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Pleural Effusion : Everything You Want to Know

Feb 10 | 3:30 PM

Pleural effusion is Fluid collected outside the lungs (in the pleural space ). There maybe Cough or Breathlessness or Symptoms of an underlying lung disease. So, we have to find out if it's a Exudate or Transudate ? How do we do that ? What are the causes of bilateral pleural effusion ? How does Liver disease, kidney disease lead to pleural effusion? All this and more to learn about Pleural Effusions in this exclusive Medflix session with Prof. Dr. Salil Bendre.

[Music] uh good evening everyone and we are glad you can be here at this and i welcome you all on behalf of team netflix for tonight's session on plural uh plural effusion and everything that you would want to know uh our speaker for this uh session is professor dr saleem he's a pulmonologist and transparent physician with nanawati global hospital and hospital mumbai and he's also teaching uh at the samaya which is also at mumbai so without any further delay thank you good evening and thank you netflix for inviting me for this session on plural effusions uh we have already had very good sessions for which we got a feedback on pneumonia then we had on x-rays so i am very glad that today we are going to discuss another very important topic a very important and a very common disease which we come across when we talk of respiratory diseases that is plural effusions and i suppose all of the people who have logged in today and who are attending this session have definitely seen patients with neural effusion either it would be unilateral means on one side or there would be patients having a bilateral means both the sides plural effusion and we need to really know why the effusions happen and what is the process in which they happen and what will be the steps we should go ahead to investigate a case of a plural effusion so to make it simple again as usual since the audience is a mixed group of doctors right from some being students to some being undergraduates to some practicing consultants and from different parts of india i am giving a basic understanding of plural effusion and then we shall proceed with the further investigations so let's come to the anatomy it's always best to start with the anatomy then we talk of the physiology then we talk of the pathology and then we talk of a diagnosis so anatomically if you can see in this diagram which i am sure every one of us knows that the lung is encased or is enveloped in a covering and that is the pleura okay now pleura has got two parts one is the visceral pleura and another is the parietal pleura so visceral pleura is the one which is stuck or which is adherent to the surface of the lung then there is a space which would be the pleural space and the parietal pleura now please understand that whenever we are talking of a diagram or an x-ray we are purely seeing a one-dimensional picture means we are just understanding that the x-ray is showing fluid but when fluid collects in a plural space it's a three-dimensional collection so it will be anteriorly laterally medially posteriorly the fluid collection is from all over and the lung is virtually floating in this fluid so though you can see in this diagram that there is only the yellow colored fluid which is on the side this fluid is actually covering the lung from all the sides anteriorly posteriorly inferiorly and medially everywhere it is collecting and the lung is actually floating in the fluid that's how it is that's why when we examine when we come to examination and we make the patient turn his position you make the patient lie down the fluid moves and that's why we get what is called as a dullness which shifts so it is called as shifting nullness so it's a three-dimensional understanding of a disease though we can see the picture as one-dimensional the understanding of the disease is three dimensional and by gravity by gravity the lower most point of the thoracic cage is the cos 2 phrenic angle that's the lowest lowermost point of the thoracic cage so if a person is standing and fluid is getting collected in the pleural space it is going to start getting collected at the lowermost area which is the costophrenic angle okay that is a costophenic angle and that's where the fluid starts collecting and then it starts increasing further and further and further so initially the fluid is in the lower part which is the lower most part which is the cost to chronic angle so the fluid is the yellow which is the costophrenic angle that is the lowermost point from which the fluid starts collecting and gradually the fluid starts going upwards okay so again you have to have a lot of imagination it's a it's like a bucket there is something in the bucket that is the lung and the lung is surrounded by fluid and fluid is starting to collect from down upwards so this is more of an anatomical description okay where you can see the liver and how the fluid collects and how the lungs start getting compressed try to remember try to understand this picture because every sign of plural effusion every clinical symptom of pleural effusion will be based on this particular understanding and as i said we will be going initially for almost 15 minutes we will be just talking of the anatomy pathology and the physiology so the fluid starts collecting and the fluid gradually increases in quantity and as the fluid increases in quantity the balloon or the lung which was here gets compressed by the fluid so the fluid is collecting from below upwards and it starts compressing the lung and it closes the lung so it is actually compressing the lung and causing the lung to close so that's why it's called as a compression collapse collapse means the lung is closing why is it closing because there is a compression caused by the fluid so the fluid compresses the lung and causes a collapse of the lungs so it's called a compression collapse so pleural fluid neural effusion as it increases in quantity causes a compression collapse of the lung okay got my point so just to make you understand first fluid is collecting between the visceral and the parietal pleura it is starting from the lower most point which is the costophrenic angle and it is collecting from down upwards as the fluid starts increasing the lungs start getting pressed from outside and the lung collapses which gives rise to the compression collapse okay so this is how the x-ray would look like so it's a completely different picture on an x-ray it is not at all as clear and as simple and as straightforward as was seen in the earlier pictures so here what you should be able to see is ideally first of all since that we had taken coincidentally one of the classes just a week back on x-rays learning x-rays you should be able to locate the right costophrenic angle means the right dome of diaphragm and the ribcage and there is a sharp acute angle which is the right costophrenic angle but if you compare it with the left side there is a whiteness or an obesity on the left side in the left costophenic angle so the left costophonic angle is blunted or obliterated you may use different adjectives it just means that we can't see the left costophrenic angle as clearly as the right costophonic angle and since it is not acute and it is obliterated or blunted there is a whiteness there that is called as opacity so there is the obesity which is obliterating the left cost to phrenic angle and the most common disease which presents in the costophrenic angle is fluid because fluid by gravity goes down and starts collecting in the claustrophonic angle which is the lower most point of the thoracic cage so the moment you see an x-ray like this where you see the opacity in the left costophrenic angle your first thought should be this could be possibly a left-sided plural collection of fluid this will be our thought process we are of course going to take help of the history we are going to take help of a sonography we are going to take help of the clinical examination so there are many other clues or hints which will help us to confirm our diagnosis but at this point of time just remember that you can see the costophenic angle and it is blunted or obliterated okay so this is just the beginning of what we mean by plural effusion so let's go to the anatomy of the pleural cavity we will go to the anatomy because we are going to relate it to the symptoms of a patient so for the anatomy let us understand that in the pleura there are two two places as we said it's the parietal pleura and in the visceral pure visceral pure you can see here that just next to the visceral pleura is the lung there is a pleural space normally this space has about 10 to 20 ml of fluid it has normally some amount of fluid but it is not detected on an x-ray because it is just and just to lubricate the two surfaces it is not a fluid which is in big quantity and it causes obliteration of the costophrenic angle it is not so okay so it is purely based on the very small layer which is purely made to lubric lubricate the parietal pleura and the visceral pleura okay that is the only reason now why should it lubricate so why should the there should be lubrication of the two pleura it's a very important question because if there would not have been any lubrication then the parietal and the visceral pleura would have had a friction they would have rubbed against each other they would have rubbed against each other and what would have happened if they would have rubbed against each other the parietal pura has got no fibers okay fibers no fibers which are pain fibers so imagine that there is a visceral pleura and there is a parietal pleura but the parietal fluoride is full of pain nerve fibers and the are having friction against each other there is going to be constant pain to the patient chest pain to the patient so if that is to be avoided the only way is to lubricate the two layers by keeping some fluid which is a physiological fluid so it's a normal space normal fluid very small quantity and that is between the parietal pleura and the visceral pleura however now let us take an example let us take an example that in case in case there is a inflammation or swelling of the parietal pleura because of some disease we will come to the etiology but some disease which is causing us a increase of in the depth or increase in the thickness of the parietal pleura that euro is going to touch against the visceral pleura if there is a thickening or similarly if there is a thickening or there is a inflammation of the parietal visceral pleura it is going to cause rubbing against the parietal pleura so whenever there is friction between the two pleura there is going to be pain and that pain is going to be called as pleuritic chest pain it is going to be called as a pleuritic chest pain why pleuritic because it is from the pleura why there is pain because the parental pleura is getting rubbed or friction and it is going to be only and only at the place where the two pure are rubbing not throughout the chest wall it is going to be just at the place where the patient is feeling that particular rubbing so patient will come to us and say doctor i'm getting pain exactly at this point i get a pain where i can exactly show you and if i take a deep breath then the pain increases if i take a deep breath it increases why it is increasing because the lung is inflating on a deep breath and a parietal pleura is rubbing against the visceral pleura visceral pure is rubbing against the parietal pleura and that causing the pleuritic chest pain so the first symptom of a pleural disease would be pleuritic chest pain why it is so because of the inflammation of the pleura and it is called as pleuritis or pleura c okay it could be pleuritis or pleurisy either of it pleuritis or pleurisy so we are just talking about the first thing that one there is a space between the two pleura it has a lubricating fluid in it however if the lure gets inflamed or swollen then they would rub against each other and this rubbing would give rise to inflammation give rise to stimulation of the pain fibers in the parietal pure and give rise to pain so it would be a pleuritic chest pain arising because of the pleuritic the parietal pleura being affected so that is about the pain which happens now let's go a little little deeper into understanding why does fluid get collected excessively and for for that matter we should know why fluid is present as a balance so there is always some influx and efflux going on in the pleural cavity plural cavity is not free of any movement your plural cavity is absolutely dynamic and there is always fluid coming in and going out coming in and going out that's going on happening it is not going to be like a constant okay this is the only quantity remaining no it is not so that balance is maintained because of two important changes which happen so as you can see in this diagram please take a minute to understand this and the next slide because they form the basis of your treatment you can see the visceral pleura you can see the parietal pleura now in the visceral pleura in the visceral pleura is the area of the interstitium that is the wall of the lungs and they has the lymphatics it has the capillaries okay lymphatics and the capillaries and there is a pressure in it which is called as the hydrostatic pressure hydrostatic pressure is the pressure which is there in the capillaries similarly there are capillaries and lymphatics in the parietal pleura but the parietal pleura capillaries are the systemic capillaries and the visceral pleura is the pulmonary capillaries from the interstitium and from the bronchial tree bronchial arteries bronchial vessels so there is a pulmonary lymphatic capillary drainage happening in the visceral pleura and there is a pulmonary systemic capillary drainage happening in the parietal pleura so there is a balance between this which is happening this balance is purely based on one pressure which is called as the capillary hydrostatic pressure capillary hydrostatic pressure it may be sounding a little non-clinical at this point but we have to understand what is this capillary hydrostatic pressure so just remember at this point of time there is a plural a parietal pleural circulation which is talking about the systemic capillaries and there is a visceral pleural circulation which is about the lymphatics and the capillaries and the bronchial vessels and the bronchial capillaries that's the visceral circulation and there is a balance maintained by the capillary hydrostatic pressure so one that is the capillary hydrostatic pressure we are going to deal with one more pressure which is called as a plasma oncotic pressure okay plasma oncotic pressure now we'll go to the next slide to really understand what do you mean by the plasma oncotic pressure so we come to this particular slide so there is a pleural space as you can see there is a visceral pleura as you can see and here you can very clearly say there are micro vessels from the bronchi from the alveoli from the interstitium there are intercostal micro vessels and the lymphatics in the parietal pleura and there is a flow of this particular fluid because of the hydrostatic pressure because of the hydro static pressure okay so if there is a hydrostatic pressure which is increasing in a particular ailment in a particular illness in a particular disease if the hydrostatic pressure increases then the excessive fluid starts getting collected into the pleural space so if the capillary hydrostatic pressure increases then there is a excessive collection of fluid in the pleural space got it so try to go through each and every point which we discussed till now that there is a circulation in the visceral pleura and there is a circulation in the parietal pleura the parietal pleural circulation will be the systemic circulation the circulation which is arising during in the visceral pure is a bronchial micro vessel circulation and if the the hydrostatic pressure increases because of any reason then the more and more fluid starts getting collected into the plural space okay at this point i hope everyone is understanding and going to remember this particular aspect about the hydrostatic pressure we will still stick to this diagram i am not going to the next slide because though we have a next slide describing it better but still i will at this point take some more time to make you understand you can see here those blue arrows where there is a bronchial micro vessel and there is a fluid going into the pleural space and there are intercostal micro vessels and the fluid going into the pleural space if because of some reason okay this drainage is not adequate and the hydrostatic pressure increases so which conditions will the hydrostatic pressure increase normally normally the heart is pumping the heart is pumping there is an ejection fraction the heart is pumping and the blood is going into the aorta from the aorta there is a bronchial artery and the bronchial arteries pumping the blood into the bronchial circulation and the venous drainage is taking away blood and entering into the superior vena cava and the inferior vena cava so if the heart reduces its pumping to be medically talking about if the heart reduces ejection fraction okay the pumping of the heart is low or the heart pump is not adequate or there is a failing heart then there is a back pressure so there is a back pressure because the heart cannot pump so the venous drainage is getting affected venous drainage is getting affected the superior vena cava is getting filled up with lot of blood which is not getting drained into the heart and there is a back pressure from the veins which are draining into the superior vena cava and finally there would be a high pressure in the micro vessels along the vasculature along the pleura that is the parietal pleura the intercostal pleura the intercostal vessels so they all these vessels will get loaded with a excessive hydrostatic pressure so the pressure increases in these vessels because there is a back pressure that back pressure is upon happened because the heart is not pumping and because the heart is not pumping this increases the hydrostatic pressure and finally what does the patient come to you with patient comes to you with pleural effusion so a patient may come to you with pure effusion but the cause could be failure of the heart the card cause could be congestive cardiac failure so this is just an example of a mechanism which you can correlate if you get a patient of plural effusion but the ejection fraction is only 20 or 25 so if the heart is feeling there is congestive cardiac failure and there is plural effusion one of the main reasons of that plural effusion will be actually increase in the hydrostatic pressure and that hydrostatic pressure is leading to fluid getting collected into the pleural cavity okay so that's why we need to really know this small small things about what is the hydrostatic pressure and how it causes filling up of the effusion now this is a little more colorful diagram as you can see there is a pulmonary capillary and here you can see one more addition very very well drawn is that there is a pulmonary capillary and it is actually draining into the pulmonary lymphatics also so there is a drainage into the lymphatics similarly on the side of the parietal pleura there is collection of fluid and see the blue arrows which are draining into the pleural lymphatics so it is not only the capillaries but it is also the lymphatics which are equally important in draining away the excessive fluid so one we have discussed about the hydrostatic pressure where there can be excessive hydrostatic pressure and fluid may get collected into the plural cavity one of the reasons we said was that the heart was not pumping there was a cardiac failure and that's why the pleural fluid got collected into the cavity the plural cavity now here we are coming at one more mechanism that there is a normally say let's say the hydrostatic pressure is fine at least the capillary and the blood circulation is normal so the blood flowing through the systemic capillaries is all okay but then the lymphatics also have to drain the excessive fluid in case because of some disease the lymphatics get blocked okay imagine that the particular blue arrow which is showing the lymphatics channels they are getting blocked so the fluid is unable to get drained into the lymphatic channels and fluid may again start getting collected into the pleural space so there could be one more mechanism of pleural get a plural fluid getting collected if the lymphatics get blocked if the lymphatics get blocked so if the lymphatics get blocked you can easily make out whether it is a lymphatic fluid which is got collected or not because when you remove the fluid for testing when we remove this fluid you will find it to be white in color because it is lymph lymphatic drainage is affected so lymph starts getting collected into pleural space so if you remove the fluid it's almost like a milky white fluid which comes out the moment you see a milky white fluid coming out when you are putting a needle for removing fluid your impression straight away comes to this is actually because of a lymphatic collection in the plural cavity okay so we have just tried to understand one is hydrostatic pressure going high causing fluid collection second lymphatic drainage being affected leading to lymph collection into the neural cavity on x x-ray can you make it it is lymphatic we can't make out that is a lymphatic because on x-ray it would only look like a blunting of the costophrenic angle so this is another example now we will come to the third example of fluid collection we talked about two pressures if you remember about 10 minutes back when i was showing the diagram of the pleura and the viscera the visceral pleura there were two pressures i tried to talk about one pressure was the hydrostatic pressure and we said if the hydrostatic pressure is much more then there would be collection of fluid in the pleural cavity there was one more pressure which we talked about which was the oncotic pressure okay that is a plasma oncotic pressure now what is this oncotic pressure exactly so oncotic pressure yes as doctor nasir hussein has said it's oncotic pressure so as what is this oncotic pressure so remember now if you understand blood circulation or blood flow in a vessel then there is in the blood vessel there is a rbc and inside the rbc there is plasma which has the hemoglobin and outside the rbc there is a serum serum okay the serum so whenever we say centrifuge the blood the rbcs come down they sit at the bottom and we get a serum now this serum contains albumin this serum contains protein and there is similar protein in the extravascular space also in the external vascular space so i am just going back to the diagram which we saw a few slides prior so that i i can explain in a better fashion what exactly i mean to talk about so so there is a particular pressure which is the oncotic pressure as you can see at the top the topmost arrows we are talking about plasma oncotic pressure on either side in the parietal pleura and the visceral pleura and in between is the pleural space but if you can see this particular oncotic pressures are balanced okay it's equivalent because that's the same pressure which is in the vascular and extravascular compartment and this is purely controlled by the protein the protein or the colloids the proteins or the colloid that's why it can be called as colloid oncotic pressure okay so it's a it's controlled by the proteins the protein content in the blood in the serum decides the oncotic pressure so lesser the number of proteins lesser is the oncotic pressure so serum protein less serum albumin less there will be imbalance in the oncotic pressure and fluid will start collecting into the extra vascular space into the space like a peritoneal cavity or a pleural cavity because of the pressure difference because of the oncotic pressure difference so try to understand this particular things i would say try to digest it because i am talking of proteins but try to understand it that there is a plasma oncotic pressure which is controlled by the proteins in the plasma in the serum and this serum fruit proteins decides the oncotic pressure if the serum albumin is less serum protein is less then there is an abnormality in the pressures and the fluid starts getting collected into the cavities around it which could be either the peritoneal cavity or the pleural cavity so there is a mechanism by which we can say that the fluid starts getting collecting collected in the pleural cavity in a patient in whom the proteins are going to be less in whom the serum proteins are going to be less in the person in whom the serum albumin is going to be less okay so we have discussed two mechanisms one we talked another three mechanism one we talked about increased hydrostatic pressure i gave you an example about congestive cardiac failure cardiac failure related to any reason it could be myocardial ischemia it could be infection it could be arrhythmias in all these conditions where the heart pumping reduces there is a possibility that the hydrostatic pressure increases because the superior vena caval drainage is affected the intercostal venous drainage is affected and the fluid starts getting collected into the pleural cavity that is one the other possibility is that the serum albumin is low serum proteins are low and that's why there is a fluid collection into the pleural cavity and of course one of the reasons is the impaired lymphatic drainage as dr sapn is saying there is impaired lymphatic drainage which leads to the fluid or the lymph getting collected into the pleural cavity so three mechanisms we have discussed till now but we need to know now what are the mechanisms deeper to this so let us go bit by bit because we have to just not wait at saying okay serum proteins are less and that's why there is effusion so if we consider serum protein as one particular content then why in a particular person does a serum protein reduce so the causes would be very very simple if we break it down to a flow chart one is that the patient or the person is taking less intake of proteins so one that the source of protein is less second possibility is that the patient is unable to generate proteins on its own because there is always a protein synthesis going on in our body and proteins are synthesized in the liver amino acids are formed in the liver essential amino acids and the protein linkages protein generation is in the liver so liver is the main organ of protein synthesis so if at all the patient is not having a good intake of proteins the protein could be less second is if there is a liver disease which is a chronic liver disease even then the protein content will be less because the synthesis of proteins is not happening example is liver cirrhosis third is patient is having good amount of protein the liver is also functioning good but the excretion of proteins is in excess more than what should be so a disease where there is proteinuria unnecessary or unrequired unessential loss of proteins example is a kidney disease where there is a loss of proteins like syndrome so there could be a disease where the renal function is affected and there is protein loss let's consider that the patient is having good amount of protein patient does not have a liver problem patient neither has any kidney problem so he is eating good amount of protein from the mouth where is the protein going it's going into the stomach from the stomach it is going into the duodenum and then it is going into intestine protein absorption happens in the intestine so if there is a disease in the intestine itself where the protein absorption is not proper not adequate then also the serum proteins will start going down example malabsorption syndrome enteritis decentry colitis so all the intestinal diseases if they are chronic if they are going for a long time will affect the absorption of proteins so there could be one of those diseases one more disease is possible where even the bone marrow is getting suppressed so there are multiple entities which can actually lead to low serum protein and low serum albumin now let's put this all into a patient scenario let's say doctor rothwood or doc one of the doctors who is joined here i can't see all the names but i am just individualizing that one of you are seeing a patient with plural effusion okay it's a case whether where there is one on the side there is a blunting of the claustrophobic angle and there is a blunting of the cost of any angle so you understand oh this could be a case of plural effusion so the possibilities which go through your mind should be at that point of time one it could be increased hydrostatic pressure two it could be lymphatic obstruction three it could be low oncotic pressure these are the three possible mechanisms of that particular effusion now we will come to the fourth and the last mechanism of effusion once you understand this mechanism the fourth mechanism it will be a little easy for you to actually start interpreting from x-rays also so the fourth mechanism is neither connected to the oncotic pressure neither connected to the to the hydrostatic pressure itself okay it is neither of them it is not at all hydrostatic pressure not at all the oncotic pressure not at all the lymphatic drainage it is purely based on the permeability of the mesothelium or the vasculature permeability so the imagine that there is a pleura which is the visceral pleura and there is a disease in the lungs that is within the lungs there is a disease now this disease is progressing outwards outwards outwards and it starts causing inflammation of the pleura now understand the word inflammation you should remember your books on pathology okay so you need you should remember your books on pathology and you will have to remember that when we say inflammation suppose right now you have a fall or someone has some trauma on the limb or the legs what happens is pain next is swelling that is edema and there is increase in the temperature so you have the basic changes in the inflammatory in area which is fluid collection that is edema edema is increased capillary permeability so there is a vasculature damage the endothelial damage under capillary leakage and fluid starts collecting into the pleural cavity because of inflammation because of increased capillary leakage here we are not talking of hydrostatic pressure neither we are talking of oncotic pressure neither we are talking of lymphatic drainage we are only talking of inflammation leading to capillary permeability and leakage okay so there is fluid collection into the neural cavity because of inflammation so finally we come to four different mechanisms so dr qureshi i can tell you that there is no difference between pleural effusion and hydrothorax they mean the same effusion is collection in fluid in the pleural cavity hydrothorax is also collection of fluid in the neural cavity so four mechanisms we have discussed till now one is increased hydrostatic pressure second low oncotic pressure three lymphatic drainage being affected four capillary permeability that is inflammatory fluid okay inflammatory fluid now one more highlight of inflammation we should remember at this point of time because it is going to be actually the the crux of how we differentiate fluids whenever we say that there is edema there is capillary permeability this permeability allows proteins to exude it into the extravascular space so the endothelial wall changes its permeability and it allows the albumins or the proteins from the vasculature to exude this process of fluid capillary permeability going causing the albumin or the proteins to go outside is called exudation so the fluid which collects in the pleural cavity because of inflammation is a rich in protein fluid it's a protein rich fluid okay it's a protein rich fluid i hope i have been able to clear few things till now because if you are able to really understand what i am explaining then it's going to be a very very simple affair for you for the next few slides which we are going to go through we have already crossed around 40 minutes of talks but it needed so much of time to really make you understand rather than mugging up causes of plural effusion one two three four five six there's no point of doing or remembering causes of plural effusion if you know the mechanism then you don't really need to remember each and every cause okay so i hope we are through with this and we will go to the next slide where we come to the most important aspect of translation and exudation i'll keep on emphasizing and re-emphasizing these points so let's go to the executive first because that's a little simple to understand so exudative means it occurs due to inflammation occurs due to increased capillary permeability rich in proteins okay these three things you need to keep it in mind exudation inflammatory rich in proteins increased capillary permeability transitive are all the things which we discussed prior increased hydrostatic pressure low plasma oncotic pressure okay increase hydrostatic pressure low plasma oncotic pressure if if if you have been able to understand till here it's like almost 70 percent of my job done because it's now just just trying to imagine what could be the different reasons of increased hydrostatic pressure one of the causes of increased hydrostatic pressure we said the heart was not able to pump or heart was failing okay heart was feeling now let us take one more reason where there could be a back pressure let's imagine okay one of the disease where the heart is pumping properly heart is pumping properly but outside the heart remember there is a cover and that cover is called as the pericardium so if this pericardium is becoming fibrous because of some disease we are not talked about what disease but we are talking of a envelope of the heart which is not allowing the heart to beat okay the pericardium is so hard and so stiff that it is not allowing the heart to beat even then there will be a back pressure such a disease is called as constrictive constrictive means the pericardium is constricting the heart so such a disease is called as constrictive pericarditis constrictive pericarditis we will still think of one more example okay heart is pumping properly pericardium is normal the superior vena cava is actually entering into the right atrium superior vena cava but unfortunately the superior vena cava is blocked with a clot or a thrombus okay it's clot or a thrombus so if there is a thrombus in the superior vena cava then there will be a back pressure again and same process of increased hydrostatic pressure fluid collection into the pleural cavity and plural effusion so you can think of different diseases name wise but finally end point will be the cardiac output is not good the heart is not pumping properly the fluid is getting collected there's a back pressure there is a venous drainage which is being affected and the venous drainage being affected giving rise to increased hydrostatic pressure and fluid getting collected someone may even say that there is a malignancy and this malignancy is blocking the capillaries which is a hematic hematogenous spread ok blood bone spread off a malignancy and those malignant cells are blocking the different vessels of the intest hostile veins or blood vessels that is also causing a back pressure increased oncotic pressure and fluid collection into the pleural cavity so you don't really need to you know go by the list of causes there is a drainage of capillaries drainage which is affected of the veins it would give rise to increase hydrostatic pressure and there would be plural effusion you may it may be cardiac failure it may be superior vena cavas thrombosis it may be constitutive pericarditis it could be a malignancy related relate leading to intercostal veins getting blocked so various various reasons could be there there could be a mass in the lung which is very close to the superior vena cava and that mass is actually compressing the superior vena cava because mass is a solid mass so it is causing compression of the svc the superior vena cava what is going to happen the drainage of the svc is going to be affected and that's why there will be increased hydrostatic pressure and fluid starts collecting all right so that is the translative neural effusion now i will take five minutes more for you people to still understand the difference in these two different causes okay it is it is it is very subtle but it is very characteristic when we talk of transudates we said that the hydrostatic pressure is increasing when we said about transudate we said that the oncotic pressure is low let's let's start from oncotic pressure a patient has got cirrhosis protein generation protein synthesis is less so there is hypoproteinaemia there is hypoalbuminemia because of which there is really decreased oncotic pressure because there is decreased oncotic pressure now this oncotic pressure is not to be not going to be decreased only on the right side or the left side it is going to be decreased throughout the circulation of the plural on both the sides all right so you are going to remember now that all the causes all the causes or i would say most of the causes of transmutative like hypoproteinemia nutritional hypoproteinaemia nephrotic syndrome cirrhosis of the liver malabsorption syndrome all of these are causes where the protein content is less in the blood and blood is everywhere and everywhere means on both the sides of the lungs on the both the sides of the pleura so in simple words what i'm trying to stress on for all of you is that if you see bilateral plural effusion okay please imagine this if you see bilateral plural effusion what will you suspect first transitive or exudative that's my question i hope everyone is able to answer it is as the correct answer because otherwise my 40 minutes will be of waste i reframe my question if you see a fusion on both the sides what will be your first impression exudative or translated oops i think someone said exudative yeah so thankfully majority of you have put the correct answer see let me tell you one thing there is nothing which can be 100 in medicine okay exudative effusions can present with bilateral inflammation both the sides there is an infection both the sides has pneumonia both the sides are pleural disease and then there is a pleural diffusion it will be executive on both the sides that's not impossible it can be possible but we are talking in general if you see a patient with a x-ray showing bilateral purely fusion please think in terms of a transudate as the first possibility exudate you can think about next first will be a translate okay if you have not understood this you can ask me again if you want but try to remember this particular equation exudative will come back to execute executive so exudative is an inflammatory fluid inflammation is localized okay it will be at the localized placements there is a lung infection like an ammonia either a right sided pneumonia or a left sided pneumonia that particular lung will get inflamed that inflammation will progress to the pleura and the pleura will give rise to fluid collection because of the capillary permeability so most often most often mark by words most often the patients who have unilateral pleural effusion are usually exudative or inflammatory okay usually inflammatory so if you have been clear with this then i will add one more statement here so that it makes things a little more clear almost all of the inflammatory fluids are infective okay almost all of the inflammatory fluids are infective okay almost all of the inflammatory fluids are infective so we will just go to the next slide this is a very very uh world-renowned slide i can say because this is the gold standard for segregating transmutative and exudative effusions so there are there are selective causes like dr vikas is asking about which principle of diffusion in acute pancreatitis now i'm just taking offshoot from the slide here because of this question of pancreatitis so pancreatitis as the word suggests is inflammatory okay it is an inflammation of the pancreas pancreas is in very close proximity to the diaphragm correct and the diaphragm has a pleura which is covering it which is the diaphragmatic pleura so there is a indirect inflammation of the pleura also and there will be inflammatory fluid or increased capillary permeability and there is a strong possibility that it will be a executive fluid of secondary to pancreatitis so there is a very high chance that it's going to be an exudative neural effusion high chances obviously you are going to aspirate or do a tapping and then send it for checking now dr sima is asking about in tuberculosis so again let's go back to the earlier explanation tuberculosis is an infection infection gives rise to inflammation inflammation give rise to increased capillary permeability increased capillary permeability will give rise to an exudation of the fluid into the pleural cavity so it will be a exudative neural effusion in tuberculosis because it's infective okay so this is a simple simple explanation now if you want to be confused if i am your examiner then i can say that okay a tb patient is malnourished because he's not eating well he's got nausea he's got anorexia and he's having poor protein intake so he could also develop hypoproteinaemia and hypoproteinaemia could have given rise to pleural effusion so even that is possible in a patient of tuberculosis but what is the first possibility the first possibility is that it could be more likely going to be a tuberculosis plural effusion okay more likely but dr sima i'll tell you an example so that you can understand your own question let's say you have got two tb patients okay you have a two tb patient patient a and patient b one tb patient has a unilateral pleural effusion only on the right side and patient b has bilateral pleural effusion on both the sides in patient a there is one sided in patient b there is both sided both have tb so you will suspect translative in patient a or patient b exactly so we will suspect more likely to be a translative in a patient b because we are seeing bilateral purely fusion so we will naturally do this test as we can see there is a lights criteria which every book has so you can either remember it in the form of plural fluid proteins and then the ldh because ldh is an inflammatory marker everyone knows that lactate is an inflammatory byproduct so more the inflammation more is the lactate more is the ldh so if the ratio if the ldh is very high that means the pleural fluid is inflammatory in nature or infective in nature so very simple understanding from this slide which talks about the lights criteria and you need to actually aspirate the fluid and send it for checking now as the questions are coming i can see some questions talking of a trauma traumatic cause of a plural effusion now now the answer itself is a self-explanatory answer we are here not talking of hydrostatic pressure we are not talking of oncotic pressure we are not talking of lymphatic drainage neither are we talking of inflammation when we talk of trauma there is a break in the capillary breach in the capillary connectivity so there is a break or a rupture and what will come out of the capillary is blood so blood stead starts collecting into the pleural cavity and that effusion is called as a hemothorax because it's blood and it is happening because of the breach in the continuity of the blood vessel it is like if a person falls and there is bleeding it could be leading to a trauma and there is blood which is spilled out so rib fracture may actually traumatize the pleura itself or if there is a trauma during a biopsy many different reasons but traumatic procedures can give rise to an accident can give rise to hemothorax so we will just go with the example i i just told you about the congestive heart failure and increased hydrostatic pressure and that leading to neural effusion because there's a back pressure which increases so this is the different this is one of the mechanisms which we talked about now we have a big list of different reasons of uh transudates okay there would be a exudates and translates and as you can see most of the executive causes are infections bacterial infection tuberculosis viral infections fungal infections parasitic infections rickettsial infections so there are many causes pancreatic diseases so many many many causes please remember that if we just talk of what are the causes of plural effusion i think medflicks have to arrange one week of a lecture okay only on plural effusions and so i don't think we can talk of each and every cause of plural diffusion what we are trying to tell you is an idea where you can understand what are the diffusions because of and what are the different common mechanisms so the moment you see a bilateral diffusion please think in terms of a transudate you know why transitions happen now if you see a unilateral diffusion first thing in terms of exudative effusion malignancies themselves i'll give you an example of malignancy how they can be confusing now when a patient has a cancer or neoplasm many times you must have heard that the patient loses appetite patient is unable to eat well so there could be hypo proteinaemia and that can give rise to a transitive effusion if this malignancy if there is a lung malignancy and it is causing obstruction of the bronchus then there could be a pneumonia which may happen distal to the bronchus and this pneumonia can actually spread to the pleura giving rise to a effusion secondary to an infection or inflammation so it could be an exudative pleural effect so there could be different different mechanisms of the same disease but finally your diagnosis will be coming about aspirating and sending it for checking dr nasir is asking what about copd cases so copd itself is not a cause of plural effusion chronic obstructive pulmonary disease or asthma they don't cause pleural effusion they are diseases of the lungs they are not diseases of the pleura so if you have a patient of copd you are talking of a patient of copd who has bilateral pleural effusion then it could be because of the mechanism which we discussed but not because of the copd it could be because of right heart failure patient could be having copd with pulmonary hypertension pulmonary hypertension giving rise to car pulmonary car pulmonary giving rise to right heart failure right heart failure giving rise to increased capillary hydrostatic pressure and that giving rise to plural effusion so it could be all related to a beginning of copd but not that the copd is causing the plural effusion all right so there will be obviously many questions talking about covet patients and other things and other things but i think we will talk for five minutes and then we will break before we have any further questions uh yes so yes we see plural diffusion in copd cases as i said copd with lung infection can present with effusion copd with hypoproteinemia can present with the pleural effusion so there can be different mechanisms but not copd itself causing plural diffusion the way asthma itself cannot give rise to pleural effusion it would not be copd itself giving rise to pleural effusion so transudate as a as is put here please remember transient rates are fluid which are low in proteins exudates are fluid which are high in protein so more than three gram percent percent proteins then it will be more likely to be exudate and if it is less than three gram percent of proteins more likely to be a transulate and if it is a transverse that's a big googly for any of your doctors okay it's going to be too difficult to treat a translative effusion it is always easy to treat a executive effusion because exudative means local infection and you're going to treat it transitive means most probably a systemic cause so cirrhosis of liver can give rise to persistent diffusions repeated diffusions hypoproteinemia repeated effusions there is there are many such causes of plural effusions but i'll just show you a few x-rays then then we can stop we will uh so how does there is one question about how does embolism lead to an exudation so i will just try to simplify the mechanism because if you know the mechanism you will know why it is accurate what is the meaning of an embolism embolism means a blood clot so blood goes and clots and causes stoppage of the blood circulation into the into the pulmonaries so there is a area where the blood gets clotted or stopped and there is no circulation in that area there is no circulation that area dies which is called an infection so there is a pulmonary infection now this infection infected lung is not a normal lung it doesn't have the normal blood vessels and the normal circulation so it causes wrinkling if you can't call in simple words or changes of inflammation inflammatory necrosis so if you say infection means necrosis necrosis are of different types i'm sure you remember necrosis of different type casiation necrosis liquefaction necrosis ischemic necrosis so whenever there is an ischemic necrosis there is increased capillary permeability and so there is increase in the protein content in the fluid which gets collected in the pleural cavity so if there is an embolism and there is a pleural effusion then there is a very high chance that this fluid is going to be a exudative neural effusion okay so that is the way we can explain about an executive fluid in a pulmonary embolism or a plural or a pulmonary infection all right so this is a rough flow chart i want to show you so that we can't of course continue for a long time today maybe we will take some some other session to talk about how to investigate a case of plural effusion because there are many aspects towards diagnosis many aspects towards treatment and today's session was primarily to make you understand about what are the plural effusions what are translates what are exudates and what are the mechanisms of pleural effusion all right so just leaving you off with a couple of x-rays so that you are able to comprehend what you see when you see the x-ray now i'm just showing couple of x-rays so and i'll put one or two questions so that you people can start thinking about it on the x-ray which you see what is the most likely cause a transmutative or executive so as most of you have correctly put up most likely i am saying most likely this is going to be a exudative plural effusion it's unilateral okay if it would have been bilateral i would have put it possibly transverity of course confirmation is not on x-ray confirmation is only by doing a plural fluid aspiration remember that all right we can get an x-ray like this as well you can see this x-ray it's almost like a straight line going downwards not always going downwards and forming a concavity it could be something like this which could be a thick fluid if there is thick fluid then it almost forms a convex line so such fluid or such effusions are called as loculated means encapsulated or thick there is a plural thickened end making them into small small pockets or lucky light soluble oculated dural effusion so you may see some x-rays like this as well you can see some of the x-rays which may be looking like a right-sided opacity and even this could be one of the causes of or mechanism could be a encapsulated neural effusion or loculated pleural effusion so yes it could be uh thickened pleura and the best investigation beyond this or at this point of time is actually to do a sonography of the chest okay usg of the chest because usg is a very very easy test bedside test and it tells us not only whether the fluid is loculated but it also quantifies the fluid and it helps us to know where to do the tapping also so many many different x-rays many explanations many causes and many things yet to you know understand about plural effusion but i suppose we will have to stop at that because i am sure too much exhaustion too much of information will always make you get confused and it may not be so receptive so i thank you all for being with me today and i hope you enjoyed the discussion dr nivedita you can take over from here thank you so as usual that was an amazing uh session and i think there are a few questions basically about uh when we cover the treatment aspect of plural effusion uh so we we will get in touch with her and we will have the second part of this session pretty soon um and i think so most of the questions um were answered if anybody would like to come up on stage and ask some questions or we can do that as well as a question about the tracheal shift and plural fusion paper explain about that yes so uh it's it's again in the x-rays if we go back to the x-rays at some point as the fluid gets collected in the pleural cavity full of air so as fluid collects the trachea and the mediastinum is going to be pushed to the opposite side it's going to wave so if there's a left sided pleural effusion then the trachea and the heart or what we call as mediastinum so mediastinum compresses of the trachea and the heart so they are going to be pushed to the opposite side that is only if the fluid is in large quantity enough to cause the fluid to be pushed to the opposite source i think that's again a very simple explanation that's one of the clues where we think about that could be a plural diffusion rather than a collapse because collapse of the lung will pull the heart or the trachea to the same side so i think that much it would be good for them to understand after that that's great uh there's i think one more on uh mixed edema or led to trans due to plural effusion if you could explain on that so what what we'll do individually one one disease it would be too much difficult and two is too short explanation to tell them about like sle rheumatoid arthritis there are drug induced pleural effusion some medicines can cause drugs radiation can cause drugs thyroid abnormalities can cause effusions so i think maybe whenever we take another session we'll have these individualized causes and explanation to talk about shuffle that would be great i mean and i also saw a request to start your own uh pulmonology club i think we'll also talk to sir about that and we get that started based on uh and like so said we'll get into these individual treatments and we'll attain sessions as per that uh and if you've missed any of the questions we will get in touch with you and get them answered for you all uh thank you so much for coming in okay thank you so much had a good time

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dr. Salil Bendre

Dr. Salil Bendre

Pulmonologist & Transplant Physician, Nanavati Max Hospital, Global Hospital & Masina Hospital, Mumbai

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dr. Salil Bendre

Dr. Salil Bendre

Pulmonologist & Transplant Physician, Nanavat...

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