I.                    Pleural Effusion

a.       Transudative: from either elevated capillary pressure (CHF) or decreased oncotic pressure (hypoalbuminemia);

                                                               i.      Causes: CHF, cirrhosis, PE, nephrotic syndrome, hypoalbuminemia, peritoneal dialysis, atelectasis.

b.      Exudative: increased permeability (from damage caused by infection, malignancy, embolism);;

                                                               i.      Causes: viral infection, bacterial pneumonia, PE, TB, malignancy (lung, breast, lymphoma).

                                                             ii.      Dx:

1.      effusion

a.       protein pleural/ protein serum >.5

b.      LDH pleural/ LDH serum >.6

c.       LDH > 2/3 the upper limit of normal serum LDH

2.      xray: 

a.       blunting of costophrenic angles, at least 250 mL of fluid necessary. 

b.      Lateral decubitus xray is best

3.      thoracentesis

a.       Don’t do thoracentesis if you see effusion <10mm thick (can cause a pneumothorax)

b.      If thoracentesis is done, Order 4 Cs on the fluid drained: Cytology, Cell count, Culture, Chemistry (glucose, protein included).

                                                            iii.      Treatment:

1.      transudative: diuretics, sodium restriction. If massive, can do thoracentesis

2.      exudative: treat underlying disease

3.      parapneumonic (in presence of pneumonia)

a.       antibiotics

b.      if complicated or empyema:

                                                                                                                                       i.      chest tube

                                                                                                                                     ii.      thrombolytic agents (streptokinase + urokinase)

                                                                                                                                    iii.      surgical lysis of adhesions may be necessary

II.                 Empyema: pus within the pleural space

a.       Complication of pneumonia

b.      Extension of other foci (mediastinitis or abscess) into the pleural space

c.       Treatment: thoracentesis, antibiotics, rib resection/open drainage.

III.               Pneumothorax: air in pleural space

a.       Spontaenous – without any trauma

                                                               i.      Primary (simple)

1.      occurs in happy individuals

2.      rupture of subpleural blebs (air-filled sacs on the lung) at the apices of lungs… causing parts of lung to collapse… usually asymptomatic and no treatment necessary… since these patient have good pulmonary reserve.

3.      recurrence is up to 50% in 2 years.

                                                             ii.      Secondary (complicated)… to underlying disease (COPD, asthma, ILD, neoplasms, CF, TB.

1.      more dangerous – these patients have less pulmonary reserve.

b.      Traumatic: thoracentesis, central lines, transthoracic needle aspiration. So you need to get a CXR after these procedures.

c.       Treatment: nothing if small, one-way vale chest tube (small chest tube), oxygen, chest tubes,

IV.              Tension Pneumothorax: air enters the pleural space but is unable to escape à causes ipsilateral lung to collapse and shifts the mediastinum away from the pneumothorax.

a.       Causes: mechanical ventilation, CPR, trauma