PENYAKIT PLEURA

Theopilus O’Lay
SMF Paru RSUD Dok 2 Jayapura
Penyakit Pleura yang sering
dijumpai di klinik:

1. Efusi Pleura
2. Pneumotoraks
3. Empiema toraks
4. Tumor Pleura
Allen Widysanto, KLATEN, JAN 31,2007
Anatomi Rongga Pleura

Rib cage

Lung

Parietal Pleura

Pleural Space

Visceral Pleura
 Anatomi Rongga Pleura (1)
Rongga pleura dibentuk oleh :
 Membran serosa yg kuat berasal dr mesoderm
 Pleura parietalis membungkus rongga dada
bagian dlm pleura viseralis membungkus paru
 Tebal rongga pleura 10-20 mikron
 Berisi cairan 25-50 cc berfungsi sbg pelicin
 Merupakan rongga potensial diantara pleura
viseralis dan parietalis
 Mempunyai tekanan negatif
 Mengandung rendah protein
 Anatomi Rongga Pleura (2)
 Pleura parietal diperdarahi kapiler sistemik &
pleura viseral kapiler pulmoner
 Cairan pleura dihasilkan pleura parietal, filtrasi
ke rongga pleura, diabsorpsi pleura viseral
masuk ke sistem limfatik melalui stomata
limfatik kmd ke sirkulasi darah
 Cairan dihasilkan 0,01ml/kg/jam dikeluarkan
saluran limfatik kecepatan 0.2 ml/kg/jam (20x
lebih besar)
Physiology of the Pleural Space

From: Cretien, J, Bignon, J., Hirsch, A, eds: The Pleura in Health and Disease.
New York: Marcel Dekker, 1985, p182.
Ventilasi

FAAL PARU

Brain
Difusi
(Kontrol
pernapasan)

Perfusi
 GANGGUAN VENTILASI PARU
Ggan RESTRIKSI fungsi paru :
yaitu kondisi abnormal dimana
kemampuan ekspansi paru berkurang

Ggan OBSTRUKSI fungsi paru :

yaitu kondisi abnormal dimana
terjadi hambatan aliran udara
karena adanya penyempitan saluran
pernapasan
Pendahuluan

Pneumothoraks : udara di dalam rongga pleura

1803 : istilah  Itard

1819 : gejala klinik  Laenec
1932 : modern  Kjaergard
Klasifikasi berdasarkan etiologi :
- Spontan : primer dan sekunder
- Traumatik
- Iatrogenik
 Primary spontaneous pneumothorax occurs
in persons without clinically apparent lung
disease
 Secondary spontaneous pneumothorax is a
complication of preexisting lung disease

Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.

 Iatrogenic pneumothorax results from a
complication of a diagnostic or therapeutic
intervention
 Traumatic pneumothorax is caused by
penetrating or blunt trauma, with air entering
the pleural space directly through the chest wall;
visceral pleural penetration; or alveolar rupture
due to sudden compression of the chest

Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.

Etiology

 Primary  Secondary
 Bulla subpleura in 76-  COPD
100% VATS and  Pneumocystis carinii
thoracotomy pneumonia (PCP)
 Tuberculosis

Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.

 Tekanan alveolar meningkat

Robekan dinding alveoli

Udara bocor keluar

Intertisial paru

Septa lobuler
Perifer Sentral
 
Bulla Pneumomediastinum

Distensi

Pecah

Pneumotoraks
Patofisiologi
DIAGNOSIS

ANAMNESIS
 Acute onset Dyspnea
 Stabbed - Chest Pain
 Cough
 Progressive symptoms (in tension
pneumothorax)

Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.

ANAMESIS

 Primary Spontaneous  Secondary Spontaneous

 occur while the patient is  Dyspnea always present
at rest and is usually severe degree
 ipsilateral pleuritic chest  Most patients experiences
pain or acute dyspnea. ipsilateral chest pain.
 Symptoms usually  Symptoms do not resolve
resolve within 24 hours spontaneously

Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.

PHYSICAL EXAMINATION

 Inspection: - static : concave on affected side

- dynamic: decrease movement
of chest wall
Palpation: - widened intercostal space
- diminished fremitus

 Percussion: - hyperresonant

 Auscultation: - decrease / absent breath sounds

on affected side
Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.
GENERAL MANAGEMENT

 Evacuating air from pleural space

 Preventing Recurrences

Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.

 RADIOLOGICAL EXAMINATION

 Chest X-Ray:
 Identification of a thin, visceral pleural line (<1 mm
in width) that is found to be displaced from the chest
wall
 Radioluscent Image - avasculair
 Collapse of Lung
 Mediastinal Shift

CT Scan: should be performed to

differentiate between these two
conditions (bullae-PnTh)

Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.

 Management pneumothorax

1. Observation - Oxygenation
2. Simple Aspiration with a catheter
3. Chest tube insertion
4. Pleurodesis
5. Thoracoscopy
6. VATS
7. Thoracotomy
8. Physiotherapy – Incentive Spirometri

Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.

Simple Aspiration

Instrument needed:
1. Abbocath 14
2. 3-way stop cock
3. 50 mL syringe
4. Blood set
5. Bottle with fluid
Trocar chest tube (conventional)
 Prosedur trocar tube thoracostomy
•Insisi kulit sepanjang 2-4 cm, pelebaran tumpul sampai tembus pleura
•Trocar dimasukkan ke dalam rongga pleura, stylet dicabut, ibu jari operator
menutup lubang trocar
•Masukkan chest tube yang telah diklem ujung proximalnya (buka ibu jari
operator terlebih dulu)
•Tahan chest tube lalu trocar ditarik keluar (ke arah proximal chest tube)
•Klem dipasang di antara trocar dan dinding dada, trocar ditarik keluar lalu klem
proximal dibuka
•Klem dapat dibuka setelah chest tube disambungkan ke pleural drainage system

Light RW. Chest tubes. In: Light RW, ed. Pleural diseases. 2001.p.378-90.
 Prosedur trocar tube thoracostomy
(inner trocar)
•Insisi kulit sepanjang 2-4 cm, pelebaran tumpul sampai tembus pleura
•Trocar dimasukkan ke dalam rongga pleura, inner trocar pelan-pelan dicabut
•Klem dipasang di antara dinding dada dan trocar , klem dapat dibuka setelah chest tube
disambungkan ke pleural drainage system

Light RW. Chest tubes. In: Light RW, ed. Pleural diseases. 2001.p.378-90.
 CONFIRMING SITE OF DRAIN
INSERTION
 A chest tube should not be inserted without further image
guidance if free air or fluid cannot be aspirated with a needle at
the time of anaesthesia. [C]
 Imaging should be used to select the appropriate site for chest
tube placement. [B]
 A chest radiograph must be available at the time of drain
insertion except in the case of tension pneumothorax. [C]
 Chest drain insertion should be performed without substantial
force. [C]
 Supplemental oxygen should also be considered (BMJ Career
Focus 2004)
Operative tube thoracostomy
procedure
 Prosedur operative tube thoracostomy
•Insisi kulit sepanjang 3-4 cm, pelebaran tumpul sampai tembus pleura
•Jari operator dimasukkan ke dalam rongga pleura
•Masukkan chest tube yg telah diklem ujung proximalnya ke dlm rongga pleura
dg tuntunan hemostat
•Klem dapat dibuka setelah chest tube disambungkan ke pleural drainage system

Light RW. Chest tubes. In: Light RW, ed. Pleural diseases. 2001.p.378-90.
Lokasi

ICS 5
Mid axillar line (MAL)

Lateral sites: medial axillar

line
Knot - Sutures

Sahn SA. Spontaneous pneumothorax. N Engl J Med 2000; 342: 868-74.

 • Drainage system to keep
intrapleura negative pressure
• Sterilized tube and bottle to avoid
infection
• Water as Sealed can be antiseptic
solution
• Keep tip of tube always below
water surface

Light RW. Chest tubes. In: Light RW, ed. Pleural diseases. 2001.p.378-90.
 Indication

 Simple
Pneumothorax
 Hydropneumothorax
 Pyopneumothorax

 Suction

Light RW. Chest tubes. In: Light RW, ed. Pleural diseases. 2001.p.378-90.
Three bottle (chamber) system

3 2 1

3 2 1
 WSD

Selang WSD

Botol
WATER SEALED DRAINAGE (WSD)

Important point to evaluate:

 Oscilation – Tube Patency
 Bubbles - Fistula
 Fluid - Production
 Fluid - Color
Remove fluid & air

Choose site

Suture tube to chest

Explore with finger

Place tube with clamp

Continous Suction Setting
From bottles to a box To suction From patient

from patient

Suction Water seal Collection

control bottle bottle
bottle

Suction Water seal Collection

control chamber chamber
chamber
From box to bedside
At the bedside
 Keep drain below the chest
for gravity drainage
 This will cause a pressure
gradient with relatively higher
pressure in the chest
 Fluid, like air, moves from an
area of higher pressure to an
area of lower pressure
 Same principle as raising an IV
bottle to increase flow rate
 Chest Drain Removal
 The timing of removal of the chest drain is dependant
on the original reason for insertion and clinical
progress.
 No Air Leaks in last 24h of PNX
 No Fresh Bleeding in the last 24h of hemothx
 Fluid loss <200ml in last 24h
 24 Hours Pre-Removal: Suction is disconnected and
Gravity Drainage for 24 hours
 In cases of pneumothorax, the chest tube should not
be clamped at the time of its removal. [B]
Chest Drain Removal

 Pre-medicated pain killer before removal tube

 An aseptic technique for removal appropriately.
 Apply Sterile Petroleum Jelly Gauze Dressing.
 Have Patient Take a Deep Breath & Bear Down
(Valsalva Maneuver) (to increase the pleural
pressure and prevent air entering the pleural
cavity) and the tube is withdrawn quickly.
 The previously placed suture is then tied to close
the hole and tie sutures securely.
 Cover Site with Air-Tight Dressing
Post-Removal

 Chest X-Ray (To Evaluate for Pneumothorax

or Reaccumulation of Fluid)
 Wound is Observed for Drainage
 Dressing is Changed as Needed
 Observe Patient for Respiratory Distress
00:19:59

Pleurodesis
 Pleurodesis adalah penyatuan pleura viseralis
dengan parietalis baik secara kimiawi, mineral
ataupun mekanik, secara permanen untuk
mencegah akumulasi cairan maupun udara dalam
rongga pleura.
 Tindakan ini merupakan induksi iatrogenik agar
terbentuk simfisis pleura visceral dan parietal.
 Tujuan pleurodesis adalah mengobliterasi rongga
pleura dan mencegah akumulasi cairan atau udara.

Davies and Lee, 2008; Rodriguez-Panadero and Antony, 1997

Tension Pneumothoraks
 Gawat darurat medis
 Udara dapat memasuki
rongga pleura selama
inspirasi ttp tidak dapat
keluar pada saat ekspirasi
 Manifestasi klinik : distress
napas, sianosis,dan biasanya
terjadi keringat berlebihan,
hipotensi dan takikardi.
TENSION PNEUMOTHORAX

 Progressive Dyspnea

 Decrease Conciousness

 Emergency treatment –
decompression pressure
TENSION PNEUMOTHORAX

 Progressive Dyspnea

 Tachycardia more 135 bps

 Hypotension

 Cyanosis
TENSION PNEUMOTHORAX

 Intrapleural pressure exceeds from atmosphere

pressure at inspiration or expiration
 Valve Mechanism
 Inspired Air can not escape as expiration
 Mediastinum compression decrease cardiac
output, as well as venous return
Tension pneumothoraks…

 Diagnosis
 Dipikirkan pada pasien dengan
kondisi yang menurun secara
tiba-tiba setelah : ventilasi
mekanik atau telah menjalani
suatu prosedur yang dapat
mengakibatkan pneumothoraks
 Foto thoraks : pergeseran
mediastinum kontralateral dan
penekanan diafragma ipsilateral
 GAMABARAN KLINIK

PNEUMO
TORAKS
TENSION

1. ECG RAD
2. VALTAGE
PREKORDIAL
3. QRS KOMPLEKS
Tension Pneumothorax
Tension pneumothoraks…

 Penatalaksanaan
 Oksigen
konsentrasi tinggi
 Dekompresi
/kontra ventil
sementara
 Pemasangan
selang dada (chest
tube)
 CONCLUSION
 Pneumothorax is collection of air or gas in pleural
cavity between chest wall and lung
 Symptoms are suddenly, chest pain, dyspnea and
needs suddent treatment
 Aims of management pneumothorax is evacuating
air from pleural space and preventing recurrences
 Tension Pneumothorax is emergeny situation
Efusi Pleura
 EFUSI PLEURA

DEFINISI

 Penumpukan cairan yg
berlebihan di dalam rongga
pleura
Anatomi Rongga Pleura
Anatomi Rongga Pleura

Rib cage

Lung

Parietal Pleura

Pleural Space

Visceral Pleura
 Patofisiologi Efusi Pleura (1)

Efusi pleura terjadi OK :

Penumpukan cairan pleura di dlm rongga pleura akibat
transudasi/eksudasi yg berlebihan
 Pembentukan melebihi penyerapan
 Pembentukan normal, penyerapan terganggu
 Patofisiologi Efusi Pleura (2)

 Efusi pleura transudatif : faktor sistemik mempengaruhi

pembentukan/penyerapan atau ketidakseimbangan tekanan
onkotik dan hidrostatik, permeabilitas kapiler thd protein
normal, contoh: gagal jantung, sirosis hepatis, gagal ginjal

 Efusi pleura eksudatif : terjadi perubahan permukaan

atau permeabilitas dari kapiler atau pleura, contoh:
keganasan, tuberkulosis, pnemonia
 Transudate vs exudate
 Common causes
Transudate Exudate
• Congestive heart failure • Cancer,
• Chirrosis • pneumonia,
• Nephrotic syndrome • trauma,
• Pulmonary embolism • tuberculosis,
• pulmonary embolism,
• rheumatoid arthritis, SLE

 Criteria for
differentiation – <0.5 – >0.5
 Ratio of pleural fluid – <0.6 – >0.6
protein / serum protein
– ]<2/3 upper limit of normal – >2/3 upper limit of
 Ratio of pleural fluid
serum normal serum
LDH / serum LDH
 Pleural fluid LDH
 Patofisiologi Efusi Pleura (3)

 Peningkatan pembentukan cairan pleura

- penurunan tek onkotik (hipoalbumin)
- peningkatan tek hidrostatik kapiler (CHF)
- peningkatan permeabiliti kapiler (pnemonia)
- penurunan tek negatif intrapleura (atelektasis)

 Penurunan absorpsi cairan pleura

- obstruksi saluran limfatik (keganasan)
Pleural
Effusions
PENDEKATAN KLINIS PASIEN
EFUSI PLEURA

mediastinal
shift

distension
 PENDEKATAN KLINIS PASIEN
EFUSI PLEURA

 Peningkatan densiti,
sudut kostofrenikus
tumpul
 Cairan sedikit, foto
lateral dekubitus
 Tebal cairan < 10
mm, tdk signifikan,
pungsi pleura sulit
Efusi pleura bilateral

Fluid
collection in
both lower
lobes of the
lungs due to
CHF
Pemeriksaan penunjang

 USG Toraks
 CT-Scan Toraks
 Biopsi pleura
 Torakoskopi
 Bronkoskopi
Pungsi Pleura

Suatu prosedur diagnostik & terapi utk

mengatasi sesak
Tindakan mencari penyebab efusi,
membedakan transudat atau eksudat
Transudat tdk memerlukan pemeriksaan
penunjang lanjutan, tatalaksana penyebab
CHF, sirosis hepatis, sindroma nefrotik
Eksudat penyakit berasal dari asal efusi,
memerlukan pemeriksaan lebih lanjut utk
mencari penyebabnya
Pungsi Pleura
Pemeriksaan warna cairan pleura
- seroxantokrom (infeksi,dll)
- serohemoragik (keganasan, trauma)
- purulen (empiema)
- putih susu/kilotoraks (keganasan,
sarkoidosis, amiloidosis, TB)
Pemeriksaan mikrobiologi, biokimia,
sitologi
Pemeriksaan sitologi dpt diulang bila hasil
negatif nilai positif lebih besar pd 25%
kasus
Pungsi Pleura

Pemeriksaan mikrobiologi
- pewarnaan gram, kultur & resistensi mo
- BTA, kultur & resistensi
- jamur (immunocompromised)

Pemeriksaan biokimia membedakan transudat

dan eksudat memakai kriteria Light’s
Kriteria Light’s eksudat jika :
 Protein cairan pleura / protein serum > 0.5
 LDH cairan pleura / LDH serum > 0.6
 LDH cairan pleura > 2/3 nilai N LDH serum
Kriteria lain eksudat :
 LDH cairan pleura > 0.45 nilai LDH serum
 Kolesterol cairan pleura > 45 mg/dL
 Protein cairan pleura > 2.9 g/dL
 Laboratorium
 LDH > 1000 IU/L
Empiema, keganasan,
rematoid
 Glukosa< 30 mg/dL
Empiema, rematoid
 Glukosa 30 – 50 mg/dL
 Limfosit > 85%
TB , kilotoraks,
limfoma, rematoid,
 Limfosit 50 – 70%
Keganasan
 Sel mesotel > 5%
TB
 ADA > 43 U/mL
TB

TB, Lupus, keganasan

 KESIMPULAN
• Efusi pleura adalah penumpukan cairan di
rongga pleura akibat kelainan di pleura, paru
atau ekstraparu
• Evakuasi cairan pleura (pungsi pleura)
merupakan tindakan utk diagnosis dan terapi
• Diagnosis etiologi cairan pleura bila ditemukan
pd pemeriksaan mikrobiologi tdp kuman atau
sitologi sel-sel tumor
• Tatalaksana efusi pleura berdasarkan etiologinya