in Pleural space • Pus may be thin as serous fluid or thick as impossible to aspirate. • May involve the whole pleural space or only part of it (Loculated) and is usually Unilateral. Neutrophil Leucocytes are present in large numbers.

Aetiology : • Secondary to infection in a lung (bacterial pnuemonias and TB) • Other causes of sub absces Trauma or Surgery Esophegeal Rupture phrenic .

Pathology : • Thick Shaggy. inflammatory exudate • Pus under considerable pressure • Pus may rupture into a Bronchus (Bronocho Pleural Fistula) or track through the Chestwall to form Subcutatneous absces or Sinus (Empyema necessitans) .

Clinical Features : • Suspected in patient with pulmonary infection with persisting Pyrexia despite treatment .

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Empyema .Investigations : • Radiological Examinations As of Pleural Effusion Horizontal Fluid levelPyopneumothorax • Ultrasound and CT • Aspiration of fluid Thick and turbid.

Histology and Culture To differentiate TB and NonTuberculous disease. .• Other Features suggesting Empyema Fluid Glucose < 60 mg/dL LDH > 1000 units/Lt Fluid pH < 7 • Pleural Biopsy.

2 – 4 weeks I.V Cefuroxime with Metronidazole • Surgical Decortication .Management : • Treatment of Non-Tuberculous Empyema Intercostal tube drain connected to underwater-seal • Antibiotic Treatment.V Co-Amoxiclav or I.

• Treatment of Tuberculous Empyema Intercostal tube drainage • Anti Tuberculosis treatment • Complications calcificaton Fibrothorax Pleural .