[부천] 흉막질환 학생용 메뉴얼

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                                    19993287(56) 유복열

16. PLEURA

Anatomy of the pleura

DISEASES OF THE PLEURAL SPACE

1. Pneumothorax

Definition)Accumulation of gas in the pleural space

2 Types

-Spontaneous pneumothorax

-Secondary pneumothorax(traumatic, diagnostic, therapeutic events)

Causes of secondary spontaneous pneumothorax

Airway disease

Bullous disease

Chronic obstructive pulmonary disease

Asthma

Cyst(congenital)

Pneumatocele

Cystic fibrosis

Interstitial Disease

Idiopathic pulmonary fibrosis

Eosinophilic granuloma

Carcoidosis

Tuberous sclerosis

Collagen vascular diseases

Infections

Anaerobic pneumonia

Staphylococcal pneumonia

Gram-negative pneumonia

Lung abscess

Actinomycosis

Norcardiosis

Tuberculosis

Atypical mycobacteria

Pneumocystis carinii pneumonia

Neoplasms

Primary

metastatic

Others

Endometriosis

Ehlers-Danlos syndrome

Pulmonary embolism

Marfan's sydrome

Primary Spontaneous Pneumothorax

is a disease of young adults.

Most patients are between 20-30 years, 85% Under 40 years

results from rupture of a pulmonary bleb

more common on the right side (Both in 10%)

-Recurrence rate: 20-50% after initial episode

                  60-80% after secondary episode

-Bleb site: apices of the upper lobes

Secondary Spontaneous Pneumothorax

20% of patients are related to Underlying pulmonary disease(esp. COPD, Malignant neoplasm, pul. TB)

peak incidence between 45-65 years

results from progressive destruction of alveolar walls

Low mortality(16%) in patients with 2nd penumothorax & COPD

Neonatal Spontaneous Pneumothorax

associated with hyaline membrane disease, renal malformation, Potter's synd, meconium aspiration

*In chidren can be secondary to cystic fibrosis

Catamenial Spontaneous Pneumothorax

right side in 90% of patients

usually within 48-72 hours after beginning of menses.

Pleural or Pulmonary endometriosis

Complications of Spontaneous Pneumothorax

hemothorax(from torn subclavian vein) in 3% patients

Empyema is rare ,but associated with abscess, pul TB, ruptured esophagus

Tension pneumothorax 2~3% of patients

Management of Spontaneous Pneumothorax

aims to alleviate symptoms, recognize complications, prevent recurrences

Obsevation

Thoracentesis

Thoracostomy

Chemical pleurodesis

Surgery for Spontaneous Pneumothorax

9~20% of patients require surgical therapy

Indications for thoracotomy in patients with spontaneous pneumothorax

Massive air leak that prevents lung reexpansion

Persistent air leak for more than 5 days

Recurrent pneumothorax(2nd episode)

Complications of pneumothorax:

  Hemothorax

  Epyema

  Chronic pneumothorax

Epecific surgical indications for conditions causing secondary spontaneous pneumothorax

Occupational indications after first episode:

  Airelien pilots

  Scuba divers

  Individuals living in remote areas

Previous contralateral pneumothorax

Bilateral simultanous pneumothorax

Presence of large cysts visible on chest roentgenogram

Transaxillary apical pleurectomy have fewer major complications

Thoracoscopic Surgery for Spontaneous Pneumothorax

inserted through 2cm incision: identify, resect blebs, perform pleurodesis

shorter hospital stay, less post-op pain, earlier return to work

Pneumothorax in Patients with Acquired Immunodeficiency Syndrome

associated with Pneumocystis carinii pneumonia

6% of AIDS patients

recurrence rate: 65% (after conservative therapy)

Motality: 50%

Chemical pleurodesis: ineffective

Iatrogenic Pneumothorax

Causes

-Mechanical ventilator(esp.PEEP)

-thoracentesis

-pleural piopsy

-needle aspiration biopsy

-central venous catheter

-malpositioned nasogastric tube

-esophageal obturator airway

-acupunture

-stellate ganglion block

-esophageal perforation

-transbronchial lung biopsy

2. Spontaneous Hemothorax

Etiology of spontaneous

Pulmonary

Bullous emphysema

Necrotizing infections

Pulmonary embolus with infarction

Tuberculosis

Arteriovenous malformation

Hereditary hemorrhagic telangiectasia

Pleural

Torn pleural adhesions secondary to spontaneous pneumothorax

Neopla는

Endormetriosis

Pulmonary Neoplasms

Primary

Metastases

 Melanoma

 Trophoblastic tumors

Blood Dyscrasias

Thrombocytopenia

Hemophilia

Complication of systemic anticoasulation

won Willebrand's disease

Abdominal Pathology

pnacreatic pseudocyst

Splenic artery aneurysm

Hmoperioneum

Thoracic Pathology

Ruptured horacic aortic aneurysm

Hemothorax: Blood in the pleural space

Pathophysiology

if free of contaminants and bacteria is absorbed spontaneously in most patients

can progress to fibrothorax

after several days of hamorrhage, angioblastic and fibroblastic proliferation occurs

within weeks outer fibrin film is fully organized and a thick membrane develops

Management

Initial treatment: Volume resuscitation to maintain BP

Within 7~10 days after cease hemorrhage surgical therapy should be undertaken

If pul. AVM cause bleeding, wedge resection is best therapy

3. Chylothorax

Etiology and Pathophysiology

Trauma & neoplasms are major causes

Blunt and penetrating trauma(gunshot, stab wound)

surgical procedures

Vomiting, violent coughing(tearing thoracic duct)

Below T5~T6 level: Rightsided chylothorax

Above T5~T6 level: Leftsided chylothorax

In adult Tumor is a major(50%~) cause

Diagnosis

The fluid is milky and nonclotting

Most chylous effusion: cholesterol: triglyceride ratio >1

TG level>110mg/dL

*Pseudochylouthorax: tuberculosis, Rheumatoid arthritis, DM

(milky, turbid fluid, high level of cholesterol & TG, cause pleura thickening & calcification)

Management

thoracostomy tube drainage

NPO

*contraindication of thoracotomy: vertebral fracture, multiple organ injury.

Operative Management

3 techniques: direct closure of the fistula

              suture of the leaking mediastinal pleura

              supradiaphragmatic ligation of the duct

4. Pleural Effusions

is an accumulation of fluid in the pleural space frome excessive transudation or exudation of interstitial fluid from the pleural surfaces

Symptoms: pleuritic chest pain and dyspnea

Pathophysiology

Increased hydrostatic pressure ex)heart failure

Increased capillary permeability ex)pneumonia

Decreased plasma colloide oncotic pressure ex) hypoalbuminemia

Increased intrapleural negative pressure ex)athectasis

Impaired lymphatic drainage of the pleural space ex) obstruction of lymphatic drainage by tumor, radiation, fungal disease

*Tranxudate: not involved  in the primary pathologic process (ex: congestive heart disease<83% of patients>, hypoalbuminemia)

*Exudate: results from disease of the pleural surface or lymphatics (ex: bacterial pneumonia, TB, malignant disease<43% of patients> etc.)

Pleural fulid protein/ serum protein>0.5

Pleural fluid LDH/ serum LDH>0.6

Pleural fluid LDH> two-third of the upper limit of normal for serum LDH

Diagnosis of Pleural Effusion

-Obliterance of costodiaphragmatic sinus(convex=>concave if >250mL) in upright chest film

-No parenchymal infiltrate or air bronchograms

-A spur-like projection into a fissure may occur where a fissure meets the diaphragm or chest wall is an additional sign of pleural fluid.

*Loculated pleural effusion is possible

Clinical and Laboratory Diagnosis in Pleural Effusions

Diagnosis        Diagonostic pleural Fluid test      Usual time course

Empyema           Observation(pus,putrid odor)        Immediately to 48hr

                    :stain or culture

Malignancy         Cytology                            24-48 hr

Lupus pleuritis      Lupus erythematosis               Minutes to hours

                    cells present

Tuberculosis        Stain, culture                       Minutes to 3 wk

Esophageal rupture  Amylase, pH                       Hours

Fungal pleurisy      Stain, culture                      minutes to days

Chylothorax      Centrifugation,lipoprotein,electophresis   minutes to 48hr

Hemothorax      Centrifugation                          Minutes  

Urinothorax      Creatinine(pleural fluid and serum)      Hours

Causes of Exudative Effusions

-Maliganant effusion

-Postmyocardial infaction syndrome

-Collagen-vascular diseases

-Subdiaphragmatic inflammation

-Pulmonary embolism

-Pulmonary infection

Management of Pleural Effusion

-Thoracentesis

-Thoracostomy and chemical pleurodesis

-Radiotherapy

-Surgical pleurodesis and pleurectomy

-Pleuroperitoneal shunt

5. Empyema

An acummulation of pus in the pleural space

Pathogenesis

3 phases

1)The exudative or acute phase: low viscosity, low celluar content, normal glucose & pH

2)The fibrinopurulent for transitional phase: increased PMN, fibrin deposit

3)The organizing or chronic phase(5 day~6 weeks) characterized by organization of the pleural peel with ingrowth of capillaries and fibroblasts: viscous, high in sediment, pH<7.0, glucose< 40mg/dL

*50% of empyema from pneumonic process

Organism                  Incidence        Incidence of

                           of effusion     Infected effusion

                                           (Empyema)

Anaerobic                       35                   90

Aerobic                           

Gram-positive                  

  Streptococcus pneumoniae    40-60                <5

  Staphylococcus aureus        70                    80

  (children)

  S. aureus(adult)               40                    20

Gram-negative

  Escherichia coli               50                    90

  Pseudomonas                  50                   90

Clinical Presentation of Postpneumonic Empyema

-Pleuritic chest pain

-Heavy sensation

-Febrile

-Tachypneic,

-Tachycardic

-Purulent sputum

Physical exam

-Decreased respiratory excursion

-pain on percussion

-friction rub

-distant-to- absent breath sounds on auscultation of the involved side

Diagnosis of Empyema

Aspiration of pus from the pleural space establishes the diagnosis of empyema

-appropriate cultures, Gram's stain, pH, cell count with differential, glucose, protein, LDH, and cytology, if there is suspicion of malignacy, with current antibiotic use, the pleural fluid may be only slightly cloudy, and cultures may fail to grow in 50% of patients.

*Repeatedly sterile culture and fails therapy===> TB or fungal infection

Management

Depends on its cause

Acute and transitional Empyema

If empyema is in the acute phase the pleural fluid has a low viscosity and may be removed entirely by thoracentesis, IN this situation , the combination of thoracentesis and antibiotics can be definitive treatment, particularly in children

In transitional phase, reexpansion & drainage more difficult

Fibronolytic enzyme used to improve chest tube drainage

Chronic empyema

begins approximately 6 weeks after the onset of the acute illness

is treated by open drainage and debridement of the cavity

Long-standing empyema causes crowding of the ribs and a rib resection is usually required.

6. Bronchopleural Fistula

A sinus tract between a bronchus and the pleural space

Most common cause is breakdown of the bronchial closure after partial or complete resection of the lung

Risk factor

-Malnutrition

-DM

-radiation therapy

-inflammatory involvement of the bronchal stump

-devascularization fo the stump

Management Bronchopleural Fistula

Acute bronchopleural fistula

During acute onset of a postpneumonectomy bronhopleural fistula, the patient should be turned onto the operated side to prevent aspiration of pleural fluid into the contralateral lung until adequate thoracostomy drainage is achieved. When a leak occurs 24 개 48 hours after pulmonary resection, the bronchus should be resutured, provided there is no residual tumor or bronchial infection at the resection line and an empyema is not present.

Chronic bronchopleural fistula

Meticulous dissection of the fistula tract down to normal bronchial cartilage is required, and a muscle flap must be placed over the bronchial closure.

commonly used muscle: -larissimus dorsi

                         -serratus anterior

                          -pectoralis major

                          -rectus abdominis

7. Fibrothorax

is the pathologic obliteration of the pleural space in which the two layers of pleura becom adherent and the lung is covered by a thick layer of the mucosa cauterized.

8. Post-Thoracotomy Pleural Space

Persistent dead space after thoracotomy is a hazard for infection or reduced pulmonary function

The size of this space decreases gradually by shifting of the mediastinal structures toward the side of the resection & by evevation of diaphragm

Management for infection

-Closed pleural biopsy

-Video-assisted pleuroscopy

-transverse CT scan

9. Tuberculosis of the Pleura

Pathology

The pleura infected by rupture of subpleural focus into the pleural space or shedding of the bacilli into the pleural space from involved lymph nodes.

=> Tuberculous empyema

Clinical Features and Diagnosis

The onset of tuberculous pleurisy is abrupt in two-third of patients and insidious in the remainder amyloid disease.

In Older age is incidious

Symptoms

-nonproductive cough

-pleuritic chest pain

-night sweats

-dyspnea

-weakness

-weight loss

Tuberculin skin test is positive in 70~80% of patients