makalaah inggris
TRANSCRIPT
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CHAPTER 1
INTRODUCTION
1.1 Background
Every year more than 60,000 Americans die of pneumonia.Its aparticular concern for
older adults and peoplewith chronic illness or impaired immune systems,but it can also strike
young,healthy people.
There are many kinds of pneumonia ranging in seriousness from mild to
threatening.Pneumonia acquired while in the hospital can be particulary virulent anddeadly.Normally, very small amounts of pleural fluid are present in the pleural spaces, and
fluid is not detectable by routine methods. When certain disorders occur, excessive pleural
fluid may accumulate and cause pulmonary signs and symptoms. Simply put, pleural
effusions occur when the rate of fluid formation exceeds that of fluid absorption. Once a
symptomatic, unexplained pleural effusion occurs, a diagnosis needs to be established
Pleural effusions may not produce any symptoms in some patients. Others may
experience shortness of breath, a dry, non-productive cough, or pleuritic-type chest pain (a
sharp pain, usually on breathing in, which worsens with coughing). See your doctor if you areworried about any of these symptoms. Other patients may complain of symptoms stemming
from the cause of their effusion, for example swollen legs or feet in congestive heart failure.
Pleural effusion is defined as the collection of at least 10-20 mL of fluid in the pleural space.
Pleural effusion develops because of excessive filtration or defective absorption of
accumulated fluid. Pleural effusion may be a primary manifestation or a secondary
complication of many disorders. The clinical picture and presenting symptoms depend on the
underlying disease and the size of the effusion.
Pleural effusion is a condition very commonly related to pneumonia. Pleural effusion
commonly caused by bacterial infection, like Streptococcus, and then other risk factor. This
disease easily found in developing countries and several in England, Canada, USA.
Rarely, some patients may require further treatment for effusions which do not resolve, or
which recur despite repeated thoracentesis. They may undergo a procedure called
pleurodesis (pleural sclerosis), where a chemical is injected into the pleural space to induce
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scarring. This scarring sticks the two layers of pleura together so that no fluid can accumulate
between them.
1.2 Problems
The problem that will be discussed in this paper is the mechanism that links
pneumonia to pleural effusion.This thesis will explain in detail both diseases as individual and
linked subjects.
There are two thin membranes in the chest, one (the visceral pleura) lining the lungs, and the
other (the parietal pleura) covering the inside of the chest wall. Normally, small blood vessels
in the pleural linings produce a small amount of fluid that lubricates the opposed pleural
membranes so that they can glide smoothly against one another during breathing
movements. Any extra fluid is taken up by blood and lymph vessels, maintaining a balance.
When either too much fluid forms or something prevents its removal, the result is an excess
of pleural fluid--an effusion. The most common causes are disease of the heart or lungs, and
inflammation or infection of the pleura.
There are two types of pleural effusion: the transudate and the exudate. This is a very
important point because the two types of fluid are very different, and which type is present
points to what sort of disease is likely to have produced the effusion. It also can suggest the
best approach to treatment.
Some of the pleural disorders that produce an exudate also cause bleeding into the
pleural space. If the effusion contains half or more of the number of red blood cells present in
the blood itself, it is called hemothorax. When a pleural effusion has a milky appearance and
contains a large amount of fat, it is called chylothorax. Lymph fluid that drains from tissues
throughout the body into small lymph vessels finally collects in a large duct (the thoracic duct)
running through the chest to empty into a major vein. When this fluid, or chyle, leaks out of
the duct into the pleural space, chylothorax is the result. Cancer in the chest is a common
cause.
Pleural effusions may also be associated with the leakage of fluid due to higher than
normal pressures in the lung circulation, such as with congestive heart failure (CHF) or from
low protein in the blood, as in liver disease, severe malnutrition, and in certain kidney
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conditions when protein is filtered into the urine. Infection, blockage of blood supply to the
lung (Pulmonary Embolism), or cancer in the lung itself can result in accumulation of fluid in
the pleural space. If pleural effusions become infected with bacteria, inflammatory reaction
results that creates an abscess in the pleural space (empyema).
The inner surface of the chest wall and the surface of the lungs are covered by the parietal
and visceral pleural, respectively, with a potential space of 10-24 m between the 2 pleural
surfaces. This space is normally filled with a small amount of fluid. However, large amounts of
fluid can accumulate in the pleural space under pathologic conditions. The parietal pleura
have sensory innervation and small apertures that aid in the absorption of particles and fluid.
Systemic arterial vessels supply both pleural surfaces. Lymphatic vessels from the parietal
pleura drain to lymph nodes along the anterior and posterior chest wall, whereas lymphatics
from the visceral surface drain to the mediastinal lymph nodes. The pleural space normally
contains 0.1-0.2 mL/kg of a colorless alkaline fluid, which has
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erythematosus effusions are usually small, bilateral and are polymorphonuclear exudates.
The finding of an ANA titer that exceeds that of serum is diagnostic. Severe pleurisy is
frequent.
With a pleural effusion, some imbalance between production and reabsorption of
pleural fluid leads to excess fluid building up in the pleural space.
Pleural effusions may not produce any symptoms in some patients. Others may experience
shortness of breath, a dry, non-productive cough, or pleuritic-type chest pain (a sharp pain,
usually on breathing in, which worsens with coughing). See your doctor if you are worried
about any of these symptoms.
1.3 Limitations of problem
There are some limited established in this paper in order to prevent an over discussion of
the subject matter.The limits will only include:
What is the definition of the disease?
What causes disease?
Who can get disease?
How does the mechanism of the
disease work?
What are the symptoms of the
disease?
How is the disease diagnosed?
What treatments can be used to cure
the disease?
What complications can happen from
the disease?
What is the prognosis for someone
who suffers from the disease?Eventhough there may be some extra details added,they only serve to help clarify the
correlation between the two diseases.
1.4 Objectives
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The purpose of this paper is to provide the reader with more information in regards to
pneumonia and pleural effusion and the relation between two diseases. By, reading this
paper, the reader will obtain facts regarding.
- The definition of pneumonia and pleural effusion
- The etiology of pneumonia and pleural effusion
- The epidemiologi of pneumonia and pleural effusion
- The pathophysiology of pneumonia and pleural effusion
- The symptoms of pneumonia and pleural effusion
- The tests used to diagnose pneumonia and pleural effusion
- The treatments used of pneumonia and pleural effusion- The complications of pneumonia and pleural effusion
- The prognosis of pneumonia and pleural effusion
Furthermore, by being informed hopefully the reader realized the seriousness of this two
diseases.
1.5 Method of writing
The creation of this paper is made the possible with the aid of various sources such
as the the library, internet, and journal of medicine.
1.6 Frame of writing
CHAPTER I. INTRODUCTION
I.1 Background
I.2 Problems
I.3 Limitation of problem
I.4 Objectives
I.5 Method of writing
CHAPTER II. PNEUMONIA
CHAPTER III. PLEURAL EFFUSIONCHAPTER IV. THE CORRELATION BETWEEN PNEUMONIA AND PLEURAL EFFUSION
CHAPTER V. CONCLUSION
CHAPTER VI. BIBLIOGRAPHY
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CHAPTER II
PNEUMONIA
2.1 DEFINITION
Pneumonia is an illness of the lungs and respiratory system in which the
alveoli(microscopic air-filledsacs of the lung responsible for absorbing oxygen from
atmosphere)become inflamed and flooded with fluid.It also occurs in all age groups and is
aleading cause of death among the elderly and people who are chronically and terminally ill.
Pneumonia may also occur from chemical or physical injury to the lungs or indirectly
due to another medical illness,such as lung cancer or alcohol abuse.
2.2 Etiology
Your lungs are two spongy organs surrounded by amoist membrane(the pleura).Each
lung is divided into lobes(three on the right and two on the left).When you inhale,air is carried
through the windpipe(trachea) to your lungs.Inside your lungsthere are major airways calledbronchi.The bronchi repeatedly subdivide into many smaller airways (branchioles),which
finally end in clusters of tiny air sacs called alveoli.
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Your body has mechanisms to protect your lungs from infections.In fact,youre
frwquently exposed to bacteria and viruses that can causes pneumonia,but your body
normally prevents most of these organisms from invading and overwhelming your airways.
There,white blood cells(leukocytes),a key part of your immune system,began to attack
the invading organisms.The accumulating pathogens,white cells and immune proteins cause
tha air sacs to become inflamed and filled with fluid,leading to the difficult breathing that
characterizes many types of pneumonia.If both lungs are involved,its called double
pneumonia.
2.3 Epidemiology
Pneumonia is acommon illness in all parts of the world .It is major cause of death
among all age groups.In children,the majority of deaths occur in the newborn period,with over
twomillion deaths ayear worldwide.The WHO(World Health Organization) estimates that one
in three newborn infant deaths are due to pneumonia.Mortality from pneumonia generally
decreases with age until late adulthood.Elderly individuals,however,are at particular risk for
pneumonia and associated mortality.
More cases of pneumonia occur during the winter months than during other times of
the year.Pneumonia occurs more commonlyin males than females,and more often blacks
than Caucasians.Individuals with underlying illness such as Alzheimers disease,cystic
fibrosis,emphysema,tobacco smoking,alcoholism or immune system problems.
2.4 CLASSIFICATION
Pneumonia is some times classified according to the cause of pneumonia:
Community acquired pneumonia.This refers to pneumonia you acquire in the course of
your daily life at school,work or the gwm,for instance
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Hospital-acquired (nosocomial) pneumonia.If youre hospitalized,youre at higher risk
of pneumonia,especially if you are on mechanical ventilator,are intensive care unit or
have a compromised immune system.
Aspiration pneumonia.This type of pneumonia is consuming too much alcohol.This
happens when the inebriated person passes out,and then vomits due to the effects of
alcohol anthe stomach.
2.5 PATHOPHYSIOLOGY
The symptoms of infectious pneumonia are caused by the invasion of the lungs by
microorganisms and by the immune systems response to the infection.Although over onehundred stains of microorganism can cause pneumonia,only a few of them are responsible
for most cases.The most common causes of pneumonia are viruses and bacteria.Less
common causes of infectious pneumonia include fungi and parasites.
2.6 SIGN AND SYMPTOMS
Pneumonia can be difficult to spot .t often mimics a cold or the flu,beginning with a
cough and a fever, so you may not realize you have a more serious condition.Chest pain is
acommon symptom of many types of pneumonia.Pneumonia symptoms can vary
greatly,depending on any underlying conditions you may have and the typeof organisms
causing the infection:
Bacteria
Viruses
Mycoplasma
Fungi
Pneumocystis carinii
2.7 TEST AND DIAGNOSIS
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Thoracoscopy is an excellent technique to determine the etiology of an undiagnosed
exudative pneumonia. The procedure is superior to the old closed pleural biopsy techniques
because of its higher diagnostic yield. A rigid thoracoscope with a cold light source is used
and second point of entry is necessary to provide biopsy forceps access to the pleural space.
This technique continues to be most helpful in diagnosing malignant effusions (including
mesothelioma), tuberculosis, and trapped lung
2.8 TREATMENT AND THERAPY
The best way to clear up a pneumonie is to direct treatment at what is causing it, rather
than treating the effusion itself. If heart failure is reversed or a lung infection is cured by
antibiotics, the effusion will usually resolve. However, if the cause is not known, even after
extensive tests, or no effective treatment is at hand, the fluid can be drained away by placing a
large-bore needle or catheter into the pleural space, just as in diagnostic thoracentesis. If
necessary, this can be repeated as often as is needed to control the amount of fluid in the
pleural space. If large effusions continue to recur, a drug or material that irritates the pleural
membranes can be injected to deliberately inflame them and cause them to adhere close
together--a process called sclerosis. This will prevent further effusion by eliminating the
pleural space. In the most severe cases, open surgery with removal of a rib may be necessary
to drain all the fluid and close the pleural space
2.9 COMPLICATION
Bacteria in bloodstream
Fluid accumulation an infection around the lung
Lung abscess
Respiratory and circulatory failure
Pleural effusion
Emphysema
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2.10 PROGNOSIS
Pneumonia can be determined and effectively treated, the effusion itself will
reliably clear up and should not recur. In many other cases, sclerosis will prevent
sizable effusions from recurring. Whenever a large effusion causes a patient to be
short of breath, thoracentesis will make breathing easier, and it may be repeated if
necessary. To a great extent, the outlook for patients with pleural effusion depends on
the primary cause of effusion and whether it can be eliminated. Some forms of pleural
effusion, such as that seen after abdominal surgery, are only temporary and will clear
without specific treatment. If heart failure can be controlled, the patient will remain
free of pleural effusion. If, on the other hand, effusion is caused by cancer that cannot
be controlled, other effects of the disease probably will become more important.
CHAPTER III
PLEURAL EFFUSION
3.1 DEFINITION
Pleural effusion is the buildup of excess fluid in the space between the pleura. Thepleura are two thin, moist membranes around the lungs. There are two layers of pleura:
Inner layer attached to the outside of the lungs
Outer layer lines the inside of the ribcage
Pleural effusion occurs when too much fluid collects in the pleural space (the space
between the two layers of the pleura). It is commonly known as "water on the lungs." It is
characterized by shortness of breath, chest pain, gastric discomfort (dyspepsia), and cough.
There are two thin membranes in the chest, one (the visceral pleura) lining the lungs, and theother (the parietal pleura) covering the inside of the chest wall. Normally, small blood vessels
in the pleural linings produce a small amount of fluid that lubricates the opposed pleural
membranes so that they can glide smoothly against one another during breathing
movements. Any extra fluid is taken up by blood and lymph vessels, maintaining a balance.
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When either too much fluid forms or something prevents its removal, the result is an excess
of pleural fluid--an effusion. The most common causes are disease of the heart or lungs, and
inflammation or infection of the pleura
3.2 ETIOLOGY
The etiology of transudative pleural effusion
Among the most important specific causes of a transudative pleural effusion are:
Congestive heart failure. This causes pleural effusions in about 40% of patients and is
often present on both sides of the chest. Heart failure is the most common cause of
bilateral (two-sided) effusion. When only one side is affected it usually is the right
(because patients usually lie on their right side).
Pericarditis. This is an inflammation of the pericardium, the membrane covering the
heart.
Too much fluid in the body tissues, which spills over into the pleural space. This is
seen in some forms of kidney disease; when patients have bowel disease and absorb
too little of what they eat; and when an excessive amount of fluid is given
intravenously.
Liver disease. About 5% of patients with a chronic scarring disease of the liver called
cirrhosis develop pleural effusion.
The etiology of exudative pleural effusions
A wide range of conditions may be the cause of an exudative pleural effusion:
Pleural tumors account for up to 40% of one-sided pleural effusions. They may arise
in the pleura itself (mesothelioma), or from other sites, notably the lung.
Tuberculosis in the lungs may produce a long-lasting exudative pleural effusion.
Pneumonia affects about three million persons each year, and four of every ten
patients will develop pleural effusion. If effective treatment is not provided, an
extensive effusion can form that is very difficult to treat.
Patients with any of a wide range of infections by a virus, fungus, or parasite that
involve the lungs may have pleural effusion.
Up to half of all patients who develop blood clots in their lungs (pulmonary embolism)
will have pleural effusion, and this sometimes is the only sign of embolism.
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Connective tissue diseases, including rheumatoid arthritis, lupus, and Sjgren's
syndrome may be complicated by pleural effusion.
Patients with disease of the liver or pancreas may have an exudative effusion, and the
same is true for any patient who undergoes extensive abdominal surgery. About 30%
of patients who undergo heart surgery will develop an effusion.
Injury to the chest may produce pleural effusion in the form of either hemothorax or
chylothorax.
3. 3 EPIDEMIOLOGI
In the US : Pleural effusion affects 1.3 million individuals each year. Approximate annual
incidences of pleural effusions are based on major underlying disease processes, as follows:
congestive heart failure, 500,000; bacterial pneumonia, 300,000; malignancy, 200,000;
pulmonary embolus, 150,000; cirrhosis with ascites, 50,000; pancreatitis, 20,000; and
tuberculosis, 2,500.
Internationally : The relative annual incidence of pleural effusion is estimated to be 320 per
100,000 people in industrialized countries. When extrapolating these figures to apply to other
countries, the distribution and incidence of pleural effusion causes are dependent on the
population studied.
I
3.4 CLASSIFICATION
There are two types of pleural effusion: the transudate and the exudate. This is a very
important point because the two types of fluid are very different, and which type is present
points to what sort of disease is likely to have produced the effusion. It also can suggest the
best approach to treatment.
Transudates
A transudate is a clear fluid, similar to blood serum, that forms not because the pleural
surfaces themselves are diseased, but because the forces that normally produce and remove
pleural fluid at the same rate are out of balance. When the heart fails, pressure in the small
blood vessels that remove pleural fluid is increased and fluid "backs up" in the pleural space,
forming an effusion. Or, if too little protein is present in the blood, the vessels are less able to
hold the fluid part of blood within them and it leaks out into the pleural space. This can result
from disease of the liver or kidneys, or from malnutrition.
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Exudates
An exudate--which often is a cloudy fluid, containing cells and much protein--results from
disease of the pleura itself. The causes are many and varied. Among the most common are
infections such as bacterial pneumonia and tuberculosis; blood clots in the lungs; and
connective tissue diseases, such as rheumatoid arthritis. Cancer and disease in organs such
as the pancreas also may give rise to an exudative pleural effusion.
Special types of pleural effusion
Some of the pleural disorders that produce an exudate also cause bleeding into the pleural
space. If the effusion contains half or more of the number of red blood cells present in the
blood itself, it is called hemothorax. When a pleural effusion has a milky appearance and
contains a large amount of fat, it is called chylothorax
3.5 PATHOPHYSIOLOGY
The inner surface of the chest wall and the surface of the lungs are covered by the
parietal and visceral pleural, respectively, with a potential space of 10-24 m between the 2
pleural surfaces. This space is normally filled with a small amount of fluid. However, large
amounts of fluid can accumulate in the pleural space under pathologic conditions. The
parietal pleura have sensory innervation and small apertures that aid in the absorption of
particles and fluid.
3.6 SIGN AND SYMPTOMS
Some types of pleural effusion do not cause symptoms. Others cause a variety of symptoms,
including:
Shortness of breath
Chest pain
Stomach discomfort
Cough
Coughing up blood
Shallow breathing
Rapid pulse or breathing rate
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Weight loss
Fever, chills, or sweating
Hiccupping
Pleuritic chest pain, chest pressure, dyspnea, and cough are the most common
symptoms of pleural effusion. Pain may occur with little fluid formation as the symptom is
related to the intense inflammation of the pleural surfaces. Chest pressure usually does not
occur until the effusion is in the moderate (500-1500 ml) to large (>1500 ml) category.
Dyspnea rarely occurs with small effusions unless significant pleurisy is present and often the
patient will not complain of dyspnea until the effusion is massive with contralateral
mediastinal shift on the chest x-ray. Cough is usually related to the associated atelectasis,
which to some degree accompanies all pleural effusions. Classic physical findings associated
with pleural effusions may occur when the volume begins to exceed 500 ml and include
diminished breath sounds, dullness to percussion, reduced tactile and vocal fremitus, and
occasionally a pleural friction rub. In contrast to pneumonia and atelectasis, crackles are not
heard with an isolated pleural effusion
3.7 TEST AND DIAGNOSIS
The doctor will ask about your symptoms and medical history, and perform a physical
exam. This may include listening to or tapping on your chest.
When pleural effusion is suspected, the best way to confirm it is to take chest x rays, both
straight-on and from the side. The fluid itself can be seen at the bottom of the lung or lungs,
hiding the normal lung structure. If heart failure is present, the x-ray shadow of the heart will
be enlarged. An ultrasound scan may disclose a small effusion that caused no abnormal
findings during chest examination. A computed tomography scan is very helpful if the lungs
themselves are diseased.
3.8 TREATMENT AND THERAPY
The best way to clear up a pleural effusion is to direct treatment at what is causing it,
rather than treating the effusion itself. If heart failure is reversed or a lung infection is cured by
antibiotics, the effusion will usually resolve. However, if the cause is not known, even after
extensive tests, or no effective treatment is at hand, the fluid can be drained away by placing
a large-bore needle or catheter into the pleural space, just as in diagnostic thoracentesis. If
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necessary, this can be repeated as often as is needed to control the amount of fluid in the
pleural space. If large effusions continue to recur, a drug or material that irritates the pleural
membranes can be injected to deliberately inflame them and cause them to adhere close
together--a process called sclerosis. This will prevent further effusion by eliminating the
pleural space. In the most severe cases, open surgery with removal of a rib may be
necessary to drain all the fluid and close the pleural space
3.9 COMPLICATIONS
A lung surrounded by a fluid collection for a long time may collapse. Pleural fluid that
becomes infected may turn into an abscess, called an empyema, which requires prolonged
drainage with a chest tube placed into the fluid collection. Pneumothorax (air within the chest
cavity) can be a complication of the thoracentesis procedure.
3.10 PROGNOSIS
When the cause of pleural effusion can be determined and effectively treated, the
effusion itself will reliably clear up and should not recur. In many other cases, sclerosis will
prevent sizable effusions from recurring. Whenever a large effusion causes a patient to be
short of breath, thoracentesis will make breathing easier, and it may be repeated if
necessary.
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CHAPTER IV
THE CORRELATION BETWEEN PNEUMONIA AND PLEURAL
EFFUSION
4.1 CASE
An estimated 45 million cases of infectious pneumonia occur annually in the United
States, with up to 50,000 deaths directly attributable to it. Pneumonia is a common immediate
cause of death in persons with a variety of underlying diseases. With the use of
immunosuppressive and chemotherapeutic agents for treating transplant and cancer patients,
pneumonia caused by infectious agents that usually do not cause infections in healthy
persons (that is, pneumonia as an opportunistic infection) has become commonplace.
Moreover, individuals with acquired immune deficiency syndrome (AIDS) usually die from an
opportunistic infection, such as pneumocystis pneumonia or cytomegalovirus pneumonia.
Concurrent with the variable and expanding etiology of pneumonia and the more frequent
occurrence ofopportunistic infections is the development of new antibiotics and other drugs
used in the treatment of pneumonia. See also Acquired immune deficiency syndrome (AIDS);
Opportunistic infections.
A 70-year-old man with an 80-pack-year history of smoking and a history of
congestive heart failure presents with increasing shortness of breath. He also has aching
chest pain on the right side that worsens with deep inspiration. He is a febrile. The chest
radiograph reveals bilateral pleural effusions, with morepleural fluid on the right than on the
left. How should thispatient be evaluated?
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Although many different diseases may cause a pleural effusion, the most common
causes in the United States are congestiveheart failure, pneumonia, and cancer. The diagnostic
workup of a patient with a pleural effusion will depend on the probable causes. Because
pleural effusion is a secondary effect of many different conditions, the key to preventing it is
to promptly diagnose the primary disease and provide effective treatment. Timely treatment of
infections such as tuberculosis and pneumonia will prevent many effusions. When effusion
occurs as a drug side-effect, withdrawing the drug or using a different one may solve the
problem.
Although antibiotics can treat some of the most common forms of bacterial
pneumonias, antibiotic-resistant strains are a growing problem. For that reason, and because
the disease can be very serious, it's best to try to prevent infection in the first place. The
history and the physical examination are critical in guidingthe evaluation of pleural effusion.
Several aspects of the physical examination should receive special attention. Chest
examinationtypically reveals dullness to percussion, the absence of fremitus,and diminished
breath sounds or their absence. Distended neck veins, an S3 gallop, or peripheral edema
suggests congestiveheart failure, and a right ventricular heave or thrombophlebitissuggests
pulmonary embolus. The presence of lymphadenopathyor hepatosplenomegaly suggests
neoplastic disease, and ascitesmay suggest a hepatic cause.
Since conditions other than pleural effusions may produce similarradiologic findings,
alternative imaging studies are frequently necessary to verify that a pleural effusion is
present. Ultrasonographicstudies or lateral decubitus radiographs are used most commonly,
but computed tomographic (CT) scans of the chest allow imaging of the underlying lung
parenchyma or mediastinum
4.2 PathogeneisMost cases of pneumonia and pleural effusion are contracted by breathing in small
droplets that contain the bacteria or virus that can cause pneumonia. These droplets get into
the air when a person infected with these germs coughs or sneezes. In other cases,
pneumonia is caused when bacteria or viruses that are normally present in the mouth, throat,
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or nose inadvertently enter the lung. During sleep it is quite common for people to aspirate
secretions from the mouth, throat, or nose. Normally, the body's reflex response (coughing
back up the secretions) and immune system will prevent a pneumonia from starting.
However, if a person is in a weakened condition from another illness, a severe pneumonia
can develop. People with emphysema, heart disease, and swallowing problems, as well as
alcoholics, drug users and those who have suffered a stroke or seizure are at higher risk for
developing pneumonia.
Once the bacteria, virus or fungus enter the lungs, they usually settle in the air sacs of
the lung where they rapidly grow in number. This area of the lung then becomes filled with
fluid and pus as the body attempts to fight off the infection.
The cause of the effusion remains unclear in the cases of asubstantial percentage of
patients with exudative effusions after the history, physical examination, and analysis of
pleural fluid.32 If the effusion persists despite conservative treatment, thoracoscopy should
be considered, since it has a high yield for cancer or tuberculosis. If thoracoscopy is
unavailable, alternative invasive approaches are needle biopsy and open biopsy of the
pleura. No diagnosis is ever established for approximately 15 percent of patients despite
invasive procedures such as thoracoscopyor open pleural biopsy.
Pleural effusion in cancer patients can be caused by several different conditions.
Blockage of the lymphatic system, a series of channels for drainage of body fluids, interferes
with the removal of pleural fluid. Blockage of the veins of the lungs increases the pressure at
the pleurae which causes fluid accumulation. Cancerous cells may seed onto pleurae and
cause inflammation which increases fluid in the pleural space. High numbers of cancerous
cells may collect in the pleural space (tumorcell suspensions) which causes extra fluid to be
released. Accumulation of fluid in the abdominal cavity may cross over to the pleural space.
Pneumonia and Pleural effusion itself is not a disease as much as a result of many
different diseases. For this reason, there is no "typical" patient in terms of age, sex, or other
characteristics. Instead, anyone who develops one of the many conditions that can produce
an effusion may be affected.
-symptoms
Pneumonia and pleural effusion suspected in any patient who has fever, cough, chest
pain, shortness of breath, and increased respirations (number of breaths per minute). Fever
18
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with a shaking chill is even more suspicious. Many patients cough up clumps of sputum,
commonly known as spit. These secretions are produced in the alveoli during an infection or
other inflammatory condition. They may appear streaked with pus or blood. Severe
pneumonia results in the signs of oxygen deprivation. This includes blue appearance of the
nail beds or lips (cyanosis).
The invading organism causes symptoms, in part, by provoking an overly-strong
immune response in the lungs. In other words, the immune system, which should help fight
off infections, kicks into such high gear, that it damages the lung tissue and makes it more
susceptible to infection. The small blood vessels in the lungs (capillaries) become leaky, and
protein-rich fluid seeps into the alveoli. This results in less functional area for oxygen-carbon
dioxide exchange. The patient becomes relatively oxygen deprived, while retaining potentially
damaging carbon dioxide. The patient breathes faster and faster, in an effort to bring in more
oxygen and blow off more carbon dioxide.
Mucus production is increased, and the leaky capillaries may tinge the mucus with
blood. Mucus plugs actually further decrease the efficiency of gas exchange in the lung. The
alveoli fill further with fluid and debris from the large number of white blood cells being
produced to fight the infection.
Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are normally
hollow air spaces within the lung, instead become solid, due to quantities of fluid and debris.
Viral pneumonias and mycoplasma pneumonias, do not result in consolidation. These types
of pneumonia primarily infect the walls of the alveoli and the parenchyma of the lung.
The key symptom of a pleural effusion is shortness of breath. Fluid filling the pleural
space makes it hard for the lungs to fully expand, causing the patient to take many breaths so
as to get enough oxygen. When the parietal pleura is irritated, the patient may have mild pain
that quickly passes or, sometimes, a sharp, stabbing pleuritic type of pain. Some patients will
have a dry cough. Occasionally a patient will have no symptoms at all. This is more likely
when the effusion results from recent abdominal surgery, cancer, or tuberculosis. Tapping on
the chest will show that the usual crisp sounds have become dull, and on listening with a
stethoscope the normal breath sounds are muted. If the pleura is inflamed, there may be a
scratchy sound called a "pleural friction rub."
19
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Most people who develop pneumonia and pleural effusion initially have symptoms of a
cold which is then followed by a high fever (sometimes as high as 104 degrees), shaking
chills, and a cough with sputum production. The sputum is often bloody. Chest pain may
develop on one side and the patient may become short of breath. In other cases of
pneumonia, there can be a slow onset of symptoms. A worsening cough, headaches, and
muscle aches may be the only symptoms. At times, the individual's skin color may change
and become dusky or purplish due to their blood being poorly oxygenated.
The signs and symptoms of pneumonia and pleural effusion are usually nonspecific,
consisting of fever, chills, shortness of breath, and chest pain. Fever and chills are more
frequently associated with infectious pneumonias but may also be seen in pneumonitis. The
physical examination of a person with pneumonia or pneumonitis may reveal abnormal lung
sounds indicative of regions of consolidation of lung tissue. A chest x-ray also shows the
consolidation, which appears as an area of increased opacity (white area). Cultures of
sputum orbronchial secretions may identify an infectious organism capable of causing the
pneumonia.
When pneuumonia and pleural effusion is suspected, the best way to confirm it is to
take chest x rays, both straight-on and from the side. The fluid itself can be seen at the
bottom of the lung or lungs, hiding the normal lung structure. If heart failure is present, the x-ray shadow of the heart will be enlarged. An ultrasound scan may disclose a small effusion
that caused no abnormal findings during chest examination. A computed tomography scan is
very helpful if the lungs themselves are diseased.
In order to learn what has caused the effusion, a needle or catheter is often used to
obtain a fluid sample, which is examined for cells and its chemical make-up. This procedure,
called a thoracentesis, is the way to determine whether an effusion is a transudate or
exudate, giving a clue as to the underlying cause. In some cases--for instance when cancer
or bacterial infection is present--the specific cause can be determined and the correcttreatment planned. Culturing a fluid sample can identify the bacteria that cause tuberculosis
or other forms of pleural infection. The next diagnostic step is to take a tissue sample, or
pleural biopsy, and examine it under a microscope. If the effusion is caused by lung disease,
placing a viewing tube (bronchoscope) through the large air passages will allow the examiner
20
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to see the
Your doctor may first suspect pneumonia and pleural effusion based on your medical
history and a physical exam. During the exam, your doctor will listen to your lungs with a
stethoscope to check for abnormal bubbling or crackling sounds (rales) and for rumblings
(rhonchi) that signal the presence of thick liquid. Both these sounds may indicate
inflammation caused by infection.
You're also likely to have chest X-rays to confirm the presence of pneumonia and
pleural effusion to determine the extent and location of the infection. Your doctor can suspect
pneumonia, but he or she can't diagnose it without a chest X-ray.
You may also have blood tests to check your white cell count, or to look for the presence of
viruses, bacteria or other organisms. Sometimes your doctor may examine a sample of your
phlegm or your blood to help identify the microorganism that's causing your illness.
The extent of all this testing depends on how sick you are and your underlying risk factors,
and whether or not you're responding to therapy.
chest x rays and computed tomography scans may be performed to diagnose pleural
effusion. Thoracentesis, the removal of pleural fluid through a long needle, is usually
performed for diagnostic purposes. Fluid removed by thoracentesis will be sent to the lab to
be thoroughly evaluated. Thoracoscopy, in which a wand-like lighted camera (endoscope) is
inserted through the chest, may be conducted to diagnose pleural effusion. During
thoracoscopy, samples (biopsy) ofpleura may be taken.
Pleural effusion can hinder the normal function of the lungs. Symptoms of pleural
effusion include chest pain, chest heaviness, breathing difficulties, and a dry cough. Patients
with malignant pleural effusions tend to be weak and have a short-span life expectancy. The
prognosis depends on the type of cancer. Sixty-five percent of patients with malignant pleural
effusions die within three months and 80% die within six months. However, patients with
pleural effusion related to breast cancer have a longer life expectancy.
Chest x rays and computed tomography scansmay be performed to diagnose pleural
effusion. Thoracentesis, the removal of pleural fluid through a long needle, is usually
performed for diagnostic purposes. Fluid removed by thoracentesis will be sent to the lab to
be thoroughly evaluated. Thoracoscopy, in which a wand-like lighted camera (endoscope) is
inserted through the chest, may be conducted to diagnose pleural effusion. During
21
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thoracoscopy, samples (biopsy) ofpleura may be taken.
Pleuritic chest pain, chest pressure, dyspnea, and cough are the most common
symptoms of pleural effusion. Pain may occur with little fluid formation as the symptom is
related to the intense inflammation of the pleural surfaces. Chest pressure usually does not
occur until the effusion is in the moderate (500-1500 ml) to large (>1500 ml) category.
Dyspnea rarely occurs with small effusions unless significant pleurisy is present and often the
patient will not complain of dyspnea until the effusion is massive with contralateral
mediastinal shift on the chest x-ray. Cough is usually related to the associated atelectasis,
which to some degree accompanies all pleural effusions. Classic physical findings associated
with pleural effusions may occur when the volume begins to exceed 500 ml and include
diminished breath sounds, dullness to percussion, reduced tactile and vocal fremitus, and
occasionally a pleural friction rub. In contrast to pneumonia and atelectasis, crackles are not
heard with an isolated pleural effusion.
4.3 SYMPTOMS
Pneumonia and pleural effusion suspected in any patient who has fever, cough, chest
pain, shortness of breath, and increased respirations (number of breaths per minute). Fever
with a shaking chill is even more suspicious. Many patients cough up clumps of sputum,
commonly known as spit. These secretions are produced in the alveoli during an infection or
other inflammatory condition. They may appear streaked with pus or blood. Severe
pneumonia results in the signs of oxygen deprivation. This includes blue appearance of the
nail beds or lips (cyanosis).
The invading organism causes symptoms, in part, by provoking an overly-strong
immune response in the lungs. In other words, the immune system, which should help fight
off infections, kicks into such high gear, that it damages the lung tissue and makes it more
susceptible to infection. The small blood vessels in the lungs (capillaries) become leaky, and
protein-rich fluid seeps into the alveoli. This results in less functional area for oxygen-carbon
dioxide exchange. The patient becomes relatively oxygen deprived, while retaining potentially
damaging carbon dioxide. The patient breathes faster and faster, in an effort to bring in more
oxygen and blow off more carbon dioxide.
Mucus production is increased, and the leaky capillaries may tinge the mucus with
blood. Mucus plugs actually further decrease the efficiency of gas exchange in the lung. The
22
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alveoli fill further with fluid and debris from the large number of white blood cells being
produced to fight the infection.
Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are normally
hollow air spaces within the lung, instead become solid, due to quantities of fluid and debris.
Viral pneumonias and mycoplasma pneumonias, do not result in consolidation. These types
of pneumonia primarily infect the walls of the alveoli and the parenchyma of the lung.
The key symptom of a pleural effusion is shortness of breath. Fluid filling the pleural
space makes it hard for the lungs to fully expand, causing the patient to take many breaths so
as to get enough oxygen. When the parietal pleura is irritated, the patient may have mild pain
that quickly passes or, sometimes, a sharp, stabbing pleuritic type of pain. Some patients will
have a dry cough. Occasionally a patient will have no symptoms at all. This is more likely
when the effusion results from recent abdominal surgery, cancer, or tuberculosis. Tapping on
the chest will show that the usual crisp sounds have become dull, and on listening with a
stethoscope the normal breath sounds are muted. If the pleura is inflamed, there may be a
scratchy sound called a "pleural friction rub."
Most people who develop pneumonia and pleural effusion initially have symptoms of a
cold which is then followed by a high fever (sometimes as high as 104 degrees), shaking
chills, and a cough with sputum production. The sputum is often bloody. Chest pain may
develop on one side and the patient may become short of breath. In other cases of
pneumonia, there can be a slow onset of symptoms. A worsening cough, headaches, and
muscle aches may be the only symptoms. At times, the individual's skin color may change
and become dusky or purplish due to their blood being poorly oxygenated.
The signs and symptoms of pneumonia and pleural effusion are usually nonspecific,
consisting of fever, chills, shortness of breath, and chest pain. Fever and chills are more
frequently associated with infectious pneumonias but may also be seen in pneumonitis. The
physical examination of a person with pneumonia or pneumonitis may reveal abnormal lung
sounds indicative of regions of consolidation of lung tissue. A chest x-ray also shows the
consolidation, which appears as an area of increased opacity (white area). Cultures of
sputum orbronchial secretions may identify an infectious organism capable of causing the
pneumonia
23
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IV.4 DIAGNOSIS
When pneuumonia and pleural effusion is suspected, the best way to confirm it is to
take chest x rays, both straight-on and from the side. The fluid itself can be seen at the
bottom of the lung or lungs, hiding the normal lung structure. If heart failure is present, the x-
ray shadow of the heart will be enlarged. An ultrasound scan may disclose a small effusion
that caused no abnormal findings during chest examination. A computed tomography scan is
very helpful if the lungs themselves are diseased.
In order to learn what has caused the effusion, a needle or catheter is often used to
obtain a fluid sample, which is examined for cells and its chemical make-up. This procedure,
called a thoracentesis, is the way to determine whether an effusion is a transudate or
exudate, giving a clue as to the underlying cause. In some cases--for instance when cancer
or bacterial infection is present--the specific cause can be determined and the correct
treatment planned. Culturing a fluid sample can identify the bacteria that cause tuberculosis
or other forms of pleural infection. The next diagnostic step is to take a tissue sample, or
pleural biopsy, and examine it under a microscope. If the effusion is caused by lung disease,
placing a viewing tube (bronchoscope) through the large air passages will allow the examiner
to see the
Your doctor may first suspect pneumonia and pleural effusion based on your medical
history and a physical exam. During the exam, your doctor will listen to your lungs with a
stethoscope to check for abnormal bubbling or crackling sounds (rales) and for rumblings
(rhonchi) that signal the presence of thick liquid. Both these sounds may indicate
inflammation caused by infection.
You're also likely to have chest X-rays to confirm the presence of pneumonia and
pleural effusion to determine the extent and location of the infection. Your doctor can suspect
pneumonia, but he or she can't diagnose it without a chest X-ray.
You may also have blood tests to check your white cell count, or to look for the presence of
viruses, bacteria or other organisms. Sometimes your doctor may examine a sample of your
phlegm or your blood to help identify the microorganism that's causing your illness.
The extent of all this testing depends on how sick you are and your underlying risk factors,
and whether or not you're responding to therapy.
chest x rays and computed tomography scans may be performed to diagnose pleural
24
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effusion. Thoracentesis, the removal of pleural fluid through a long needle, is usually
performed for diagnostic purposes. Fluid removed by thoracentesis will be sent to the lab to
be thoroughly evaluated. Thoracoscopy, in which a wand-like lighted camera (endoscope) is
inserted through the chest, may be conducted to diagnose pleural effusion. During
thoracoscopy, samples (biopsy) ofpleura may be taken.
Pleural effusion can hinder the normal function of the lungs. Symptoms of pleural
effusion include chest pain, chest heaviness, breathing difficulties, and a dry cough. Patients
with malignant pleural effusions tend to be weak and have a short-span life expectancy. The
prognosis depends on the type of cancer. Sixty-five percent of patients with malignant pleural
effusions die within three months and 80% die within six months. However, patients with
pleural effusion related to breast cancer have a longer life expectancy.
Chest x rays and computed tomography scansmay be performed to diagnose pleural
effusion. Thoracentesis, the removal of pleural fluid through a long needle, is usually
performed for diagnostic purposes. Fluid removed by thoracentesis will be sent to the lab to
be thoroughly evaluated. Thoracoscopy, in which a wand-like lighted camera (endoscope) is
inserted through the chest, may be conducted to diagnose pleural effusion. During
thoracoscopy, samples (biopsy) ofpleura may be taken.
25
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CHAPTER V
CONCLUSION
Pleural effusions are associated with many systemic disorders. Thoracentesis to
determine if the pleural fluid is a transudate or an exudate coupled with other appropriate
diagnostic studies provides a diagnosis most of the time. Because pleural fluid findings are
often nonspecific (except for positive cytology and bacteriology), clinical correlation and
response to therapy are critical. Not every pleural fluid study needs to be ordered on every
pleural effusion. Clinical judgement remains the key.
Pleural effusions are associated with many systemic disorders. Thoracentesis to
determine if the pleural fluid is a transudate or an exudate coupled with other appropriate
diagnostic studies provides a diagnosis most of the time. Because pleural fluid findings are
often nonspecific (except for positive cytology and bacteriology), clinical correlation and
response to therapy are critical. Not every pleural fluid study needs to be ordered on every
pleural effusion. Clinical judgement remains the key.
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Pleural effusions are associated with many systemic disorders. Thoracentesis to
determine if the pleural fluid is a transudate or an exudate coupled with other appropriate
diagnostic studies provides a diagnosis most of the time. Because pleural fluid findings are
often nonspecific (except for positive cytology and bacteriology), clinical correlation and
response to therapy are critical. Not every pleural fluid study needs to be ordered on every
pleural effusion. Clinical judgement remains the key.
CHAPTER VI
BILBIOGRAPHY
Ross DS: Pleural effusion. In: Harwood-Nuss AL, Linden CH, eds. The Clinical
Practice of Emergency Medicine. 1996: 649-52.
Sahn SA: An undiagnosed pleural effusion. Hosp Pract (Off Ed) 1993 Jun 15; 28(6):
60-4, 67; discussion 67-8
McEwen JI: Pleural effusion. In: Rosen P, Barkin RM, eds. Emergency Medicine
Concepts and Clinical Practice. 1998: 1521-5.
Heffner JE. Evaluating diagnostic tests in the pleural space. Clin Chest Med
1998;19.2:277-293.
Light RL. Disorders of the Pleura. Harrisons Principles of Internal Medicine
1998; chapter 262, 13472-1475.
27
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Roper WH. Primary serofibrinous pleural effusion in military personnel. Am
Rev Tuberc 1955;71:616-634
Kinasewitz GT. Pleuritis and Pleural Effusion. Pulmonary and Critical Care
Medicine on CD-ROM 1997; Chapter One
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