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Diseases of the pleura

Pleural Effusions. Mechanisms of accumulation:1-Increase in entry rate normal entry rate(0.01mL/kg/hr;around 16.8mL/day for a 70kg patient).2-Decrease in exit rate exit rate can increase to 0.28mL/kg/hr. Pleural Effusions Increased Fluid Entry. 1-Increase in microvascular pressure.2-Decr

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Diseases of the pleura

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    1. Diseases of the pleura J. Tavares,MD,FACP,FCCP,FAASM

    2. Pleural Effusions Mechanisms of accumulation: 1-Increase in entry rate normal entry rate(0.01mL/kg/hr;around 16.8mL/day for a 70kg patient). 2-Decrease in exit rate exit rate can increase to 0.28mL/kg/hr

    3. Pleural Effusions Increased Fluid Entry 1-Increase in microvascular pressure. 2-Decrease in pleural pressure(atelectasis) 3-Decrease in plasma oncotic pressure 4-Increase in permeability

    5. Pleural Effusions Decreased Fluid Exit 1-Interference with the ability of the lymphatics to contract a)-inflammation b)-hypothyroidism c)-malignancy 2-Inhibition of lymphatic function a)-phrenic nerve paralysis,atelectasis,granulomas,etc

    6. Pleural Effusions Evaluation 1-History: Typically asymptomatic: BAPE Hypoalbuminemia Nephrotic syndrome Rheumatoid effusion Urinothorax Yellow nail syndrome Trapped lung

    7. Pleural effusions Evaluation 1-History Typically symptomatic Bacterial pneumonia carcinomatous effusion CHF Lupus pleuritis Mesothelioma Pulmonary embolism

    8. Pleural Effusion Evaluation 2-Physical examination normal if fluid volume is less than 250mL Around 500mL: dullness to percussion, decreased fremitus and decreased intensity of the sounds. >1000mL:egophony(E to A change) at the upper level of the effusion.

    9. Pleural Effusion Evaluation 3-Radiology Isolated pleural effusion: a)TB,Lupus,Metastatic cancer b)Massive effusion with contralateral shift(carcinoma,usually a nonlung primary) c)Massive without contralateral shift(lung cancer of the ipsilateral main stem or mesothelioma)

    13. Pleural Effusion Evaluation 4-Pleural fluid analysis Virtually all patients with newly discovered pleural effusions should have thoracenthesis. Exception: typical CHF patient(but,if fever,pleuritic chest pain,unilateral effusion or left effusion greater than right:TAP)

    14. Pleural Effusion Evaluation 4-Pleural fluid analysis( ? How useful) a-definitive diagnosis: 25% patients b-presumptive diagnosis:additional 50% pts c-excludes other causes:15% of patients.

    19. Pleural Effusion Evaluation 4-Pleural fluid analysis a)Observation hemothorax milky(chylothorax,cholesterol,empyema) black(aspergillus niger) yellow-greenish(rheumatoid) brown(amoebic liver)

    20. Pleural Effusion Evaluation 4-Pleural fluid analysis b)Total protein and LDH fluid prot/serum prot>0.5 fluid LDH/serum LDH>0.67 Sensitivity of 98% and specificity of 74% LDH>1000:empyema,rheumatoid,paragonimiasis Total protein>7.0:waldenstrom macrogl,MM

    21. Pleural Effusion Evaluation 4-Pleural fluid analysis c)pH<7.30: empyema,rheumatoid pleurisy d)-glucose fluid/serum<0.5 e)-Triglycerides/Cholesterol TG>110mg/dL: likely chylothorax f)Adenosine deaminase:>50U/L in TB

    22. Pleural Effusion Management Malignant pleural effusions median survival after recognition: 4 months A-repeated thoracenthesis B-Long term pleural catheter C-Pleurodesis D-Pleurectomy E-Shunt

    25. Pleural Effusion Management Trapped Lung a)Observation b)Thoracenthesis if symptomatic c)Decortication

    28. Pneumothorax Management A-Primary spontaneous pneumothorax 7.4/100,000/yr in men in the US(37UK) 1.2 /100,000/yr in women in the US(15.4UK Risk factors:smoking,Marfan,Family Hx,homocystinuria,thoracic endometriosis. Smoking:in 505 patients with PSP,91% were smokers.

    29. Pneumothorax Management A-Primary spontaneous pneumothorax <2 to 3 cm(20%):02 supplement/observation >3cm or symptomatic:needle aspiration. failed aspiration: chest tube and consider thoracoscopy. Unstable patients:Chest tube insertion.

    30. Pneumothorax Management Supplemental oxygen: Normal resorption is 1.25%/hr 100% oxygen: 12.5%/hr VATS pleurodesis

    31. Pneumothorax Management B-Secondary spontaneous pneumothorax All patients shoul be hospitalized <2cm and stable: observe >2cm or unstable:chest tube

    32. Pneumothorax Management C-Air travel Boyle’s law:volume inversely proportional to pressure. Recommendations: 1-No fly if current pneumothorax or congenital pulmonary cysts 2-avoid flying during COPD exacerbations 3-iatrogenic pneumothorax in normal lungs:ok to fly 4 to 6 weeks after resolution of PTX 4-may be contraindicated: spont.PTX,bullous emphysema.

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