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CHAPTER 1

INTRODUCTION

1.1 Background

Every year more than 60,000 Americans die of pneumonia.Its aparticular concern for

older adults and peoplewith chronic illness or impaired immune systems,but it can also strike

young,healthy people.

There are many kinds of pneumonia ranging in seriousness from mild to

threatening.Pneumonia acquired while in the hospital can be particulary virulent anddeadly.Normally, very small amounts of pleural fluid are present in the pleural spaces, and

fluid is not detectable by routine methods. When certain disorders occur, excessive pleural

fluid may accumulate and cause pulmonary signs and symptoms. Simply put, pleural

effusions occur when the rate of fluid formation exceeds that of fluid absorption. Once a

symptomatic, unexplained pleural effusion occurs, a diagnosis needs to be established

Pleural effusions may not produce any symptoms in some patients. Others may

experience shortness of breath, a dry, non-productive cough, or pleuritic-type chest pain (a

sharp pain, usually on breathing in, which worsens with coughing). See your doctor if you areworried about any of these symptoms. Other patients may complain of symptoms stemming

from the cause of their effusion, for example swollen legs or feet in congestive heart failure.

Pleural effusion is defined as the collection of at least 10-20 mL of fluid in the pleural space.

Pleural effusion develops because of excessive filtration or defective absorption of

accumulated fluid. Pleural effusion may be a primary manifestation or a secondary

complication of many disorders. The clinical picture and presenting symptoms depend on the

underlying disease and the size of the effusion.

Pleural effusion is a condition very commonly related to pneumonia. Pleural effusion

commonly caused by bacterial infection, like Streptococcus, and then other risk factor. This

disease easily found in developing countries and several in England, Canada, USA.

Rarely, some patients may require further treatment for effusions which do not resolve, or

which recur despite repeated thoracentesis. They may undergo a procedure called

pleurodesis (pleural sclerosis), where a chemical is injected into the pleural space to induce

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scarring. This scarring sticks the two layers of pleura together so that no fluid can accumulate

between them.

1.2 Problems

The problem that will be discussed in this paper is the mechanism that links

pneumonia to pleural effusion.This thesis will explain in detail both diseases as individual and

linked subjects.

There are two thin membranes in the chest, one (the visceral pleura) lining the lungs, and the

other (the parietal pleura) covering the inside of the chest wall. Normally, small blood vessels

in the pleural linings produce a small amount of fluid that lubricates the opposed pleural

membranes so that they can glide smoothly against one another during breathing

movements. Any extra fluid is taken up by blood and lymph vessels, maintaining a balance.

When either too much fluid forms or something prevents its removal, the result is an excess

of pleural fluid--an effusion. The most common causes are disease of the heart or lungs, and

inflammation or infection of the pleura.

There are two types of pleural effusion: the transudate and the exudate. This is a very

important point because the two types of fluid are very different, and which type is present

points to what sort of disease is likely to have produced the effusion. It also can suggest the

best approach to treatment.

Some of the pleural disorders that produce an exudate also cause bleeding into the

pleural space. If the effusion contains half or more of the number of red blood cells present in

the blood itself, it is called hemothorax. When a pleural effusion has a milky appearance and

contains a large amount of fat, it is called chylothorax. Lymph fluid that drains from tissues

throughout the body into small lymph vessels finally collects in a large duct (the thoracic duct)

running through the chest to empty into a major vein. When this fluid, or chyle, leaks out of

the duct into the pleural space, chylothorax is the result. Cancer in the chest is a common

cause.

Pleural effusions may also be associated with the leakage of fluid due to higher than

normal pressures in the lung circulation, such as with congestive heart failure (CHF) or from

low protein in the blood, as in liver disease, severe malnutrition, and in certain kidney

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conditions when protein is filtered into the urine. Infection, blockage of blood supply to the

lung (Pulmonary Embolism), or cancer in the lung itself can result in accumulation of fluid in

the pleural space. If pleural effusions become infected with bacteria, inflammatory reaction

results that creates an abscess in the pleural space (empyema).

The inner surface of the chest wall and the surface of the lungs are covered by the parietal

and visceral pleural, respectively, with a potential space of 10-24 m between the 2 pleural

surfaces. This space is normally filled with a small amount of fluid. However, large amounts of

fluid can accumulate in the pleural space under pathologic conditions. The parietal pleura

have sensory innervation and small apertures that aid in the absorption of particles and fluid.

Systemic arterial vessels supply both pleural surfaces. Lymphatic vessels from the parietal

pleura drain to lymph nodes along the anterior and posterior chest wall, whereas lymphatics

from the visceral surface drain to the mediastinal lymph nodes. The pleural space normally

contains 0.1-0.2 mL/kg of a colorless alkaline fluid, which has


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erythematosus effusions are usually small, bilateral and are polymorphonuclear exudates.

The finding of an ANA titer that exceeds that of serum is diagnostic. Severe pleurisy is

frequent.

With a pleural effusion, some imbalance between production and reabsorption of

pleural fluid leads to excess fluid building up in the pleural space.

Pleural effusions may not produce any symptoms in some patients. Others may experience

shortness of breath, a dry, non-productive cough, or pleuritic-type chest pain (a sharp pain,

usually on breathing in, which worsens with coughing). See your doctor if you are worried

about any of these symptoms.

1.3 Limitations of problem

There are some limited established in this paper in order to prevent an over discussion of

the subject matter.The limits will only include:

What is the definition of the disease?

What causes disease?

Who can get disease?

How does the mechanism of the

disease work?

What are the symptoms of the

disease?

How is the disease diagnosed?

What treatments can be used to cure

the disease?

What complications can happen from

the disease?

What is the prognosis for someone

who suffers from the disease?Eventhough there may be some extra details added,they only serve to help clarify the

correlation between the two diseases.

1.4 Objectives

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The purpose of this paper is to provide the reader with more information in regards to

pneumonia and pleural effusion and the relation between two diseases. By, reading this

paper, the reader will obtain facts regarding.

- The definition of pneumonia and pleural effusion

- The etiology of pneumonia and pleural effusion

- The epidemiologi of pneumonia and pleural effusion

- The pathophysiology of pneumonia and pleural effusion

- The symptoms of pneumonia and pleural effusion

- The tests used to diagnose pneumonia and pleural effusion

- The treatments used of pneumonia and pleural effusion- The complications of pneumonia and pleural effusion

- The prognosis of pneumonia and pleural effusion

Furthermore, by being informed hopefully the reader realized the seriousness of this two

diseases.

1.5 Method of writing

The creation of this paper is made the possible with the aid of various sources such

as the the library, internet, and journal of medicine.

1.6 Frame of writing

CHAPTER I. INTRODUCTION

I.1 Background

I.2 Problems

I.3 Limitation of problem

I.4 Objectives

I.5 Method of writing

CHAPTER II. PNEUMONIA

CHAPTER III. PLEURAL EFFUSIONCHAPTER IV. THE CORRELATION BETWEEN PNEUMONIA AND PLEURAL EFFUSION

CHAPTER V. CONCLUSION

CHAPTER VI. BIBLIOGRAPHY

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CHAPTER II

PNEUMONIA

2.1 DEFINITION

Pneumonia is an illness of the lungs and respiratory system in which the

alveoli(microscopic air-filledsacs of the lung responsible for absorbing oxygen from

atmosphere)become inflamed and flooded with fluid.It also occurs in all age groups and is

aleading cause of death among the elderly and people who are chronically and terminally ill.

Pneumonia may also occur from chemical or physical injury to the lungs or indirectly

due to another medical illness,such as lung cancer or alcohol abuse.

2.2 Etiology

Your lungs are two spongy organs surrounded by amoist membrane(the pleura).Each

lung is divided into lobes(three on the right and two on the left).When you inhale,air is carried

through the windpipe(trachea) to your lungs.Inside your lungsthere are major airways calledbronchi.The bronchi repeatedly subdivide into many smaller airways (branchioles),which

finally end in clusters of tiny air sacs called alveoli.

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Your body has mechanisms to protect your lungs from infections.In fact,youre

frwquently exposed to bacteria and viruses that can causes pneumonia,but your body

normally prevents most of these organisms from invading and overwhelming your airways.

There,white blood cells(leukocytes),a key part of your immune system,began to attack

the invading organisms.The accumulating pathogens,white cells and immune proteins cause

tha air sacs to become inflamed and filled with fluid,leading to the difficult breathing that

characterizes many types of pneumonia.If both lungs are involved,its called double

pneumonia.

2.3 Epidemiology

Pneumonia is acommon illness in all parts of the world .It is major cause of death

among all age groups.In children,the majority of deaths occur in the newborn period,with over

twomillion deaths ayear worldwide.The WHO(World Health Organization) estimates that one

in three newborn infant deaths are due to pneumonia.Mortality from pneumonia generally

decreases with age until late adulthood.Elderly individuals,however,are at particular risk for

pneumonia and associated mortality.

More cases of pneumonia occur during the winter months than during other times of

the year.Pneumonia occurs more commonlyin males than females,and more often blacks

than Caucasians.Individuals with underlying illness such as Alzheimers disease,cystic

fibrosis,emphysema,tobacco smoking,alcoholism or immune system problems.

2.4 CLASSIFICATION

Pneumonia is some times classified according to the cause of pneumonia:

Community acquired pneumonia.This refers to pneumonia you acquire in the course of

your daily life at school,work or the gwm,for instance

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Hospital-acquired (nosocomial) pneumonia.If youre hospitalized,youre at higher risk

of pneumonia,especially if you are on mechanical ventilator,are intensive care unit or

have a compromised immune system.

Aspiration pneumonia.This type of pneumonia is consuming too much alcohol.This

happens when the inebriated person passes out,and then vomits due to the effects of

alcohol anthe stomach.

2.5 PATHOPHYSIOLOGY

The symptoms of infectious pneumonia are caused by the invasion of the lungs by

microorganisms and by the immune systems response to the infection.Although over onehundred stains of microorganism can cause pneumonia,only a few of them are responsible

for most cases.The most common causes of pneumonia are viruses and bacteria.Less

common causes of infectious pneumonia include fungi and parasites.

2.6 SIGN AND SYMPTOMS

Pneumonia can be difficult to spot .t often mimics a cold or the flu,beginning with a

cough and a fever, so you may not realize you have a more serious condition.Chest pain is

acommon symptom of many types of pneumonia.Pneumonia symptoms can vary

greatly,depending on any underlying conditions you may have and the typeof organisms

causing the infection:

Bacteria

Viruses

Mycoplasma

Fungi

Pneumocystis carinii

2.7 TEST AND DIAGNOSIS

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Thoracoscopy is an excellent technique to determine the etiology of an undiagnosed

exudative pneumonia. The procedure is superior to the old closed pleural biopsy techniques

because of its higher diagnostic yield. A rigid thoracoscope with a cold light source is used

and second point of entry is necessary to provide biopsy forceps access to the pleural space.

This technique continues to be most helpful in diagnosing malignant effusions (including

mesothelioma), tuberculosis, and trapped lung

2.8 TREATMENT AND THERAPY

The best way to clear up a pneumonie is to direct treatment at what is causing it, rather

than treating the effusion itself. If heart failure is reversed or a lung infection is cured by

antibiotics, the effusion will usually resolve. However, if the cause is not known, even after

extensive tests, or no effective treatment is at hand, the fluid can be drained away by placing a

large-bore needle or catheter into the pleural space, just as in diagnostic thoracentesis. If

necessary, this can be repeated as often as is needed to control the amount of fluid in the

pleural space. If large effusions continue to recur, a drug or material that irritates the pleural

membranes can be injected to deliberately inflame them and cause them to adhere close

together--a process called sclerosis. This will prevent further effusion by eliminating the

pleural space. In the most severe cases, open surgery with removal of a rib may be necessary

to drain all the fluid and close the pleural space

2.9 COMPLICATION

Bacteria in bloodstream

Fluid accumulation an infection around the lung

Lung abscess

Respiratory and circulatory failure

Pleural effusion

Emphysema

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2.10 PROGNOSIS

Pneumonia can be determined and effectively treated, the effusion itself will

reliably clear up and should not recur. In many other cases, sclerosis will prevent

sizable effusions from recurring. Whenever a large effusion causes a patient to be

short of breath, thoracentesis will make breathing easier, and it may be repeated if

necessary. To a great extent, the outlook for patients with pleural effusion depends on

the primary cause of effusion and whether it can be eliminated. Some forms of pleural

effusion, such as that seen after abdominal surgery, are only temporary and will clear

without specific treatment. If heart failure can be controlled, the patient will remain

free of pleural effusion. If, on the other hand, effusion is caused by cancer that cannot

be controlled, other effects of the disease probably will become more important.

CHAPTER III

PLEURAL EFFUSION

3.1 DEFINITION

Pleural effusion is the buildup of excess fluid in the space between the pleura. Thepleura are two thin, moist membranes around the lungs. There are two layers of pleura:

Inner layer attached to the outside of the lungs

Outer layer lines the inside of the ribcage

Pleural effusion occurs when too much fluid collects in the pleural space (the space

between the two layers of the pleura). It is commonly known as "water on the lungs." It is

characterized by shortness of breath, chest pain, gastric discomfort (dyspepsia), and cough.

There are two thin membranes in the chest, one (the visceral pleura) lining the lungs, and theother (the parietal pleura) covering the inside of the chest wall. Normally, small blood vessels

in the pleural linings produce a small amount of fluid that lubricates the opposed pleural

membranes so that they can glide smoothly against one another during breathing

movements. Any extra fluid is taken up by blood and lymph vessels, maintaining a balance.

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When either too much fluid forms or something prevents its removal, the result is an excess

of pleural fluid--an effusion. The most common causes are disease of the heart or lungs, and

inflammation or infection of the pleura

3.2 ETIOLOGY

The etiology of transudative pleural effusion

Among the most important specific causes of a transudative pleural effusion are:

Congestive heart failure. This causes pleural effusions in about 40% of patients and is

often present on both sides of the chest. Heart failure is the most common cause of

bilateral (two-sided) effusion. When only one side is affected it usually is the right

(because patients usually lie on their right side).

Pericarditis. This is an inflammation of the pericardium, the membrane covering the

heart.

Too much fluid in the body tissues, which spills over into the pleural space. This is

seen in some forms of kidney disease; when patients have bowel disease and absorb

too little of what they eat; and when an excessive amount of fluid is given

intravenously.

Liver disease. About 5% of patients with a chronic scarring disease of the liver called

cirrhosis develop pleural effusion.

The etiology of exudative pleural effusions

A wide range of conditions may be the cause of an exudative pleural effusion:

Pleural tumors account for up to 40% of one-sided pleural effusions. They may arise

in the pleura itself (mesothelioma), or from other sites, notably the lung.

Tuberculosis in the lungs may produce a long-lasting exudative pleural effusion.

Pneumonia affects about three million persons each year, and four of every ten

patients will develop pleural effusion. If effective treatment is not provided, an

extensive effusion can form that is very difficult to treat.

Patients with any of a wide range of infections by a virus, fungus, or parasite that

involve the lungs may have pleural effusion.

Up to half of all patients who develop blood clots in their lungs (pulmonary embolism)

will have pleural effusion, and this sometimes is the only sign of embolism.

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Connective tissue diseases, including rheumatoid arthritis, lupus, and Sjgren's

syndrome may be complicated by pleural effusion.

Patients with disease of the liver or pancreas may have an exudative effusion, and the

same is true for any patient who undergoes extensive abdominal surgery. About 30%

of patients who undergo heart surgery will develop an effusion.

Injury to the chest may produce pleural effusion in the form of either hemothorax or

chylothorax.

3. 3 EPIDEMIOLOGI

In the US : Pleural effusion affects 1.3 million individuals each year. Approximate annual

incidences of pleural effusions are based on major underlying disease processes, as follows:

congestive heart failure, 500,000; bacterial pneumonia, 300,000; malignancy, 200,000;

pulmonary embolus, 150,000; cirrhosis with ascites, 50,000; pancreatitis, 20,000; and

tuberculosis, 2,500.

Internationally : The relative annual incidence of pleural effusion is estimated to be 320 per

100,000 people in industrialized countries. When extrapolating these figures to apply to other

countries, the distribution and incidence of pleural effusion causes are dependent on the

population studied.

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3.4 CLASSIFICATION

There are two types of pleural effusion: the transudate and the exudate. This is a very

important point because the two types of fluid are very different, and which type is present

points to what sort of disease is likely to have produced the effusion. It also can suggest the

best approach to treatment.

Transudates

A transudate is a clear fluid, similar to blood serum, that forms not because the pleural

surfaces themselves are diseased, but because the forces that normally produce and remove

pleural fluid at the same rate are out of balance. When the heart fails, pressure in the small

blood vessels that remove pleural fluid is increased and fluid "backs up" in the pleural space,

forming an effusion. Or, if too little protein is present in the blood, the vessels are less able to

hold the fluid part of blood within them and it leaks out into the pleural space. This can result

from disease of the liver or kidneys, or from malnutrition.

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Exudates

An exudate--which often is a cloudy fluid, containing cells and much protein--results from

disease of the pleura itself. The causes are many and varied. Among the most common are

infections such as bacterial pneumonia and tuberculosis; blood clots in the lungs; and

connective tissue diseases, such as rheumatoid arthritis. Cancer and disease in organs such

as the pancreas also may give rise to an exudative pleural effusion.

Special types of pleural effusion

Some of the pleural disorders that produce an exudate also cause bleeding into the pleural

space. If the effusion contains half or more of the number of red blood cells present in the

blood itself, it is called hemothorax. When a pleural effusion has a milky appearance and

contains a large amount of fat, it is called chylothorax

3.5 PATHOPHYSIOLOGY

The inner surface of the chest wall and the surface of the lungs are covered by the

parietal and visceral pleural, respectively, with a potential space of 10-24 m between the 2

pleural surfaces. This space is normally filled with a small amount of fluid. However, large

amounts of fluid can accumulate in the pleural space under pathologic conditions. The

parietal pleura have sensory innervation and small apertures that aid in the absorption of

particles and fluid.

3.6 SIGN AND SYMPTOMS

Some types of pleural effusion do not cause symptoms. Others cause a variety of symptoms,

including:

Shortness of breath

Chest pain

Stomach discomfort

Cough

Coughing up blood

Shallow breathing

Rapid pulse or breathing rate

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Weight loss

Fever, chills, or sweating

Hiccupping

Pleuritic chest pain, chest pressure, dyspnea, and cough are the most common

symptoms of pleural effusion. Pain may occur with little fluid formation as the symptom is

related to the intense inflammation of the pleural surfaces. Chest pressure usually does not

occur until the effusion is in the moderate (500-1500 ml) to large (>1500 ml) category.

Dyspnea rarely occurs with small effusions unless significant pleurisy is present and often the

patient will not complain of dyspnea until the effusion is massive with contralateral

mediastinal shift on the chest x-ray. Cough is usually related to the associated atelectasis,

which to some degree accompanies all pleural effusions. Classic physical findings associated

with pleural effusions may occur when the volume begins to exceed 500 ml and include

diminished breath sounds, dullness to percussion, reduced tactile and vocal fremitus, and

occasionally a pleural friction rub. In contrast to pneumonia and atelectasis, crackles are not

heard with an isolated pleural effusion

3.7 TEST AND DIAGNOSIS

The doctor will ask about your symptoms and medical history, and perform a physical

exam. This may include listening to or tapping on your chest.

When pleural effusion is suspected, the best way to confirm it is to take chest x rays, both

straight-on and from the side. The fluid itself can be seen at the bottom of the lung or lungs,

hiding the normal lung structure. If heart failure is present, the x-ray shadow of the heart will

be enlarged. An ultrasound scan may disclose a small effusion that caused no abnormal

findings during chest examination. A computed tomography scan is very helpful if the lungs

themselves are diseased.

3.8 TREATMENT AND THERAPY

The best way to clear up a pleural effusion is to direct treatment at what is causing it,

rather than treating the effusion itself. If heart failure is reversed or a lung infection is cured by

antibiotics, the effusion will usually resolve. However, if the cause is not known, even after

extensive tests, or no effective treatment is at hand, the fluid can be drained away by placing

a large-bore needle or catheter into the pleural space, just as in diagnostic thoracentesis. If

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necessary, this can be repeated as often as is needed to control the amount of fluid in the

pleural space. If large effusions continue to recur, a drug or material that irritates the pleural

membranes can be injected to deliberately inflame them and cause them to adhere close

together--a process called sclerosis. This will prevent further effusion by eliminating the

pleural space. In the most severe cases, open surgery with removal of a rib may be

necessary to drain all the fluid and close the pleural space

3.9 COMPLICATIONS

A lung surrounded by a fluid collection for a long time may collapse. Pleural fluid that

becomes infected may turn into an abscess, called an empyema, which requires prolonged

drainage with a chest tube placed into the fluid collection. Pneumothorax (air within the chest

cavity) can be a complication of the thoracentesis procedure.

3.10 PROGNOSIS

When the cause of pleural effusion can be determined and effectively treated, the

effusion itself will reliably clear up and should not recur. In many other cases, sclerosis will

prevent sizable effusions from recurring. Whenever a large effusion causes a patient to be

short of breath, thoracentesis will make breathing easier, and it may be repeated if

necessary.

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CHAPTER IV

THE CORRELATION BETWEEN PNEUMONIA AND PLEURAL

EFFUSION

4.1 CASE

An estimated 45 million cases of infectious pneumonia occur annually in the United

States, with up to 50,000 deaths directly attributable to it. Pneumonia is a common immediate

cause of death in persons with a variety of underlying diseases. With the use of

immunosuppressive and chemotherapeutic agents for treating transplant and cancer patients,

pneumonia caused by infectious agents that usually do not cause infections in healthy

persons (that is, pneumonia as an opportunistic infection) has become commonplace.

Moreover, individuals with acquired immune deficiency syndrome (AIDS) usually die from an

opportunistic infection, such as pneumocystis pneumonia or cytomegalovirus pneumonia.

Concurrent with the variable and expanding etiology of pneumonia and the more frequent

occurrence ofopportunistic infections is the development of new antibiotics and other drugs

used in the treatment of pneumonia. See also Acquired immune deficiency syndrome (AIDS);

Opportunistic infections.

A 70-year-old man with an 80-pack-year history of smoking and a history of

congestive heart failure presents with increasing shortness of breath. He also has aching

chest pain on the right side that worsens with deep inspiration. He is a febrile. The chest

radiograph reveals bilateral pleural effusions, with morepleural fluid on the right than on the

left. How should thispatient be evaluated?

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Although many different diseases may cause a pleural effusion, the most common

causes in the United States are congestiveheart failure, pneumonia, and cancer. The diagnostic

workup of a patient with a pleural effusion will depend on the probable causes. Because

pleural effusion is a secondary effect of many different conditions, the key to preventing it is

to promptly diagnose the primary disease and provide effective treatment. Timely treatment of

infections such as tuberculosis and pneumonia will prevent many effusions. When effusion

occurs as a drug side-effect, withdrawing the drug or using a different one may solve the

problem.

Although antibiotics can treat some of the most common forms of bacterial

pneumonias, antibiotic-resistant strains are a growing problem. For that reason, and because

the disease can be very serious, it's best to try to prevent infection in the first place. The

history and the physical examination are critical in guidingthe evaluation of pleural effusion.

Several aspects of the physical examination should receive special attention. Chest

examinationtypically reveals dullness to percussion, the absence of fremitus,and diminished

breath sounds or their absence. Distended neck veins, an S3 gallop, or peripheral edema

suggests congestiveheart failure, and a right ventricular heave or thrombophlebitissuggests

pulmonary embolus. The presence of lymphadenopathyor hepatosplenomegaly suggests

neoplastic disease, and ascitesmay suggest a hepatic cause.

Since conditions other than pleural effusions may produce similarradiologic findings,

alternative imaging studies are frequently necessary to verify that a pleural effusion is

present. Ultrasonographicstudies or lateral decubitus radiographs are used most commonly,

but computed tomographic (CT) scans of the chest allow imaging of the underlying lung

parenchyma or mediastinum

4.2 PathogeneisMost cases of pneumonia and pleural effusion are contracted by breathing in small

droplets that contain the bacteria or virus that can cause pneumonia. These droplets get into

the air when a person infected with these germs coughs or sneezes. In other cases,

pneumonia is caused when bacteria or viruses that are normally present in the mouth, throat,

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or nose inadvertently enter the lung. During sleep it is quite common for people to aspirate

secretions from the mouth, throat, or nose. Normally, the body's reflex response (coughing

back up the secretions) and immune system will prevent a pneumonia from starting.

However, if a person is in a weakened condition from another illness, a severe pneumonia

can develop. People with emphysema, heart disease, and swallowing problems, as well as

alcoholics, drug users and those who have suffered a stroke or seizure are at higher risk for

developing pneumonia.

Once the bacteria, virus or fungus enter the lungs, they usually settle in the air sacs of

the lung where they rapidly grow in number. This area of the lung then becomes filled with

fluid and pus as the body attempts to fight off the infection.

The cause of the effusion remains unclear in the cases of asubstantial percentage of

patients with exudative effusions after the history, physical examination, and analysis of

pleural fluid.32 If the effusion persists despite conservative treatment, thoracoscopy should

be considered, since it has a high yield for cancer or tuberculosis. If thoracoscopy is

unavailable, alternative invasive approaches are needle biopsy and open biopsy of the

pleura. No diagnosis is ever established for approximately 15 percent of patients despite

invasive procedures such as thoracoscopyor open pleural biopsy.

Pleural effusion in cancer patients can be caused by several different conditions.

Blockage of the lymphatic system, a series of channels for drainage of body fluids, interferes

with the removal of pleural fluid. Blockage of the veins of the lungs increases the pressure at

the pleurae which causes fluid accumulation. Cancerous cells may seed onto pleurae and

cause inflammation which increases fluid in the pleural space. High numbers of cancerous

cells may collect in the pleural space (tumorcell suspensions) which causes extra fluid to be

released. Accumulation of fluid in the abdominal cavity may cross over to the pleural space.

Pneumonia and Pleural effusion itself is not a disease as much as a result of many

different diseases. For this reason, there is no "typical" patient in terms of age, sex, or other

characteristics. Instead, anyone who develops one of the many conditions that can produce

an effusion may be affected.

-symptoms

Pneumonia and pleural effusion suspected in any patient who has fever, cough, chest

pain, shortness of breath, and increased respirations (number of breaths per minute). Fever

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with a shaking chill is even more suspicious. Many patients cough up clumps of sputum,

commonly known as spit. These secretions are produced in the alveoli during an infection or

other inflammatory condition. They may appear streaked with pus or blood. Severe

pneumonia results in the signs of oxygen deprivation. This includes blue appearance of the

nail beds or lips (cyanosis).

The invading organism causes symptoms, in part, by provoking an overly-strong

immune response in the lungs. In other words, the immune system, which should help fight

off infections, kicks into such high gear, that it damages the lung tissue and makes it more

susceptible to infection. The small blood vessels in the lungs (capillaries) become leaky, and

protein-rich fluid seeps into the alveoli. This results in less functional area for oxygen-carbon

dioxide exchange. The patient becomes relatively oxygen deprived, while retaining potentially

damaging carbon dioxide. The patient breathes faster and faster, in an effort to bring in more

oxygen and blow off more carbon dioxide.

Mucus production is increased, and the leaky capillaries may tinge the mucus with

blood. Mucus plugs actually further decrease the efficiency of gas exchange in the lung. The

alveoli fill further with fluid and debris from the large number of white blood cells being

produced to fight the infection.

Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are normally

hollow air spaces within the lung, instead become solid, due to quantities of fluid and debris.

Viral pneumonias and mycoplasma pneumonias, do not result in consolidation. These types

of pneumonia primarily infect the walls of the alveoli and the parenchyma of the lung.

The key symptom of a pleural effusion is shortness of breath. Fluid filling the pleural

space makes it hard for the lungs to fully expand, causing the patient to take many breaths so

as to get enough oxygen. When the parietal pleura is irritated, the patient may have mild pain

that quickly passes or, sometimes, a sharp, stabbing pleuritic type of pain. Some patients will

have a dry cough. Occasionally a patient will have no symptoms at all. This is more likely

when the effusion results from recent abdominal surgery, cancer, or tuberculosis. Tapping on

the chest will show that the usual crisp sounds have become dull, and on listening with a

stethoscope the normal breath sounds are muted. If the pleura is inflamed, there may be a

scratchy sound called a "pleural friction rub."

19
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Most people who develop pneumonia and pleural effusion initially have symptoms of a

cold which is then followed by a high fever (sometimes as high as 104 degrees), shaking

chills, and a cough with sputum production. The sputum is often bloody. Chest pain may

develop on one side and the patient may become short of breath. In other cases of

pneumonia, there can be a slow onset of symptoms. A worsening cough, headaches, and

muscle aches may be the only symptoms. At times, the individual's skin color may change

and become dusky or purplish due to their blood being poorly oxygenated.

The signs and symptoms of pneumonia and pleural effusion are usually nonspecific,

consisting of fever, chills, shortness of breath, and chest pain. Fever and chills are more

frequently associated with infectious pneumonias but may also be seen in pneumonitis. The

physical examination of a person with pneumonia or pneumonitis may reveal abnormal lung

sounds indicative of regions of consolidation of lung tissue. A chest x-ray also shows the

consolidation, which appears as an area of increased opacity (white area). Cultures of

sputum orbronchial secretions may identify an infectious organism capable of causing the

pneumonia.

When pneuumonia and pleural effusion is suspected, the best way to confirm it is to

take chest x rays, both straight-on and from the side. The fluid itself can be seen at the

bottom of the lung or lungs, hiding the normal lung structure. If heart failure is present, the x-ray shadow of the heart will be enlarged. An ultrasound scan may disclose a small effusion

that caused no abnormal findings during chest examination. A computed tomography scan is

very helpful if the lungs themselves are diseased.

In order to learn what has caused the effusion, a needle or catheter is often used to

obtain a fluid sample, which is examined for cells and its chemical make-up. This procedure,

called a thoracentesis, is the way to determine whether an effusion is a transudate or

exudate, giving a clue as to the underlying cause. In some cases--for instance when cancer

or bacterial infection is present--the specific cause can be determined and the correcttreatment planned. Culturing a fluid sample can identify the bacteria that cause tuberculosis

or other forms of pleural infection. The next diagnostic step is to take a tissue sample, or

pleural biopsy, and examine it under a microscope. If the effusion is caused by lung disease,

placing a viewing tube (bronchoscope) through the large air passages will allow the examiner

20
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to see the

Your doctor may first suspect pneumonia and pleural effusion based on your medical

history and a physical exam. During the exam, your doctor will listen to your lungs with a

stethoscope to check for abnormal bubbling or crackling sounds (rales) and for rumblings

(rhonchi) that signal the presence of thick liquid. Both these sounds may indicate

inflammation caused by infection.

You're also likely to have chest X-rays to confirm the presence of pneumonia and

pleural effusion to determine the extent and location of the infection. Your doctor can suspect

pneumonia, but he or she can't diagnose it without a chest X-ray.

You may also have blood tests to check your white cell count, or to look for the presence of

viruses, bacteria or other organisms. Sometimes your doctor may examine a sample of your

phlegm or your blood to help identify the microorganism that's causing your illness.

The extent of all this testing depends on how sick you are and your underlying risk factors,

and whether or not you're responding to therapy.

chest x rays and computed tomography scans may be performed to diagnose pleural

effusion. Thoracentesis, the removal of pleural fluid through a long needle, is usually

performed for diagnostic purposes. Fluid removed by thoracentesis will be sent to the lab to

be thoroughly evaluated. Thoracoscopy, in which a wand-like lighted camera (endoscope) is

inserted through the chest, may be conducted to diagnose pleural effusion. During

thoracoscopy, samples (biopsy) ofpleura may be taken.

Pleural effusion can hinder the normal function of the lungs. Symptoms of pleural

effusion include chest pain, chest heaviness, breathing difficulties, and a dry cough. Patients

with malignant pleural effusions tend to be weak and have a short-span life expectancy. The

prognosis depends on the type of cancer. Sixty-five percent of patients with malignant pleural

effusions die within three months and 80% die within six months. However, patients with

pleural effusion related to breast cancer have a longer life expectancy.

Chest x rays and computed tomography scansmay be performed to diagnose pleural





21
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Pleuritic chest pain, chest pressure, dyspnea, and cough are the most common

symptoms of pleural effusion. Pain may occur with little fluid formation as the symptom is

related to the intense inflammation of the pleural surfaces. Chest pressure usually does not

occur until the effusion is in the moderate (500-1500 ml) to large (>1500 ml) category.

Dyspnea rarely occurs with small effusions unless significant pleurisy is present and often the

patient will not complain of dyspnea until the effusion is massive with contralateral

mediastinal shift on the chest x-ray. Cough is usually related to the associated atelectasis,

which to some degree accompanies all pleural effusions. Classic physical findings associated

with pleural effusions may occur when the volume begins to exceed 500 ml and include

diminished breath sounds, dullness to percussion, reduced tactile and vocal fremitus, and

occasionally a pleural friction rub. In contrast to pneumonia and atelectasis, crackles are not

heard with an isolated pleural effusion.

4.3 SYMPTOMS

Pneumonia and pleural effusion suspected in any patient who has fever, cough, chest

pain, shortness of breath, and increased respirations (number of breaths per minute). Fever

with a shaking chill is even more suspicious. Many patients cough up clumps of sputum,

commonly known as spit. These secretions are produced in the alveoli during an infection or

other inflammatory condition. They may appear streaked with pus or blood. Severe

pneumonia results in the signs of oxygen deprivation. This includes blue appearance of the

nail beds or lips (cyanosis).

The invading organism causes symptoms, in part, by provoking an overly-strong

immune response in the lungs. In other words, the immune system, which should help fight

off infections, kicks into such high gear, that it damages the lung tissue and makes it more

susceptible to infection. The small blood vessels in the lungs (capillaries) become leaky, and

protein-rich fluid seeps into the alveoli. This results in less functional area for oxygen-carbon

dioxide exchange. The patient becomes relatively oxygen deprived, while retaining potentially

damaging carbon dioxide. The patient breathes faster and faster, in an effort to bring in more

oxygen and blow off more carbon dioxide.

Mucus production is increased, and the leaky capillaries may tinge the mucus with

blood. Mucus plugs actually further decrease the efficiency of gas exchange in the lung. The

22
http://www.answers.com/topic/biopsyhttp://www.answers.com/topic/pleurahttp://www.answers.com/topic/feverhttp://www.answers.com/topic/shortness-of-breath-1http://www.answers.com/topic/chillhttp://www.answers.com/topic/sputumhttp://www.answers.com/topic/spithttp://www.answers.com/topic/inflammatoryhttp://www.answers.com/topic/pushttp://www.answers.com/topic/deprivationhttp://www.answers.com/topic/cyanosishttp://www.answers.com/topic/capillarieshttp://www.answers.com/topic/tingehttp://www.answers.com/topic/biopsyhttp://www.answers.com/topic/pleurahttp://www.answers.com/topic/feverhttp://www.answers.com/topic/shortness-of-breath-1http://www.answers.com/topic/chillhttp://www.answers.com/topic/sputumhttp://www.answers.com/topic/spithttp://www.answers.com/topic/inflammatoryhttp://www.answers.com/topic/pushttp://www.answers.com/topic/deprivationhttp://www.answers.com/topic/cyanosishttp://www.answers.com/topic/capillarieshttp://www.answers.com/topic/tinge


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alveoli fill further with fluid and debris from the large number of white blood cells being

produced to fight the infection.

Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are normally

hollow air spaces within the lung, instead become solid, due to quantities of fluid and debris.

Viral pneumonias and mycoplasma pneumonias, do not result in consolidation. These types

of pneumonia primarily infect the walls of the alveoli and the parenchyma of the lung.

The key symptom of a pleural effusion is shortness of breath. Fluid filling the pleural

space makes it hard for the lungs to fully expand, causing the patient to take many breaths so

as to get enough oxygen. When the parietal pleura is irritated, the patient may have mild pain

that quickly passes or, sometimes, a sharp, stabbing pleuritic type of pain. Some patients will

have a dry cough. Occasionally a patient will have no symptoms at all. This is more likely

when the effusion results from recent abdominal surgery, cancer, or tuberculosis. Tapping on

the chest will show that the usual crisp sounds have become dull, and on listening with a

stethoscope the normal breath sounds are muted. If the pleura is inflamed, there may be a

scratchy sound called a "pleural friction rub."

Most people who develop pneumonia and pleural effusion initially have symptoms of a

cold which is then followed by a high fever (sometimes as high as 104 degrees), shaking

chills, and a cough with sputum production. The sputum is often bloody. Chest pain may

develop on one side and the patient may become short of breath. In other cases of

pneumonia, there can be a slow onset of symptoms. A worsening cough, headaches, and

muscle aches may be the only symptoms. At times, the individual's skin color may change

and become dusky or purplish due to their blood being poorly oxygenated.

The signs and symptoms of pneumonia and pleural effusion are usually nonspecific,

consisting of fever, chills, shortness of breath, and chest pain. Fever and chills are more

frequently associated with infectious pneumonias but may also be seen in pneumonitis. The

physical examination of a person with pneumonia or pneumonitis may reveal abnormal lung

sounds indicative of regions of consolidation of lung tissue. A chest x-ray also shows the

consolidation, which appears as an area of increased opacity (white area). Cultures of

sputum orbronchial secretions may identify an infectious organism capable of causing the

pneumonia

23
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IV.4 DIAGNOSIS

When pneuumonia and pleural effusion is suspected, the best way to confirm it is to

take chest x rays, both straight-on and from the side. The fluid itself can be seen at the

bottom of the lung or lungs, hiding the normal lung structure. If heart failure is present, the x-

ray shadow of the heart will be enlarged. An ultrasound scan may disclose a small effusion

that caused no abnormal findings during chest examination. A computed tomography scan is

very helpful if the lungs themselves are diseased.

In order to learn what has caused the effusion, a needle or catheter is often used to

obtain a fluid sample, which is examined for cells and its chemical make-up. This procedure,

called a thoracentesis, is the way to determine whether an effusion is a transudate or

exudate, giving a clue as to the underlying cause. In some cases--for instance when cancer

or bacterial infection is present--the specific cause can be determined and the correct

treatment planned. Culturing a fluid sample can identify the bacteria that cause tuberculosis

or other forms of pleural infection. The next diagnostic step is to take a tissue sample, or

pleural biopsy, and examine it under a microscope. If the effusion is caused by lung disease,

placing a viewing tube (bronchoscope) through the large air passages will allow the examiner

to see the

Your doctor may first suspect pneumonia and pleural effusion based on your medical

history and a physical exam. During the exam, your doctor will listen to your lungs with a

stethoscope to check for abnormal bubbling or crackling sounds (rales) and for rumblings

(rhonchi) that signal the presence of thick liquid. Both these sounds may indicate

inflammation caused by infection.

You're also likely to have chest X-rays to confirm the presence of pneumonia and

pleural effusion to determine the extent and location of the infection. Your doctor can suspect

pneumonia, but he or she can't diagnose it without a chest X-ray.

You may also have blood tests to check your white cell count, or to look for the presence of

viruses, bacteria or other organisms. Sometimes your doctor may examine a sample of your

phlegm or your blood to help identify the microorganism that's causing your illness.

The extent of all this testing depends on how sick you are and your underlying risk factors,

and whether or not you're responding to therapy.

chest x rays and computed tomography scans may be performed to diagnose pleural

24
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25/29






Pleural effusion can hinder the normal function of the lungs. Symptoms of pleural

effusion include chest pain, chest heaviness, breathing difficulties, and a dry cough. Patients

with malignant pleural effusions tend to be weak and have a short-span life expectancy. The

prognosis depends on the type of cancer. Sixty-five percent of patients with malignant pleural

effusions die within three months and 80% die within six months. However, patients with

pleural effusion related to breast cancer have a longer life expectancy.

Chest x rays and computed tomography scansmay be performed to diagnose pleural






25
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CHAPTER V

CONCLUSION

Pleural effusions are associated with many systemic disorders. Thoracentesis to

determine if the pleural fluid is a transudate or an exudate coupled with other appropriate

diagnostic studies provides a diagnosis most of the time. Because pleural fluid findings are

often nonspecific (except for positive cytology and bacteriology), clinical correlation and

response to therapy are critical. Not every pleural fluid study needs to be ordered on every

pleural effusion. Clinical judgement remains the key.







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CHAPTER VI

BILBIOGRAPHY

Ross DS: Pleural effusion. In: Harwood-Nuss AL, Linden CH, eds. The Clinical

Practice of Emergency Medicine. 1996: 649-52.

Sahn SA: An undiagnosed pleural effusion. Hosp Pract (Off Ed) 1993 Jun 15; 28(6):

60-4, 67; discussion 67-8

McEwen JI: Pleural effusion. In: Rosen P, Barkin RM, eds. Emergency Medicine

Concepts and Clinical Practice. 1998: 1521-5.

Heffner JE. Evaluating diagnostic tests in the pleural space. Clin Chest Med

1998;19.2:277-293.

Light RL. Disorders of the Pleura. Harrisons Principles of Internal Medicine

1998; chapter 262, 13472-1475.

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Roper WH. Primary serofibrinous pleural effusion in military personnel. Am

Rev Tuberc 1955;71:616-634

Kinasewitz GT. Pleuritis and Pleural Effusion. Pulmonary and Critical Care

Medicine on CD-ROM 1997; Chapter One

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