Pleural Diseases

Pleural Effusion - Fluid Follies

• Abnormal fluid in pleural space. Types: Transudate (systemic factors) vs. Exudate (local factors).
• Diagnosis: Thoracentesis, imaging (CXR, USG).

*   Pleural Protein/Serum Protein > $\textbf{0.5}$
*   Pleural LDH/Serum LDH > $\textbf{0.6}$
*   Pleural LDH > $\frac{\textbf{2}}{\textbf{3}}$ ULN (serum)

⭐ Tuberculosis is a leading cause of exudative pleural effusion in children in endemic areas like India.

Empyema Thoracis - Pus Under Pressure

Pus in pleural space, a serious complication of pneumonia.

• Etiology: S. pneumoniae (MC), S. aureus (esp. post-flu), H. influenzae.
• Stages (📌 EFO: Exudative, Fibrinopurulent, Organizing):
  • 1. Exudative: Simple effusion. Fluid: pH > 7.2, Glc > 60 mg/dL, LDH < 1000 IU/L. Antibiotics alone.
  • 2. Fibrinopurulent: Pus. Fluid: pH < 7.2, Glc < 40 mg/dL, LDH > 1000 IU/L, +ve Gram/culture. Drainage essential.

    ⭐ Surgical Indications (VATS/Decortication): Failed initial drainage, multiloculations, thick peel, bronchopleural fistula, chronic (>4-6 wks).

  • 3. Organizing: Thick inelastic peel, lung trapped. Decortication often needed.
• Diagnosis: CXR (D-shape), USG (locules, guides tap), CT for complex cases. Pleural tap vital.
• Management Algorithm:

Pneumothorax - Air Scare

• Definition: Air in pleural space, leading to lung collapse.
• Types: Spontaneous (Primary - no underlying disease; Secondary - due to lung disease), Traumatic, Iatrogenic.
• Clinical Features: Sudden onset dyspnea, pleuritic chest pain, ↓ breath sounds, hyperresonant percussion note. Tension Pneumothorax: Tracheal deviation (away from affected side), hypotension, distended neck veins, severe respiratory distress. 📌 BATTS for tension: Breathlessness, Agitation, Tracheal deviation, Tachycardia, Sweating.
• Diagnosis: CXR (visceral pleural line, absent lung markings peripherally). Ultrasound (absent lung sliding - "barcode sign").

• Management Principles:
  • Small Primary Spontaneous Pneumothorax (PSP) (<2-3cm rim of air, stable patient): Observation, supplemental O2.
  • Large PSP (≥2-3cm rim) or symptomatic / Secondary Spontaneous Pneumothorax (SSP): Needle aspiration or chest tube (ICD) insertion.
  • Recurrent / Persistent air leak / Bilateral / High-risk professions: Pleurodesis (chemical/surgical).

⭐ Tension Pneumothorax is a medical emergency! Immediate life-saving step is needle decompression (e.g., large bore cannula in 2nd intercostal space, mid-clavicular line or 4th/5th intercostal space, anterior axillary line), followed by definitive chest tube drainage.

Special Effusions - Milky & Bloody

Chylothorax (Milky Fluid)

• Patho: Lymphatic fluid (chyle) in pleura.
• Causes: Trauma (post-surgery, birth); Non-traumatic (malignancy, congenital).
• Diagnosis: Milky fluid; TG > 110 mg/dL; Chylomicrons. TG/Chol > 1. Lymphocytic.
  • vs. Pseudochylothorax (chronic, ↑Cholesterol, no chylomicrons, crystals).
• Management: Conservative (NPO, TPN, MCT diet, octreotide); Drainage; Surgery (pleurodesis, duct ligation).

⭐ Most common cause of non-traumatic chylothorax in neonates is congenital lymphatic malformations.

Hemothorax (Bloody Fluid)

• Patho: Blood in pleura.
• Causes: Trauma (commonest), iatrogenic, malignancy.
• Diagnosis: Pleural fluid Hct > 50% blood Hct. CXR/CT confirms.
• Management: Tube thoracostomy. Surgery (VATS/thoracotomy) if:
  • Initial drain > 1500 mL or > 20 mL/kg.
  • Ongoing bleed > 200 mL/hr (2-4 hrs).

High‑Yield Points - ⚡ Biggest Takeaways

• Pleural effusion: Transudates (heart failure, nephrotic syndrome) vs. Exudates (parapneumonic, TB).
• Light's criteria help differentiate, but clinical picture is vital in children.
• Empyema (pus) requires antibiotics and chest drainage; often follows bacterial pneumonia.
• Chylothorax: milky fluid, high triglycerides; causes include surgery, congenital issues.
• Pneumothorax: air in pleural space. Tension pneumothorax is an emergency needing urgent decompression.
• Tuberculous effusion: common in endemic settings, a lymphocytic exudate.