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efusi pleura

efusi pleura

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Published by: Ian Tynk Ciicis on Jan 01, 2013
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01/06/2013

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EFUSI PLEURA

dr. H. Slamet Tjahjono, Sp.P
Spesialis Penyakit Paru dan Saluran Pernapasan

SMF PENYAKIT PARU
RSUD MATARAM
2008

PENDAHULUAN

Plera --- visceralis --- paru

parietalis ---
dinding dada

Ruang antar plera 18 -- 20 μ m

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 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 EFFUSIONS
IT IS IMPORTANT TO REALIZE THAT
NOT ALL PARAPNEUMONIC
EFFUSIONS ARE THE SAME
THE FOLLOWING CLASSIFICATION
WAS DE-VELOPED TO ASSIST THE
PRACTICING PHYSICIAN . IT IS
BASED ON THE FOLLOWING:
ANATOMY OF THE PLEURAL
SPACE
BACTERIOLOGY OF THE
PLEURAL FLUID
CHEMICAL
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

THORACENTESIS
CHEST TUBE
INTR.PL THROMBOLYTIC AGENTS
THORACOSCOPY
DECORTICATION
OPEN DRAINAGE/ELOESSER’S FLAP

WATERSEALED
DRAINAGE (WSD)

PL.EFFUSIONS DX.

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

PL.EFFUSIONS DX

•INSPEKSI : TRACHEA ---> , CEMBUNG
•PALPASI : TRACHEA DEV.CEMBUNG
• STEM FREMITUS <
•PERKUSI : REDUP
• ELLIS’S S SHAPED LINE
•AUSKULTASI : SUARA NAFAS < / -

ASPIRASI CAIRAN PLEURA
OLEH

DR.H.SLAMET TJAHJONO,
Sp.P

Spesialis Penyakit Paru Dan Saluran
Pernapasan

SMF PARU RSUP MATARAM

ASPIRASI CAIRAN
PLEURA

PENGERTIAN : Aspirasi cairan pleura
adalah tindakan medis berupa pengeluaran
cairan yang terakumulasi di dalam rongga
pleura dengan jalan memasukkan jarum
atau kateter ke dalam rongga pleura.
Akumulasi cairan di dalam rongga pleura
timbul oleh karena berbagai kelainan antara
lain infeksi, tumor, kelainan jantung dan
lain sebagainya.

TUJUAN

•Tujuan aspirasi cairan pleura adalah
diagnostic dan terapi.

KEBIJAKAN

•Dilakukan di ruang tindakan oleh dokter
spesialis paru atau dokter umum yang
sudah berpengalaman.

PROSEDUR

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