notes by dr Claudio Italiano
•La pleurodesi
•Il mesotelioma
•Versamento pleurico imponente
•La toracentesi
•Heart failure
The lung is covered by the pleura which has a visceral foil, adherent to the lung, and a parietal one, adherent to the rib cage; physiologically there is a thin liquid
layer that facilitates the sliding of the two pleural sheets during respiratory acts, generally only about 10-20 ml. It is formed by virtue of complicated
homeostatic mechanisms, whereby the liquid is produced by filtration from the parietal pleura and reabsorbed by the visceral pleura.
A small part is drained by lymphatics. This filtration and reabsorption mechanism depends on:
- from hydrostatic pressure;
- from the oncotic pressure exerted by the protein;
- from the negativity of the endopleuric pressure, for which it tends to "suck"
liquid;
- from the state of the pleural surfaces, which if inflamed tend to exude;
- from the integrity of the lymphatic drainage, which if obstructed, for example
in the tumor, causes a lack of drainage.
Generally, it is rare to form liquid in the pleural cavity, since the processes
are always aimed at reabsorption, in the sense of 1 to 20, that is, the
absorption process is twenty times greater than the filtration of liquid
CRX: right pleural effusion in a patient with
refractory ascites and hepatic nodules
Previous pleuritic facts
Chronic pulmonary diseases
Autoimmunity and Vasculitis
Professional exposures (asbestos, mica, talc, silica)
Cardiovascular diseases
Gastrointestinal diseases
Thrombophilic syndromes
drugs
tumors
Thoracic traumas
Previous cardiac surgery
Acute or chronic infections
The patient with pleural effusion comes to the attention of the doctor complaining of dyspnoea, since the presence of the liquid hinders the normal
expansion of the lung with the acts of the breath.
The doctor already at the
percussion and / or auscultation (see auscultate the chest) will notice an area
of dullness (thigh sign), which means the presence of the liquid for which the
lung does not resonate with "clear pulmonary sound" and to the auscultation
there will be the abolition of the physiological vesicular murmure, since,
precisely, the aeration of the lung is deficient and the sound that is produced
reduced or absent altogether.
Obtuseness will have a higher curvilinear limit, with greater height on the axillary (Damoiseau-Ellis line), abolition of the tactile vocal tremor and disappearance of the vesicular murmure. The effusion can be unilateral, usually left or bilateral, can also be saccharged or mobile , that is, varying with the decubitus and this is also evident with the simple x-ray examination of the thorax. In the most difficult cases, a CT scan or ultrasound can be performed to better quantify the spillage or to perform guided eco and tac aspiration and drainage maneuvers.
ALWAYS WE REMEMBER that it is dangerous to blindly poke a lung, because along the lower edge of a rib the costal artery and nerve run, with the risk of creating a hemorrhage effusion. From the radiological point of view, an opaque area will be highlighted (chest x-ray, examples of thorax) that occupies the costofrenic breast alone, or an opacity that rises upwards with a concave line.
In some cases, the spill is suddenly formed by accompanying chest pain, in inflammatory forms, where the patient also accuses dyspnoea, tachycardia (arrhythmias), which is aggravated by respiratory acts and tends to disappear as the fluid increases.
There may be fever, mostly modest in serum-fibrinosis, while it is elevated, and with remittent or intermittent characteristics, if the process depends on purulent bacterial infection, a rather rare occurrence. More often than not, the effusion is manifested in the elderly, especially if heart disease with heart failure without fever and without pain, but accompanied by signs of "hunger for air" and aggravating asthenia and slanted edema with a sign of the "fovea" at acupressure in the pretibial region. Sometimes, and this occurrence is very risky, the effusion becomes pleuro-pericardial (pericarditis).
In this case the
heart, being in a pericardium sac filled with liquid, becomes unable to fill in
diastole with a noticeable reduction in flow. The cardiopathic with pleural
effusion will have dyspnoea, dry and irritating cough, poorly productive,
peripheral cyanosis, dysphonia and a sensation of precordial oppression. At the
radiological survey it will be possible to notice a "boot" cardiac silhouette.
It is not easy to diagnose a pleural effusion, the first medical act to
implement a targeted therapy. First of all, it is necessary to collect the
pleural fluid, which, we said, is very delicate and must be carried out in a
sterile environment avoiding piercing or tearing the vessels and ribs and the
lung itself and / or determining a pneumothorax, ie the passage of air into the
pleural cavity where there can not be any, by a valve mechanism (ie the air
enters the inspiratory act and can not escape.
They are:
- the examination of the chemical-physical and cytomorphological pleural fluid;
- needle biopsy
- thoracoscopy;
- exploratory thoracotomy.
Once the liquid has been obtained, it is first necessary to examine its
macroscopic characteristics, that is to say its color, which is generally quite
transparent citrus yellow (transudate), sometimes blood (suspected of neoplasms
or lacerations!), Other times very rare, chiose , purulent etc.
We then proceed to culture and cytology to rule out the presence or absence of
tumor cells (mesothelioma, lung carcinoma). Other things to look for amylasemia,
useless if you are diagnosed with pancreatitis.
Clear liquid, citrine (tumors, tbc, liver cirrhosis, ascites, post-traumatic
effusion)
Hemorrhagic fluid (trauma, neoplasia, blackish in old payments)
Fatty or milky liquid (chylothorax, broken chylord, cholesterol pleurisy)
Purulent liquid (of nauseating smell in colibacilli and anaerobic infections,
subcutaneous and tonsillar abscesses, deep asexual collections)
• Proteins: the first investigation consists in determining if the liquid
sample obtained consists of a transudate or an exudate, with the Rivalta test,
negative in the transudates because they have less protein, positive in the
exudates.
• Lactic dehydrogenase (LDH) in the pleural fluid sample.
We speak of exudate if:
• Pleural proteins / serum proteins => 0.5
• Pleural LDH / serum LDH => 0.6
• LDH> 200 U in the pleural fluid
Peculiarities of the pleural fluid
• If glucose is very low in the pleural fluid = increased cellular metabolic
activity (neoplasia and tuberculosis, or rheumatoid arthritis and lupus)
• If hyaluronic acid is present in pleural fluid> 0.8 mg / ml = malignant
endothelioma
• If LDH is increased in pleural fluid vs. blood = malignant neoplasm
• If pleural amylase / serum amylase 4: 1 = pancreatitis
• If adenosine deaminase in the liquid> 33 U = tuberculosis
• If pleural CEA> 5-7ng / ml = neoplasia
If neutrophils are present, inflammation is thought to occur; if mesothelial
cells are present, we think of an inflammatory reaction, if there are
lymphocytes to tuberculosis or lymphoma.
It is useless to say: the pleural fluid must always be treated or drained. If
the presence of pleural fluid is bilateral, it is generally thought of a
condition of heart failure and diuretic therapy is implemented. If rather the
pleural fluid is saccharged or monolateral, it is sometimes returned to the
drainage system after using a specific set, see photo.
There are numerous causes that cause pleural effusion. Between these:
Transudative pleural effusion (hydrothorax from the presence of serum):
- congestive heart failure (generally bilateral payment)
- pulmonary embolism (monolateral payment, also possible exudation)
- cirrhosis of the liver (more frequent pouring on the right)
- nephrotic syndrome (patients with severe fluid retention secondary to renal
failure)
Exudative pleural effusion:
- metapneumone (accompanied by bacterial pneumonia)
- viral and bacterial pleurisy and pneumonitis
lung and pleural tumors (malignant pleural mesothelioma, lung and mammary
carcinoma, malignant lymphomas). In these cases it is possible to find tumor
cells in the pleural fluid that often appears also hemorrhagic (not frankly
hemothorax)
tuberculous pleurisy and pleural tuberculosis (also hemorrhagic fluid)
pulmonary embolism (unilateral effusion, also possible transudation)
rheumatoid arthritis
Systemic Lupus eritematosus (LES)
acute pancreatitis
esophageal rupture secondary to chest trauma
Blood effusion of the pleura
Hemothorax (blood): with hematocrit of pleural fluid> 50% of peripheral blood
hematocrit
malignant pleural mesothelioma and other pleural tumors (sarcoma, tumor
metastasis at another site, etc.)
lung tumors
thoracic traumas
Chilean pleural fluid
chylothorax (lymph):
injury or rupture of the thoracic duct (large lymphatic vessel of the thorax) or
minor lymphatic vessels
thoracic tumors
chest trauma
any cause that makes the outflow of the lymph along the lymphatic vessels of the
thorax or which interrupts the integrity of the same
Pyothorax (pus):
purulent pleurisy, sometimes subsequent to pneumothorax due to emphysema bubble
rupture with infection of the pleural cavity by infected secretions present in
the bronchial tree
emptying in the pleural cavity of a pulmonary abscess (bronco-pleural fistula).