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pleura, is a serous membrane that covers the lung.
The parietal pleura folds back on itself at the root of the lung to become the visceral
pleura.
In health the two pleurae are in contact. when air or liquid collects between the two
membranes, the pleural cavity or sac becomes apparent . There are actually two pleural
cavities, the right and the left; each constitutes a closed unit not connected to the other.
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Pleural space is a potential space between visceral and parietal pleura.
The negative pressure of pleura prevents the lungs from collapsing during respiration.
The pressure becomes more negative in inspiration and less negative during expiration
which helps in respiration.
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Pneumothorax
Pleural effussion
Malignant mesothilioma
Pleural plaques
Dry pleurisy
Pleural fibrosis
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Pleural effussion is presence of fluid in the pleural cavity.
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Four types of fluids can accumulate in the pleural space:
Serous fluid (hydrothorax)
Blood (haemothorax)
Chyle (chylothorax)
Pus (pyothorax or empyema)
Pleural effusion is usually diagnosed on the basis of medical history and physical
examination and is confirmed by chest X-ray.
Once accumulated of fluid is more than 200ml it becomes detectable
decreased movement of the chest on the affected side
there may be tracheal deviation away from the effusion
stony dullness to percussion over the fluid
diminished breath sound on the affected side
decreased vocal resonance and fremitus
pleural friction rub Above the effusion, where the lung is compressed, there may be
bronchial breathing and egophony at the upper border.
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Transudative pleural effusions are defined as effusions that are caused by systemic factors
that alter the pleural equilibrium, or Starling forces that is
Increased hydrostatic pressure
Decreased oncotic pressure
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Chemical composition including protein, lactate dehydrogenase (LDH), albumin,
amylase, pH, glucose, Cell count and differentials.
Gram stain and culture to identify possible bacterial infections
Cytopathology to identify cancer cells, but may also identify some infective organisms.
Other tests as suggested by the clinical situation like AFB staining ,lipids, fungal culture,
viral culture, specific immunoglobulins.
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Cardiac failure
Liver cirrhosis
Hypoalbuminaemia
Nephrotic syndrome
Renal failure
Hypothyroidism
Mitral stenosis
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Exudative pleural effusions are caused by alterations in local factors that influence the
formation and absorption of pleural fluid .
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Malignancy
Parapneumonic effussions
Tuberculosis
Rheumatoid arthritis
Autoimmune diseases
Pulmonary infarction
Benign asbestos effussion
Pancreatitis
Yellow nail syndrome
Drugs
An accurate diagnosis of the cause of the effusion, transudate versus exudate, relies on a
comparison of the chemistries in the pleural fluid to those in the blood, using Light's criteria
According to Light's criteria a pleural effusion is likely exudative if at least one of the following
exists:
• The ratio of pleural fluid protein to serum protein is greater than 0.5
• The ratio of pleural fluid LDH and serum LDH is greater than 0.6
• Pleural fluid LDH is greater than ⅔ times the normal upper limit for serum LDH.
Different laboratories have different values for the upper limit of serum LDH, but
examples include 200 and 300 IU/l.
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Imaging techniques
Abram’s pleural biopsy
Pleuroscopy
Bronchoscopy
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Pneumothorax is defined as presence of air in pleural space.
The term pneumothorx was first coined by Itrad in the year 1803.
Incidence of primary spontaneous pneumothorax is 18-28/100,000 per year for men.
Incidence of primary spontaneous pneumothorax is 1.2-6/100,000 per year for women.
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Pulmonary Tuberculosis
Asthma
COPD
Intestitial lung diseases
Pneumonia
Sarcoidosis
Cystic fibrosis
Rheumatoid arthritis
Marfan’s syndrome
Histocytosis x
Lymphangioleiomyomatosis
Catamenial pneumothorax
Ehlor danlos syndrome
Tuberous sclerosis
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Pleural biopsy/aspiration
Transthoracic needle aspiration
Central venous cannulation(subclavian)
Biopsy of breast
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Liver biopsy
Medistinal biopsy
Oesophageal rupture during instrumentation
• Sharp unilateral chest pain.
sudden in onset
severe in intensity
• Dyspnoea
severe
may be progressive
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Absent or diminished chest movements on affected side
Chest may appear bulged on affected side
There may be a medistinal shift towards opposite side
Hyper resonant percussion note
Decreased or absent breath sounds
MANAGEMENT :
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Observation is the choice in small closed pneumothorax where patient is not breathless.
Patients with small <2cm pneumothorax may be considered for discharge with written
advice to return if breathlessness increases.
If admitted high flow oxygen must be given.
Breathless patients must not be left without intervention regardless of size of
pneumothorax.
Simple aspiration is recommended for all primary spontaneous pneumothoraces requiring
intervention.
If simple aspiration fails ie.,more than 2.5L fluid is aspirated and breathlesness does not
improves intercostal tube should be inserted.
Intercostal tube drainage is recommended in all patients having secondary spontaneous
pneumothax except in patients who are not breathless or have a very small pneumothorax
<1cm.
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Tension pneumothorax
Bilateral pneumothorax
Recurrent pneumothorax
Presence of dyspnoea
Failed manual aspiration
Large pneumothorax
Patients on invasive mechanical ventilator
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Recurrent pneumothorax
Secondary spontaneous pneumothorax
Bilateral pneumothorax
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Tetracycline
Talc
Bleomycin
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