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Sunday, 24 November 2013

Pleural disease – Pleural effusion – The Complications

The pleura is a thin tissue covered by a layer of cells (mesothelial cells) that surrounds the lungs and lines the inside of the chest wall.
B. Pleural effusion
It is a condition of collection of fluid within the pleural cavity as a result of heart failure, bleeding (hemothorax), infections, excessive or decreased fluid volume, etc.
B.3.1. Complications
1. Primary Sjogren’s syndrome
Sjogren’s syndrome can cause many organic changes, but is rarely accompanied by pleuritis. there is a report of a 65-year-old patient with primary Sjogren’s syndrome who developed bilateral pleuritis with moderately large effusions(35).
2. Pleurisy
Pleurisy is a medical condition of an inflammation of the lining of the pleural cavity. In the study to investigate the incidence of tuberculous pleurisy among patients with adenosine deaminase (ADA) levels of 50 IU/L or less in a pleural effusion, and without a previous diagnosis of carcinomatous pleurisy or Mycobacterium tuberculosis, found that occult tuberculous pleurisy is significantly common in patients with pleural effusion ADA levels of 50 IU/L or less and who may otherwise be diagnosed with nonspecific pleurisy(36).
3. Dullness to percussion and tactile fremitus and reduced tactile vocal fremitu
In the systematically review the evidence regarding the accuracy of the physical examination in assessing the probability of a pleural effusion conducted by the University of Toronto, and St Michael’s Hospital, indicated that dullness to percussion and tactile fremitus are the most useful findings for pleural effusion. Dull chest percussion makes the probability of a pleural effusion much more likely but requires a chest radiograph to confirm the diagnosis. When the pretest probability of pleural effusion is low, the absence of reduced tactile vocal fremitus makes pleural effusion less likely so that a chest radiograph might not be necessary depending on the overall clinical situation(37).
4. Tracheal deviation
If the effusion is large, it may be tracheal deviation away from the effusion. According to the study by Kumomoto-chuou Hospital, there is a report of a 33-year-old male admitted to our hospital because of mediastinal bleeding by the traffic accident. He was in shock state. Chest roentgenogram showed widening of the upper mediastium, massive pleural effusion and deviation trachea to right(38).
5. Other complications
In the study to independently evaluate 278 patients (196 men), aged 12 and older, admitted with respiratory symptoms.conducted at a rural hospital in India, two physicians, blinding to history and chest radiograph findings, and to each other’s results, showed that the prevalence of pleural effusion was 21% (57/278). The likelihood ratios (LRs) of positive signs ranged from 1.48 to 8.14 and their 95% confidence intervals (CIs) excluded 1. Except for pleural rub, the LRs for negative signs ranged between 0.13 and 0.71. The interobserver agreement was excellent for chest expansion, vocal fremitus, percussion and breath sounds (kappa 0.84-0.89) and good for vocal resonance, crackles and auscultatory percussion (kappa 0.68-0.78). The independent predictors of pleural effusion were asymmetric chest expansion (odds ratio [OR] 5.22, 95% CI 2.06-13.23), and dull percussion note (OR 12.80, 95% CI 4.23-38.70). For the final multivariate model, the area under receiver operating characteristic curve (ROC curve) was 0.88(39).
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(35) http://www.ncbi.nlm.nih.gov/pubmed/18197929
(36) http://www.ncbi.nlm.nih.gov/pubmed/19901882
(37) http://www.ncbi.nlm.nih.gov/pubmed/?term=Vocal+fremitus+reduced+and+Pleural+effusion
(38) http://www.ncbi.nlm.nih.gov/pubmed/9170875
(39) http://www.ncbi.nlm.nih.gov/pubmed/16965906