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 < / -
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