pluerisy. acondition affe ting plueral cavity.

Pleuritis, or pleurisy, is an inflammation of the pleura, the lining surrounding the lungs, causing chest pain and breathing difficulties, and can be caused by viral or bacterial infections, injury, or underlying conditions like cancer or autoimmune disorders.

1. CONDITIONS OF THE PLEURAL CAVITY BY MUTEGEKI ADOLF

2. Anatomy of the Pleural Cavity Visceral Pleura : The inner layer that directly covers the lungs, including the fissures between the lobes. It is firmly attached to the lung surface and moves with it during breathing. Parietal Pleura : The outer layer that lines the inside of the thoracic cavity, including the chest wall, diaphragm, and mediastinum. It is attached to the inner surface of the rib cage and the superior surface of the diaphragm. Pleural Space/Cavity : The potential space between the visceral and parietal pleura. Normally, this space is filled with a small amount of pleural fluid (about 10-20 mL per lung in a healthy adult).

3. Functions of the Pleural Cavity Lubrication : The pleural fluid within the cavity acts as a lubricant, allowing the visceral and parietal pleura to glide smoothly over each other during respiration, minimizing friction. Creating Negative Pressure : The pleural cavity helps maintain negative pressure relative to the atmosphere, which is crucial for lung expansion during inhalation. This negative pressure prevents the lungs from collapsing and helps them expand when the diaphragm and intercostal muscles contract. Facilitating Respiration : The pleural cavity enables efficient transmission of movements from the chest wall to the lungs, allowing them to expand and contract with the respiratory cycle.

4. Common Conditions of the Pleural Cavity Pleural Effusion: Pneumothorax: Hemothorax : Pleuritis (Pleurisy):

5. . 1. PLEURAL EFFUSION Pleural Effusion 29-Aug-24

6. Introduction Pleural effusion, a collection of fluid in the pleural space, is rarely a primary disease process but is usually secondary to other diseases The pleural space normally contains only about 10-20 ml of serous fluid Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatic system Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion

7. Definition Pleural effusion is a collection of abnormal amount of fluid in the pleural space

8. Classification Transudative effusions Exudative effusions

9. Transudative effusions Transudative effusions also known as hydrothoraces , occur primarily in non-inflammatory conditions; is an accumulation of low-protein, low cell count fluid Cause : Often due to systemic conditions that affect the production and absorption of pleural fluid, such as congestive heart failure, liver cirrhosis, or nephrotic syndrome. Characteristics : The fluid is typically clear, pale yellow, and low in protein and cellular content. It results from an imbalance in hydrostatic and oncotic pressures

10. Exudative effusions Exudative effusions occur in an area of inflammation; is an accumulation of high-protein fluid. An exudative effusion results from increased capillary permeability characteristic of inflammatory reaction. This types of effusion occurs secondary to conditions such as pulmonary malignancies, pulmonary infections and pulmonary embolization.

11. Causes of Exudative effusion Disseminated cancer (particularly lung and breast), lymphoma Pleuro -pulmonary infections (pneumonia). Heart failure, cirrhosis, nephrotic syndrome Other conditions sarcoidosis , systemic lupus erythematosus (SLE) Peritoneal dialysis

12. Pathophysiology Transudative pleural effusions: hydrostatic pressure , oncotic pressure Unable to remain the fluid with in a intravascular space Fluid shift interstitial space Effusion

13. Exudative effusions Invasion of microbes Initiation of inflammatory reaction Vasodilation increase capillary permeability leak of plasma protein decrease oncotic pressure fluid shift into interstitial space

14. Clinical Manifestations Usually the clinical manifestations are those caused by the underlying disease and severity of effusion Pneumonia causes fever, chills, and pleuritic chest pain, Malignant effusion may result in dyspnea and coughing

15. When a small to moderate pleural effusion is present, dyspnea may be absent or only minimal. Pleuritic chest pain, Dullness or flatness to percussion Decreased or absent breath sounds

16. Diagnostic Evaluation Chest X-ray or ultrasound detects presence of fluid. Thoracentesis biochemical, bacteriologic, and cytologic studies of pleural fluid indicates cause.

17. Complications Large effusion could lead to respiratory failure

18. Management The objectives of treatment are to discover the underlying cause, t o prevent reaccumulation of fluid , and to relieve discomfort, dyspnea, and respiratory compromise General Treatment is aimed at underlying cause (heart disease, infection). Thoracentesis is done to remove fluid, collect a specimen, and relieve dyspnea

19. Obtain history of previous pulmonary condition Assess patient for dyspnea and tachypnea Auscultate and percuss lungs for abnormali Maintaining Normal Breathing Patter n Institute treatments to resolve the underlying cause. Assist with thoracentesis if indicated Maintain chest drainage as needed Provide care after pleurodesis . Monitor for excessive pain from the sclerosing agent, which may cause hypoventilation. Administer prescribed analgesic. Assist patient undergoing instillation of intrapleural lidocaine if pain relief is not forthcoming. Administer oxygen as indicated by dyspnea and hypoxemia. Observe patient's breathing pattern, oxygen saturation

20. For Malignant Effusions Chest tube drainage, radiation, chemotherapy, surgical pleurectomy , pleuroperitoneal shunt, or pleurodesis

21. References Chintamani , Lewis, Heitkemper , Dirksen, O’Brien and Bucher. (2011). Lewis’s Medical Surgical Nursing: Assessment and Management of Clinical Problems. (7 th Ed.). Mosby. P 595 Black , J.M. , Hawks , J.H. , & Annabelle , M.K . (2005). Medical-Surgical Nursing-clinical management for positive outcomes .(6 th ed .). P 1631 Suzanne C. S., Brenda G. B., Janice L. H. , and Kerry H. C. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing .( 11th ed ). 540 Lippincott Manual of Nursing Practice. (2010).William And Wilkins.Nineth edition. 302

22. . 2. PNEUMOTHORAX Pneumothorax 29-Aug-24

23. Contents Definition Types Clinical features Risk factors Diagnosis Treatment Complications

24. Definition “Pneumothorax :  is an abnormal collection of air or gas in the pleural space separating the lung from the chest wall which may interfere with normal breathing, causing the lungs to collapse.”

25. Types of Pneumothorax Spontaneous pneumothorax: Primary: It occurs in young healthy individuals without underlying lung disease . It is due to rupture of apical sub-pleural bleb . A bleb is caused by alveolar rupture, which allows air to travel through the interlobular septum that divides the secondary pulmonary lobules to the subpleural region . The subpleural region is displaced, and a subpleural emphysematous vesicle (i.e., a bleb) is thus formed

26. Secondary:  occurs in the presence of pre-existing lung pathology. Ex : Cystic lung disease ,COPD, LUNG CANCER & T.B

27. Traumatic pneumothorax: Open: Chest wall is damaged by any wound --outside air enters pleural space and causes lungs to collapse. Closed: here chest wall is punctured or air leaks from a ruptured bronchus Iatrogenic : Ex. Postoperative Mechanical ventilation , Thoracocentesis & Central venous cannulation .

28. Is it type or complication ?! Tension pneumothorax: It is life threatening A life-threatening condition where air enters the pleural space but cannot escape, causing increased pressure in the chest, lung collapse, and compression of the heart and major blood vessels. The pleural pressure is more than the atmospheric pressure It requires emergency intervention.

29. Radiological manifestations of large pneumothorax : Mediastinal shift, Flattening of the hemidiaphragm & Lung collapse. Associated with clinical manifestations of circulatory collapse (tachycardia, hypotension & sweating). It is more common with Positive pressure ventilation & Traumatic pneumothorax.

30. Pathophysiology Air Accumulation : Air leaks into the pleural space from the lung or through the chest wall, breaking the negative pressure that normally keeps the lung expanded. Lung Collapse : The affected lung loses its ability to expand due to the loss of negative pressure, causing partial or total lung collapse. Respiratory Distress : As the lung collapses, the patient may experience decreased oxygenation and respiratory compromise. Tension Pneumothorax : If the air leak creates a one-way valve effect, air continues to accumulate, increasing intrathoracic pressure, collapsing the lung, and compressing the heart and great vessels, leading to reduced cardiac output and potential cardiac arrest

31. Risk factors Sex : men are far more likely to have a pneumothorax than are women. Smoking. Age. The type of pneumothorax caused by ruptured air blisters is most likely to occur in people between 20 and 40 years old, especially if the person is a very tall and underweight man. Genetics. Lung disease. Having an underlying lung disease — especially chronic obstructive pulmonary disease (COPD) — makes a collapsed lung more likely. Mechanical ventilation. A history of pneumothorax.

32. Aetiology (Causes) Primary Causes : Rupture of subpleural blebs (small air-filled sacs) in the lungs. High-risk factors: smoking, genetic predisposition, rapid altitude changes, or scuba diving. Secondary Causes : Lung Diseases : COPD, asthma, cystic fibrosis, interstitial lung diseases, lung infections (e.g., tuberculosis), lung malignancies, Marfan syndrome. Trauma : Penetrating or blunt chest injuries, rib fractures, or barotrauma from mechanical ventilation. Iatrogenic Causes : Complications from medical or surgical procedures involving the chest or lungs.

33. Clinical Presentations Sudden, Sharp Chest Pain : Often on the affected side, exacerbated by deep breathing, coughing, or movement. Shortness of Breath (Dyspnea) : Varies from mild to severe, depending on the size of the pneumothorax. Tachypnea (Rapid Breathing) : Compensatory mechanism to maintain oxygenation. Decreased or Absent Breath Sounds : On the affected side, due to collapsed lung tissue.

34. Hyperresonance on Percussion : Over the affected area, due to the presence of air in the pleural space. Tracheal Deviation : Away from the affected side in tension pneumothorax. Cyanosis : Bluish discoloration of the lips and skin in severe cases due to hypoxemia. Hypotension : In tension pneumothorax, due to decreased cardiac output.

35. Complications of pneumothorax Recurrence of spontaneous pneumothorax Tension pneumothorax Hydropneumothorax Encysted pneumothorax Failure of expansion of the collapsed lung Re-expansion pulmonary edema Broncho-pleural fistula Pneumomediastinum 19

36. Investigations 1. Chest X-ray : The primary diagnostic tool. It shows a visible rim between the lung margin and chest wall, indicating air in the pleural space. Tension pneumothorax may present with mediastinal shift and diaphragmatic depression.

37. Diagnosis – Chest Xray The characteristics of pneumothorax Pleural line No lung markings in pneumothorax 13

38. 2. CT Scan : Provides a more detailed view and can detect small pneumothoraces or identify underlying lung pathology. Useful in complex cases or when a chest X-ray is inconclusive.

39. CT Scanning A further use of CT is in the identification of underlying lung lesions 14

40. 3. Ultrasound : Fast and portable; useful in emergency settings to detect pneumothorax, particularly in trauma patients. 4. Arterial Blood Gas (ABG) : To assess the degree of hypoxemia and hypercapnia , especially in severe or complicated cases

41. Treatment : Goals To promote lung expansion. To eliminate the pathogenesis. To decrease pneumothorax recurrence. Treatment options Treatment options : Simple aspiration Intercostal tube drainage Guidewire tube thoracostomy Surgical treatment

42. 1. Initial Stabilization : Administer oxygen to improve hypoxemia. Monitor vital signs and respiratory status closely. 2. Observation : Small, asymptomatic pneumothoraces (<2 cm) may resolve spontaneously with close monitoring and supplemental oxygen to hasten resorption . 3. Needle Aspiration or Chest Tube Insertion : Needle Aspiration : For primary spontaneous pneumothorax or small pneumothoraces in a stable patient. Chest Tube Insertion : For large pneumothoraces , symptomatic patients, or tension pneumothorax. Inserted into the pleural space to evacuate air and allow lung re-expansion.

43. 4 . Emergency Decompression for Tension Pneumothorax : Immediate needle decompression with a large-bore needle inserted into the second intercostal space at the midclavicular line, followed by chest tube insertion to prevent recurrence. 5 . Surgical Intervention : Video-Assisted Thoracoscopic Surgery (VATS) : Indicated for recurrent pneumothoraces , persistent air leaks, or if other treatments fail. Pleurodesis : Chemical or mechanical means to adhere the lung to the chest wall and prevent recurrence. 6. Management of Underlying Causes : Address and treat the underlying conditions, such as COPD, infections, or lung malignancies.

44. 16

45. Prevention Smoking Cessation : Reduces the risk of primary spontaneous pneumothorax, especially in young individuals. Avoid High-Risk Activities : Avoid scuba diving or high-altitude flights without decompression if a history of pneumothorax exists. Careful Monitoring : Close monitoring during and after medical procedures involving the chest to minimize iatrogenic pneumothorax. Preventive Surgery : For individuals with recurrent pneumothorax or significant risk factors, surgical options like pleurodesis may be considered.

46. References : 1. Kumar and Clark Clinical Medicine 2. USMLE Step 2 CK 3. Harrison's Principles of Internal Medicine