Is the pleural effusion a transudates or exudates?

Sign	transudates	exudates
comparative density	< 1,015-1,018	>1,018
Rivalt test	negative	positive
protein	<30 g/l	>30 g/l
Pleural fluid protein/serum protein ratio	<0,5	>0,5
LDH	<1,6 mMol/l	>1,6 mMol/l
Pleural fluid LDG/serum LDG ratio	<0,6	>0,6
erythrocytes	<10*109/l	>100*109/l
leucocytes	<1*109/l	>1*109/l
pH	>7,3	<7,3
glucose	3,3-5,5 mMol/l	<3,3 mMol/l

A pneumothorax is an air in the pleural space; may occur with apparently normal lungs (primary pneumothorax) or in the presence of underlying lung disease (secondary pneumothorax); may occur spontaneously or following trauma.

Causes of pneumothorax:

1. It occurs following an air leak from apical bullae.

2. Underlying diseases: COPD, asthma, interstitial lung disease, necrotizing pneumonia, tuberculosis, Pneumocystis carinii pneumonia, cystic fibrosis, Langerhans’cell histiocytosis, lymphangioleiomyomatosis, Marfan’s syndrome, oesophageal rupture, lung cancer, catamenial pneumothorax, pulmonary infarction.

Spontaneous – due to rupture of blebs, usually in thin tall young males with history of smoking

Traumatic – iatragenic (i.e. subclavian central line insertion, excessive PPV, thoracic surgery, transbronchial lung biopsy) or penetrating chest trauma (knife, bullet).

Tension – most serious: air enters on inspiration but cannot escape on expiration = pneumothorax size increases with each breath. Lung eventually collapses under increasing pressures.

Symptoms of pneumothorax:

• Acute pleuritic chest pain due to rupture of pleura

• Acute breathlessness. It is often minimal in young patients and is more severe in secondary pneumothorax and if it is tension pneumothorax/

• Sometimes can be dry cough.

Signs of pneumothorax

Visual examination: It is severe condition of the patient. He has tachypnea, cyanosis, tachycardia. May be feel “bubbles” and “crackles” under the skin of the torso and neck if there is subcutaneous emphysema.

Visual examination of the chest: Chest is asymmetric – affected side is increased. There is diminished chest excursion on the affected side. Auxiliary muscles take part in breathing.

Palpation of the chest

It is obtained absent tactile vocal fremitus, because air in pleural space damps acoustic waves. Chest resistance is increased. Sometimes there is a tenderness of the pleural points, positive Potendzher symptom; because pleura is involved to pathology process and surrounded tissues react to this.

Percussion of the chest

Comparative percussion: Over affected lung the percussion sound is hyper-resonant.

Topographic percussion: Erroneously the lower border of the affected lung descends down and apex of lung lifts up when you make percussion but in reality lung collapses. Lower lung border excursion is absent.

Auscultation of the lung

There is quiet or absent breath sounds on the pneumothorax side.

X-ray signs of pneumothorax: no lung markings on affected side peripheral to edge of collapsed lung and depressed diaphragm, tracheal/mediastinal shift to unaffected side.

Atelectasis is complex of symptoms and signs when part of lung or whole lung doesn’t content air or content less air than normal and it collapses.

Classification:

Obstructive – due to occlusion of the airways

Compressive – due to pressure of lung by fluid or air in pleural space.

Causes of obstructive atelectasis:

1. Central lung cancer

2. Characinoid of bronchus

3. Foreign body of bronchus

4. Tumor of mediastinum

5. Enlarged lymphonodules of mediastinum or tracheal-bronchial, bronchial-pulmonary ones due to tuberculosis or metastasis.

Causes of compressive atelectasis:

1. Pleural effusion

2. Pneumothorax

3. Tumor of pleura

4. Deformation of chest.

Sign and symptoms of obstructive atelectasis

Breathlessness

Visual examination

If atelectasis large, there is severe condition o patient, tachypnea, cyanosis. Chest is asymmetric – affected side and chest excursion is diminished.

Palpation of the chest

It is obtained diminished or absent tactile vocal fremitus, because collapsed lung tissue damps acoustic waves. Chest resistance is increased.

Comparative percussion: It is dullness over atelectasis.

Topographic percussion: Lower lung border is lifted up by collapsed segments.

Auscultation of the lung

There are no any sounds over the atelectasis because air doesn’t come into alveoli.

Sign and symptoms of compressive atelectasis

Breathlessness

Visual examination

If atelectasis large, there is severe condition o patient, tachypnea, cyanosis. Chest is asymmetric – affected side is bigger than normal and chest excursion is diminished.

Palpation of the chest

It is obtained diminished or absent tactile vocal fremitus, because collapsed lung tissue damps acoustic waves. Chest resistance is increased.

Comparative percussion: It is dullness over atelectasis.

Topographic percussion: Lower lung border is lifted up by collapsed segments.

Auscultation of the lung

There is diminished bronchial sound over the atelectasis because collapsed lung tissue conducts acoustic waves from bronchus.

X-ray signs of atelectasis and addicted methods of diagnostics of atelectasis.

Diminished volume and elevated hemidiaphragm on affected side; mediastinal shift to affected side; increased opacity; scattered densities.

Materials for self-control (added)

7. Reference source

• Handbook of diseases.-.2^nd ed.- Springhouse Corporation, 2000 – P.85-86, 658-659, 668-669.

Professor assistant Demchuk H.V.