Pneumothorax Pleural effusion
Definition air within the pleural space Definition collection of fluid in the pleural space
Aetiology COPD, TB, Sarcoidosis, RA, Ankylosing Aetiology
Occurs when there is excess fluid in the pleural space because
spondylitis, trauma e.g. stab wound Too much fluid produced
Pathophysiology o Transudate effusion (<30g/L protein)
Primary pneumothorax idiopathic/rupture of Too much fluid leaves capillaries - due to high hydrostatic pressure/low oncotic pressure
pleural bleb, usually found in young, tall, slim men Causes HF, hypoalbuminaemia, hypothyroidism, Meigs’ syndrome (ascites + pleural
Secondary pneumothorax in patients w/ prior lung effusion + benign ovarian tumour)
disease e.g. COPD, Sarcoidosis, idiopathic o Exudate effusion (>30g/L protein)
pulmonary fibrosis Inflammation of pulmonary capillaries leaky fluid, immune cells + large proteins e.g.
LDH leak out)
Tension pneumothorax due to blunt, traumatic Causes Infection, malignancy, pancreatitis, PE
injuries e.g. a stab wound. Air cannot be removed Impaired fluid drainage by lymphatics (lymphatic effusion/chylothorax) thoracic duct
on expiration due to one-way flap created damaged/tumour in mediastinum that cause pressure effects
mediastinal shift + lung collapse Signs + symptoms
Signs + symptoms Small pleural effusions asymptomatic
Ipsilateral chest pain, should tip pain, dyspnoea, Large pleural effusions chest pain (pleurisy), SOB, worse when lying flat, decreased breath sounds,
decreased tactile fremitus, reduced chest expansion, dull on percussion, tracheal deviation
tachypnoea, hypoxia, cyanosis Ix
Auscultation reduced on affected side CXR: PA performed in ALL patients
Percussion hyper-resonant/normal USS recommended = increases success of aspirations
Deviated trachea Contrast CT= especially for exudative effusions
Ix Pleural aspiration
1. CXR tracheal deviation away from lesion o 21G needle and 50ml syringe should be used
o Fluid should be sent for protein, pH, LDH, cytology and microbiology
2. CT
Dx Light’s criteria (use for borderline cases)
3. ABG hypoxia? Exudates have protein >30g/L and transudates have protein <30g/L, if the protein level is between
Mx 25-35g/L Light’s criteria should be applied
Primary pneumothorax If rim of air < 2cm + not SOB An exudative is likely if at least one of:
Discharge Pleural fluid protein/serum protein >0.5
Otherwise aspirate fails? (>2cm/still SOB) chest Pleural fluid LDH/ serum LDH >0.6
Pleural fluid LDH > 2/3 the upper limits of normal serum LDH
drain
Other pleural fluid findings:
Secondary pneumothorax If > 50yrs + >2cm air + SOB Low glucose TB, RA; Raised amylase pancreatitis, oesophageal perforation; Heavily blood-
chest drain stained mesothelioma, PE, TB
Otherwise aspirate (1-2cm air) Mx
Admission for at least 24hrs Pleural infection:
< 1cm O2 + admit for 24hr If fluid is purulent or turbid/cloudy chest tube drainage
If fluid is clear but pH <7.2 chest tube drainage
Tension pneumothorax Needle decompression (mid-
Recurrent pleural infections: recurrent aspiration, pleurodesis, indwelling pleural catheter, drug Mx
clavicular line, 2nd intercostal space + chest drain to relieve Sx
insertion (safe triangle)
