5/24/2011

Pemeriksaan dan
Interpretasi Cairan Pleura

Cairan Pleura

- Berada pada rongga Pleura, sbg pelicin gesekan antara pleura

visceralis dan pleura parietalis
- Normal : cairan sedikit, Vol. 1-10 mL
-Dihasilkan secara kontinu berdasarkan :
* tekanan hidrostatik kapiler
* tekanan onkotik plasma
* permeabilitas kapiler.
- Direabsorbsi melalui limfatik dan venule
- Akumulasi cairan disebut efusi, terjadi karena imbalance produksi dan
reabsorbsi
- Berdasarkan penyebabnya, efusi pleura biasanya diklasifikasikan atas
Transudat dan Eksudat

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Transudasi adalah akumulasi cairan akibat :

- Peningkatan tek. hidrostatik dalam paru
- Penurunan tek. onkotik
Mis. Albumin plasma menurun atau tek. vena meninggi
(CHF, hipoproteinemia, sirosis, neprotik sindrom, dll)
Eksudasi adalah akumulasi cairan akibat :
- Proses inflamasi yg menyebabkan perubahan permeabilitas
membran pleura atau
- Penurunan reabsorbsi limfatik
- Penyebab a.l : Infeksi TBC, infeksi bakteri atau jamur, Neoplasma,
rheumatoid disease, SLE.
Cairan juga dapat berasal dari :
- Pancreatitis (amilase tinggi)
- Rupture esophagus (pH rendah dan amilase tinggi)
- Urine ( pH rendah dan creatinine tinggi)

Indikasi pengambilan cairan pleura

• 1. Pemeriksaan lab. (mengetahui etiologi efusi

transudat atau eksudat)
• 2. Mengurangi gejala klinik (mis.sesak, sakit)
• 3. Menghindari terjadinya kumpulan darah atau
nanah (hemitoraks, empiema)
• 4. Mengurangi cairan dalam rongga pleura untuk
diganti dgn obat kedlm rongga tsb

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Indikasi pemeriksaan cairan pleura

• 1. Mengetahui penyebab (diagnosis)

• 2. Penunjang diagnosis
• 3. Follow up penyakit, komplikasi dll
• 4. Follow up terapi

Pemeriksaan yg dianjurkan:
Rutin : 1. Makroskopis
2. Mikroskopis : Hitung sel, Hitung jenis
3. Analisa kimia : Protein, Glucose

Pemeriksaan Cairan Pleura:

Berguna utk sbgn besar pasien :
1. Pulasan langsung dan kultur m.o
2. Sitologi
Perlu utk kasus tertentu :
1. Cholesterol atau ratio fluid/serum
2. Albumin gradient
3. pH
4. CRP
5. Tumor marker
6. Enzymes (Amylase, LD)
7. Lactate
8. Alkaline Phosphatase, dll

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Kriteria Lab utk Eksudat :

- Secara Umum :
* Total Protein
* Light’s Criteria
- Khusus Pleural fluid :
1. Cholesterol > 45 mg/dL
2. Pleural fluid/serum cholesterol ratio = atau > 0,30
3. serum-pleural fluid albumin gradient = atau < 1,2 g/dL
4. Pleural fluid/serum bilirubin ratio = atau > 0,6
- Sens 98%, spec 80%

Pembedaan transudat dan exudat secara umum

• Total Protein (TP) : exudat jika TP > 3.0 g/dL

• Light’s Criteria
Rasio TP TP Cairan (E > 0.5)
TP Serum

Rasio LDH : LDH cairan (E > 0.6)

LDH serum

Rasio LDH : LDH cairan (E > 0.67)

nilai tertinggi LDH serum normal

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PLEURAL EFFUSION : PLEURAL FLIUD PROFILES IN VARIOUS DISEASE STATES

Diagnosis Gross Protei Glucose WBC & RBC Microscopic Culture Comments
Appearan n (mg/dL) Differenti (per Exam
ce (g/dL) al mcL)
(per mcL)
Normal Clear 1.0-1.5 Equal to ≤ 1000, 0 or few Neg Neg
serum mostly MN
TRANSUDATES
Congestive serous <3: Equal to <1000 <10.000 neg Neg Most common cause
heart failure some serum of pleural effusion.
times Effusion right-sided in
≥3 55-70% of patients
Nefrotic Serous <3 Equal to <1000 <1000 neg Neg Occurs in 20 % of
syndrome serum patiens. Cause is low
protein osmotic
pressure
Hepatic serous <3 Equal to <1000 <1000 Neg Neg From movement of
cirrhosis serum ascites diaphragm.
Treatment of
underlying ascites
usually sufficient.
EXUDATES
Tuberculosis Usually 90% Equal to 500- < 10.000 Concentrate May tield PPD usually positive;
serous; can ≥3; serum ; 0 10.000, Pos for AFB in MTb pleural biopsy
be bloody mey cc <60 mostly MN <50% positive; eosinophils
exceed (>10%) or mesothelial
5 g/dL cells (>5%) make
diagnosis unlikely
Malignancy Usually 90% ≥3 Equal to 1000- >100.00 Post cytology Neg Eosinophils
turbid, serum; <60 10.000 0 in 50% uncommon; fluid
bloody; 0cc in 15% of mostly MN tends to
serous cases reaaccumulate after
removal.

Diagnosis Gross Protei Glucose WBC & RBC Micro Cult Comments
Appearanc n (mg/dL) Differential (per scopi ure
e (g/dL) (per mcL) mcL) c
Exam
Empyema Turbid to ≥3 Less then serum, 25.000-100.00 <5000 Pos Pos Drainage necessary; putrid
purulent often <20 mostly PMN odor suggest anaerobic
infection

Parapneumo Clear to ≥3 Equal to serum 5000-25.000 <5000 Neg Neg Tube thoracostomy
nic-effusion, turbid mostly PMN unnecessary; associated
uncomplicate infiltrate on chest X-ray;
d fluid pH ≥7,2

Pulmonary Serous to ≥3 Equal to serum 1000-50.000 100-> Neg Neg Variable findings; 25% are
embolism, grossy mostly PMN 100.000 transudates
infarction bloody

Rheumatiod Turbid or ≥3 Very low (<40 in 1000-20.000 <1000 Neg Neg Rapid clotting time;
athritis or yelloy-green most); in Ra, 5-20 mostly PMN secondary empyema
other mg/dL common
collagen-
vascular
disease
Pancreatitis Turbid to ≥3 Equal to serum 1000-50.000 1000- Neg Neg Effusion usually left-sided;
serosanguin mostly PMN 10.000 highamylase level
eous

Esophageal Turbid to ≥3 Usually low <5000- over <5000 Pos Pos Effusion usually left-sided;
Rupture purulent; red- 50.000, mostly high fluid amylase level
brown PMN (salivary); pneumothorax in
25% of cases; pH <6.0
strongly suggest diagnosis

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TERIMA KASIH