Efusi Pleura dr. Arief.ppt

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  • EFUSI PLEURA dr. Arief Hermanto Sp.P

  • PENDAHULUANPlera visceralis --- paru parietalis --- dinding dada

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

  • Fisiologi ruang plera.Tekanan lebih rendahTak tembus air/proteinMesotel tak ada beda potensialProduksi cairan 0.5 ml /jam( waktu paruh 6-8 jam kelinci)proteinnya rendah ( 1g% pd domba)

  • MANOMETER AIR TERBUKA

  • Mekanisme efusi pleraTekanan hidrostatik meningkat

    Tekanan osmotik menurun

    Obstruksi saluran limfe

    Perubahan permiabilitas membran

  • EksudatProtein > 5 g %

    LDH cairan/plasma > 0.6

    LDH cairan > 2/3 batas atas LDH serum

    ( salah satu kriteria diatas ).

  • Cairan pleraTransudat

    Eksudat

    Chylus

  • transudatCong heart failurePericardia disCirrhosis hepatisNephrotic syPeritoneal dialisis

    MyxedemaPulmonary emboliSarcoidosis

  • eksudatNeoplastic disInfectious disPulmonary embolismGastrointestinal disCollagen vascular dispost pericardiectomypost myocard infarct

    AsbestosisSarcoidosisUremiaMeigs syndromedrug induced pleural diseasesradiotheraphy hemothorax/chylothrx

  • eksudatYellow nail syndromTrapped lungElectric burnUrinary tract obstructionIatrogenic injury

  • Eksudat (efusi plera)INFEKSI: Pyogenic bact inf Tuberculosis Actinomycosis and nocrdiosis Funngal inf Viral inf Parasitic infGASTROINTEST : 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.lymphadenopthySjogrens sy Churg Strauss syWegeners gr.tosisDRUG INDUCED Nitrofurantoin Dantrolene Methylsergid Bromocriptine Procarbacine Amiodarone

  • DX TEST FOR PL FLUIDAPPEARANCEPROTEINLDHGLUCOSEAMYLASEWHITE CELL COUNT/DIFF CYTOLOGYPCR/CHROMOSOM/MONOCLONAL ABCULTURE/STAINSPH/PCO2ANAADENOSINE DEAMINASE

  • RADIOGRAPHIC TESTSLATERAL DECUBITUS CHEST ROULTRASONOGRAPHYCOMPUTED TOMOGRAPHYMAGNETIC RESONANCE IMAGINGANGIOGRAPHY

  • INVASIVE TESTNEEDLE BIOPSY OF THE PLEURA

    BRONCHOSCOPY

    THORACOSCOPY

    OPEN BIOPSY OF THE PLEURA

  • CHF PL.EFFUSIONSTHERAPHY:

    = CHF.PATHOFISIOLOGY:

  • PERICARDIAL DIS.60% CONSTR PERICRDIS ---> EFF PL(TENDED LEFT)MECHANISM : CAPIL.PRESS > ( ??? )THERAPHY

    = PERICARD DIS

  • HEPATIC HYDROTHX.PATHOFISIOLOGY: - DIAFR.DEFECT - ONCOTIC PRES. PL.EFFUSIONS ( 30 DAYS --)LAB: PROTEIN < 1GR % LDH LEVEL LOWTHERAPHY: - CLOS.DIAFR DEFECT -> PLDESIS - PLEURODESIS. - THORACOTOMY

  • MYXEDEMA MYXEDEMA - PERICRDIS -> EFF PL (50%) --- TRANSUDATEMYXEDEMA - EFF PL TR/EXUDATE.

    THERAPHY : - THYROID REPLACEMENT

  • PARAPNEUMONIC EFFUSIONS AND EMPYEMA PL.EFF
  • PARAPNEUMONIC PL.EFFUSIONSSTAGE 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 BACTERIOLOGYBX 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 ANATOMYA0 MINIMAL, FREE-FLOWING EFFUSION (< 10 MM ON LATERAL DECUBITUS OR ULTRASOUND)

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

    A2 LARGE, FREE-FLOWING EFFUSION (> HEMITHORAX) OR LOCULATED EFFUSION OR EFFUSION WITH THICKENED PARIETAL PLEURA ACCP CONSENSUS, CHEST 2000, 118:115-1171.

  • PLEURAL FLUID CHEMISTRYCX pH UNKNOWN

    C0 pH > 7.20

    C1 pH < 7.20

    pH MUST BE MEASURED WITH BLOOD GAS MACHINEIF pH UNAVAILABLE, A GLUCOSE OF 60 MG/DL CAN BE USED

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

  • CATEGORY AND TREATMENT1 AO AND BX AND CX NO DRAINAGE2 A1 AND B0 AND CO NO DRAINAGE3 A2 OR B1 OR C1 DRAINAGE4 - B2 (PUS) DRAINAGE THERAPEUTIC THORACENTESIS OR CHEST TUBE ALONE ARE INSUFFICIENT FOR MOST PATIENTS WITH CATEGORY 3 OR 4FIBRINOLYTICS, THORACOSCOPY OR THORACOTOMY ARE ACCEPTABLE APPROACHES FOR MANAGING PATIENTS WITH CATEGORY 3 OR 4 ACCP CONSENSUS, CHEST 2000, 118:115-1171.

  • TREATMENT OF PARAPNEUMONIC EFFUSIONIF FLUID IS LOCULATED, INSERT CHEST TUBE AND INSTILL FIBRINOLYTICS DAILYIF FIBRINOLYTICS INEFFECTIVE, THORA-COSCOPY WITH BREAKDOWN OF ADHESIONSIF THORACOSCOPY UNSUCCESSFUL, FULL THORACOTOMY WITH DECORTICATIONIF FLUID MORE THAN 10 MM IN THICKNESS ON DECUBITUS, PERFORM THERAPEUTIC THORACENTESISALL THE ABOVE WITHIN 10 DAYS

  • TREATMENT OF RECURRENT PARAPNEUMONIC EFFUSIONIF FLUID RECURS AFTER THERAPEUTIC THORACENTESISREPEAT THERAPEUTIC THORACENTESIS IF SMEARS OR CULTURES POSITIVE, GLUCOSE < 60, pH < 7.00, OR LDH MORE THAN 3XOBSERVE IF NONE OF THE ABOVE AND PATIENT DOING WELLIF FLUID RECURS A SECOND TIMEINSERT CHEST TUBE IF SMEARS OR CULTURES POSITIVE, GLUCOSE < 60, pH < 7.00, OR LDH MORE THAN 3X ON SECOND THERAPEUTIC THORACENTESISOBSERVE IF NONE OF THE ABOVE AND PATIENT DOING WELL

  • PL.EFF THERAPHY THORACENTESISCHEST TUBEINTR.PL THROMBOLYTIC AGENTSTHORACOSCOPY DECORTICATIONOPEN DRAINAGE/ELOESSERS FLAP

  • WATERSEALED DRAINAGE (WSD)

  • PL.EFFUSIONS DX.ANAMNESE: SESAK TIMBUL PELAN TIDUR TELENTANG/MIRING KE SEHAT ---- SESAK > AX ETIOLOGIS

  • PL.EFFUSIONS DXINSPEKSI : TRACHEA ---> , CEMBUNGPALPASI : TRACHEA DEV.CEMBUNG STEM FREMITUS