Pleural effusion,

pneumothorax
(presentation for english medical students)
Dr. Farkas Attila, Dr. Agócs László, Dr. Kocsis Ákos, Dr. Mészáros
László, Dr. Török Klára, Dr. Bogyó Levenet, Dr. Ghimessy Áron, Dr.
Gieszer Balázs, Dr. Radeczky Péter, Dr. Rényi-Vámos Ferenc , Prof.
Dr. Lang György

National Institute of Oncology Thoracic Surgery Department,

Semmelweis University Thoracic Surgery Clinic
 I. case
Anamnestic datas
• 40 years old male patient
• Musician
• Lives in a town, called Lőrinci
• No serious illness, or operation in the past
• Smoking history: for 5 years 1 pack/day
• Alcohol: occasionally
• His problem now is slowly developed chest
pain and mild dyspnoe
 I. case
Physical examination
• In the whole right side dullnes with
percussion
• In the right side diminished breath sound
• In the right chest side decreased tactile
fremitus
• No other positive findings
 I. case
• What kind of disorder you think about?
-pleural effusion!
-atelectasis!
• What kind of test would you choose next?
-plain chest X-rays
 I. case
Plain chest X-rays
 I. case
• What are the origins of pleural fluids?
• (transudate-exudate)?
1. cardial- transudate
2. inflammation (pneumonia/pleuritis)- exudate
3. cancers (primary/secondary)- exudate (rarely
transudate)
4. pulmonary embolism- exudate (rarely transudate)
5. liver cirhossis with ascites- transudate
6. nephrotic syndrome- transudate
+(haemothorax, chylothorax, empyema)
 I. case
• How can we get information about the fluid?
- thoracocentesis /chest drainage
• What do we examine?
- machroscopically
- protein, LDH (transudate-exudate differential
diagnosis)
- cytology
- bacterial, fungal culture
 I. case
Chest tube drainage
• 4. intercostal space in the midaxillary line
• 2. intercostal space in the medioclavicular line
• Test punction!
• Always above the ribs!
 I. case
• Our patient punction:
- straw-coloured fluid
- exudate
- cytology was negative
- no bacterial or fungal infection was found
 I. case
• What’s next?

• In his town (Lőrinci) was cement and

eternit factory until 2004.
•Eternit contains asbestos
 I. case
Chest CT-scan
 I. case
Chest CT-scan
 I. case
• Mesothelioma diagnosis based on:
- VATS pleuroscopy and biopsy
• Prevent fluid appearance:pleurodesis
 I. case
Treatment
1, In case of T1-3, epithelial and hemithorax localized
form (no abdominal appearance or distant
metastasis): Operation
A, Pleurectomy and decortication ( resection of the
visceral and parietal pleura)
B, Extrapleural pleuropulmonectomy (resection of the
visceral and parietal pleura + lung + diaphragma +
pericardium)
- After the operation: chemo-radiotherapy
2, Non operable diseases:
- Chemo-radiotherapy
 II. case
Anamnesis
• 20 years old male patient
• No serious illness, or operation in the past
• Smoking: never
• Alcohol: sometimes
• His problem now is atypical left side chest
pain.
 II. case
Physical examination
• On the left, weakened respiratory sound
• On the left hypersonor percussion sound
• On the left, missing the pectoral fremitus
• Moreover negative status
 II. Case
Physical examination
• What kind of disorder you think about?
pneumothorax
• What kind of test would you choose next?
plain chest X-rays
 II. case
Plain chest X-rays
 II. case
Plain chest X-rays
 Pneumothorax symptoms
• most common is spontaneous pneumothorax
• typical symptoms:
- stabbing chest pain
- heavy cough
- dyspnoea.
• in case of tension pneumothorax, and older
patients always associated with cardiac
complaints - tachycardia, extrasystoles, acute
heart failure, cyanosis
 Types of PTX

1. Based on pressure conditions

2. Based on extension
3. Based on etiological
 1. Based on pressure conditions
simple PTX
- Open pneumothorax
- Closed pneumothorax
ventil PTX
 2. Based on extension

complete
partial
tire PTX
bilateral pneumothorax
 3. Based on etiological

primary (spontaneous) PTX

secondary
- preliminary pulmonary disease
- traumatic: open or closed
- iatrogenic pneumothorax
 II. case
• What kind of test would you choose then?
-Chest CT
 Treatment
• Observation: tire pneumothorax, or pneumothorax case of small-
scale
• Aspiration: pneumothorax may be solved, the action can be
repeated. In case of complete or tension pneumothorax is
applicable only in medical first aid.
• Drainage (thoracentesis): This is the main therapeutic procedure in
the treatment of pneumothorax. In 80-90% of cases lead to a cure
• Surgery: 10-20% of the patients so they can achieve the healing
process, which may thoracotomy / VATS. Surgery is indicated for: (1)
if neither expands the lungs during treatment intake for 48-72
hours; (2) if the drain was inserted through the 24 hours is too long-
term flow is observed; (3) if hemopneumothorax was observed and
the rate of major bleeding or is not reduced; (4) other vital organ
injury, or a reasonable suspicion; (5) recurrent pneumothorax
Empyaema thoracis
 Staging
1. exudative stage: 24-72 hours – inflamation of pleura and
enhanced permeability of blood vessels, clear pleural effusion
develops a low white blood cell count

2. fibrinopurulent stage: 7-10 days - fibrin in the pleural space ->

septa, the denser the liquid, turbid, white blood cell count
increases Indicating the presence of anaerobic bacterial
metabolism of the exudate shows a decrease in pH and glucose
combined with high LDH activity
3. organised stage: 2-4 weeks - fibroblasts infiltrate in the pleural
space, the thin intrapleural membranes thicken, become inelastic.
This rigid fibrous sheath inhibits lung to expand and reduce the
respiratory function and difficult to cure infections.
 Etiology
1. Parapneumonic effusion
2. Haematogenous spread into pleural space
3. Iatrogenic infection of the pleural space
(thoracocentesis)
4. Postoperative (pulmonary, cardiac, abdominal,
urological)
5. Descending oropharyngeal infection
6. Mediastinal infection ( oesophageal perforation)
7. Chest wall and spine infection
8. Traumatic penetrating injury
 Bacteriology
• most common Streptococcus milleri,
Sterptococcus pneumoniae, Staphylococcus
aureus
• most common in nosocomial infection:
Klebsiella, Proteus, Staphylococcus aureus,
Pseudomonas aeruginosa, MRSA
• fungal empyema is most common in
immunosuppressive conditions
 Symptoms
• acute state: septic-toxic symptoms
• chronic state: improving the general
condition; often been without a fever;
laboratory abnormalities get better;
cardiopulmonary capacity reduced; chest
pain; cough; dyspnoe
 Therapy
• 1st stage:
- pleural drainage
- targeted antibiotic therapy
- additional treatment (diet, vitamins, roboration, symptomatic
therapy)
• 2nd stage:
- drainage and lavage
- early decortication, lavage, debridement (VATS / thoracotomy)
- fibrinolysis (streptokinase),
• 3rd stage:
- decortication (VATS / thoracotomy)
- if the decorticatio not feasible, residual empyema cavity remains
fenestration ("open window" chest training window)
Fenestration
Fenestration
Haemothorax
 Etiology
• most often injuries of the chest of the
bleeding in the chest wall and blood vessels,
lungs, heart and major blood vessels or
damage to the diaphragm.
• iatrogenic hemothorax: most common
reasons for central venous
cannulation,drainage, pleurabiopsy,
transthoracic pulmonarybiopsy,
• spontaneous hemothorax: rare disease
 Symptoms
• vascular symptoms caused by blood pooling
exacerbated respiratory deterioration due to
compression atelectasis
• young, otherwise healthy patients - eg. In case
of accident caused by acute hemothorax - a
relatively greater blood loss symptoms can be
surprisingly poor for a while
 Diagnosis
• anamnesis
• physical examination
• often in connection with pneumothorax accident
mechanism, subcutaneous emphysema can be
detected
• X-ray examination shows the effusion, possible
pneumothorax, mediastinal throughput rate, rib
fractures, etc.
• puncture
 Therapy
• bed rest, routing: less than 500 ml in case of hemothorax; lower-
grade fever may accompany absorption; Duration: 1-2 weeks
• puncture: partly diagnostic and partly for therapeutic purposes;
First get the medical care have a role (diagnosis, relief)
• drainage: if more than 1000 ml hemothorax; Advantages: (1)
improved evacuation, (2) constant control bleeding, (3) faster than
expected, fewer complications
• VATS exploration: a causative diagnosis and the severity of the
bleeding to clarify
• thoracotomy is indicated when (1) vascular, lung, heart, diaphragm
injury there is a reasonable suspicion; (2) from the drain strong non
damped bleeding (more than 100 ml / h).
Chylothorax
 Etiology
1. congenital chylothorax
2. spontaneous chylothorax: no demonstrable
cause in the background
3. secondary chylothorax
- accident: thoracic duct or inferiority branch
injury
- malignant lung or mediastinal tumor: a rare
- postoperative
- after central venous catheter insertion left
subclavian vein thrombosis
 Symptoms
• general symptoms of thoracic effusions
(pleural, cardiac, respiratory)
• after a long period of time corresponding
significant fat and protein as lost serious
consequences
 Diagnostic
• anamnesis
• physical examination
• lab test
• X-ray
• puncture test: chylus viscous, cream color and
consistency, fats, triglycerides, high in protein,
high specific gravity (> 1016), usually sterile,
odourless liquid with a pH greater than 7.5.
• (A pseudochylus pathogen protein and usually
rich in fat, viscous, white fluid in the chest.)
 Therapy
• pleural drainage
• low-fat diet and protein, electrolytes and fluids
replacement
• sometimes the sustained sucking chest also
comes into play, although it is rarely a permanent
solution
• in case of postoperative chylothorax drainage
should be considered in addition to the long-term
possibility of surgery as well (the thoracic duct
and ligation visit to the site of injury)
 Prognosis
• definitely wrong
• developed cancer as a result of chylothorax
worsen due to the underlying disease already bad
prognosis
• „spontaneous" chylothorax mortality is around
50%, with significant amounts of fat, protein,
fluid and electrolyte loss
• intravenous nutrition favorably affect the
prognosis
• after successful surgery, the patient can heal,
although recurrences are common