EFUSI PLEEFUSI PLEUURARA

dr. Arief Hermanto Sp.Pdr. Arief Hermanto Sp.P

PENDAHULUANPENDAHULUAN

Plera visceralis --- paruPlera visceralis --- paru parietalis --- dinding dadaparietalis --- dinding dada

Ruang antar plera 18 -- 20 μ m Ruang antar plera 18 -- 20 μ m gerak paru lebih bebas.gerak paru lebih bebas.

Fisiologi ruang plera.

• Tekanan lebih rendah• Tak tembus air/protein• Mesotel tak ada beda potensial• Produksi cairan 0.5 ml /jam• ( waktu paruh 6-8 jam kelinci)• proteinnya rendah ( 1g% pd

domba)

MANOMETER AIR TERBUKA

Mekanisme efusi pleraMekanisme efusi plera

• Tekanan hidrostatik meningkat

• Tekanan osmotik menurun

• Obstruksi saluran limfe

• Perubahan permiabilitas membran

Eksudat

Protein > 5 g %

LDH cairan/plasma > 0.6

LDH cairan > 2/3 batas atas LDH serum

( salah satu kriteria diatas ).

Cairan plera

• Transudat

• Eksudat

• Chylus

transudat

• Cong heart failure• Pericardia dis• Cirrhosis hepatis• Nephrotic sy• Peritoneal dialisis

• Myxedema• Pulmonary emboli• Sarcoidosis

eksudat

• Neoplastic dis• Infectious dis• Pulmonary embolism• Gastrointestinal dis• Collagen vascular dis• post pericardiectomy• post myocard infarct

• Asbestosis• Sarcoidosis• Uremia• Meigs syndrome• drug induced pleural

diseases• radiotheraphy • hemothorax/chylothrx

eksudat

• Yellow nail syndrom

• Trapped lung

• Electric burn

• Urinary tract obstruction

• Iatrogenic injury

Eksudat (efusi plera)

• INFEKSI:• Pyogenic bact inf• Tuberculosis• Actinomycosis and• nocrdiosis• Funngal inf• Viral inf• Parasitic inf

• GASTROINTEST :

Esophageal perforation

Pancreatic disease

Abscess (intra abd)

Diaphragmatic hernia

Post abdominal surg

Postendosc variceal

sclerotheraphy.

Eksudat (efusi plera )

• COLLAGEN VSC.D• Rheumatoid plis• SLE• Drug induced lupus• Imm.lymphadenopthy• Sjogren’s sy • Churg Strauss sy• Wegener’s gr.tosis

• DRUG INDUCED • Nitrofurantoin• Dantrolene• Methylsergid• Bromocriptine• Procarbacine• Amiodarone

DX TEST FOR PL FLUID

• APPEARANCE

• PROTEIN

• LDH

• GLUCOSE

• AMYLASE

• WHITE CELL

• COUNT/DIFF

• CYTOLOGY• PCR/CHROMOSOM/• MONOCLONAL AB• CULTURE/STAINS• PH/PCO2• ANA• ADENOSINE

DEAMINASE

RADIOGRAPHIC TESTS• LATERAL DECUBITUS CHEST RO• ULTRASONOGRAPHY• COMPUTED TOMOGRAPHY• MAGNETIC RESONANCE IMAGING• ANGIOGRAPHY

INVASIVE TEST

NEEDLE BIOPSY OF THE PLEURA

BRONCHOSCOPY

THORACOSCOPY

OPEN BIOPSY OF THE PLEURA

CHF PL.EFFUSIONS THERAPHY:

= CHF.

PATHOFISIOLOGY:

<---- PULM EDEMA

<---- PULM V P

PERICARDIAL DIS.

60% CONSTR PERI CRDIS ---> EFF PL (TENDED LEFT) MECHANISM : CAPIL.PRESS > ( ??? )

THERAPHY

= PERICARD DIS

HEPATIC HYDROTHX.

PATHOFISIOLOGY: - DIAFR.DEFECT - ONCOTIC PRES.<

CLINICAL : - RIGHT 67% - LEFT 16% - BILAT 16%

THERAPHY : - = ASCITES - CLOSURE OF DIAFR DEFECT - PERITONEOJU GULAR SHUNT

PERITONEAL DIALYSIS

1.6% --> PL.EFFUSIONS ( 30 DAYS --) LAB: PROTEIN < 1GR % LDH LEVEL LOW THERAPHY: - CLOS.DIAFR DEFECT -> PLDESIS - PLEURODESIS. - THORACOTOMY

MYXEDEMA

MYXEDEMA - PERICRDIS -> EFF PL (50%) --- TRANSUDATE

MYXEDEMA - EFF PL TR/EXUDATE.

THERAPHY : - THYROID REPLACEMENT

PARAPNEUMONIC EFFUSIONS AND EMPYEMA PL.EFF <--- BACT.PNEUMONIA LUNG ABSCESS BRONCHIECTASIS

EMPYEMA : 60% <-- PPNIC EFF 20% <-- THX SURG

PROC 20% <--- TRAUMA

PARAPNEUMONIC PL.EFFUSIONS

STAGE I: - EXUDATIVE STAGE STAGE II - FIBROPURULENT ST

STAGE III - ORGANIZATION ST

CLASSIFICATION OF PARAPNEUMONIC EFFUSIONSIT IS IMPORTANT TO REALIZE THAT NOT ALL

PARAPNEUMONIC EFFUSIONS ARE THE SAMETHE FOLLOWING CLASSIFICATION WAS DE-VELOPED TO ASSIST THE PRACTICING PHYSICIAN . IT IS BASED ON THE FOLLOWING:

ANATOMY OF THE PLEURAL SPACEBACTERIOLOGY OF THE PLEURAL FLUIDCHEMICAL CHARACTERISTICS OF OF FLUID

ACCP CONSENSUS. CHEST 2000, 118:115-1171.

PLEURAL FLUID BACTERIOLOGY

BX CULTURE AND GRAM STAIN RESULTS UNKNOWN

B0 NEGATIVE CULTURE AND GRAM STAIN

B1 POSITIVE CULTURE OR GRAM STAIN

B2 PUS ACCP CONSENSUS, CHEST 2000, 118:115-1171.

PLEURAL SPACE ANATOMY

A0 MINIMAL, FREE-FLOWING EFFUSION (< 10 MM ON LATERAL DECUBITUS OR ULTRASOUND)

A1 SMALL TO MODERATE FREE-FLOWING EFFUSION (>10 MM AND < ½ HEMITHORAX)

A2 LARGE, FREE-FLOWING EFFUSION (> ½ HEMITHORAX) OR LOCULATED EFFUSION OR EFFUSION WITH THICKENED PARIETAL PLEURA

ACCP CONSENSUS, CHEST 2000, 118:115-1171.

PLEURAL FLUID CHEMISTRY

CX pH UNKNOWN

C0 pH > 7.20

C1 pH < 7.20

pH MUST BE MEASURED WITH BLOOD GAS MACHINE

IF pH UNAVAILABLE, A GLUCOSE OF 60 MG/DL CAN BE USED

ACCP CONSENSUS, CHEST 2000, 118:115-1171.

CATEGORY AND TREATMENT

1 – AO AND BX AND CX NO DRAINAGE

2 – A1 AND B0 AND CO NO DRAINAGE

3 – A2 OR B1 OR C1 DRAINAGE

4 - B2 (PUS) DRAINAGE

THERAPEUTIC THORACENTESIS OR CHEST TUBE ALONE ARE INSUFFICIENT FOR MOST PATIENTS WITH CATEGORY 3 OR 4

FIBRINOLYTICS, THORACOSCOPY OR THORACOTOMY ARE ACCEPTABLE APPROACHES FOR MANAGING PATIENTS WITH CATEGORY 3 OR 4

ACCP CONSENSUS, CHEST 2000, 118:115-1171.

TREATMENT OF PARAPNEUMONIC EFFUSION

IF FLUID IS LOCULATED, INSERT CHEST TUBE AND INSTILL FIBRINOLYTICS DAILY

IF FIBRINOLYTICS INEFFECTIVE, THORA-COSCOPY WITH BREAKDOWN OF ADHESIONS

IF THORACOSCOPY UNSUCCESSFUL, FULL THORACOTOMY WITH DECORTICATION

IF FLUID MORE THAN 10 MM IN THICKNESS ON DECUBITUS, PERFORM THERAPEUTIC THORACENTESIS

ALL THE ABOVE WITHIN 10 DAYS

TREATMENT OF RECURRENT PARAPNEUMONIC EFFUSION

IF FLUID RECURS AFTER THERAPEUTIC THORACENTESIS– REPEAT THERAPEUTIC THORACENTESIS IF SMEARS OR

CULTURES POSITIVE, GLUCOSE < 60, pH < 7.00, OR LDH MORE THAN 3X

– OBSERVE IF NONE OF THE ABOVE AND PATIENT DOING WELL

IF FLUID RECURS A SECOND TIME– INSERT CHEST TUBE IF SMEARS OR CULTURES POSITIVE,

GLUCOSE < 60, pH < 7.00, OR LDH MORE THAN 3X ON SECOND THERAPEUTIC THORACENTESIS

– OBSERVE IF NONE OF THE ABOVE AND PATIENT DOING WELL

PL.EFF THERAPHY

THORACENTESISCHEST TUBEINTR.PL THROMBOLYTIC AGENTSTHORACOSCOPY DECORTICATIONOPEN DRAINAGE/ELOESSER’S FLAP

WATERSEALED DRAINAGE (WSD)

PL.EFFUSIONS DX.PL.EFFUSIONS DX.

• ANAMNESE:ANAMNESE:

• SESAK TIMBUL PELAN SESAK TIMBUL PELAN

• TIDUR TELENTANG/MIRING KE TIDUR TELENTANG/MIRING KE

• SEHAT ---- SESAK >SEHAT ---- SESAK >

• AX ETIOLOGIS AX ETIOLOGIS

PL.EFFUSIONS DXPL.EFFUSIONS DX

• INSPEKSI : TRACHEA ---> , CEMBUNGINSPEKSI : TRACHEA ---> , CEMBUNG

• PALPASI : TRACHEA DEV.CEMBUNGPALPASI : TRACHEA DEV.CEMBUNG

• STEM FREMITUS <STEM FREMITUS <

• PERKUSI : REDUP PERKUSI : REDUP

• ELLIS’S S SHAPED LINEELLIS’S S SHAPED LINE

• AUSKULTASI : SUARA NAFAS < / - AUSKULTASI : SUARA NAFAS < / -