lulu's life

1. Pleurae: Visceral & Parietial layer--Serous Plueral Fluid (Capillary layer)
2. Pleural blood supply: bronchial a. and pulmonary vein  

Transudate
Increase hydrostatic pressure---heart failure(40%)
‧Heart failure-->pulmonary hypertension-->mean capillary pressure↑
    -->the pleural fluid can't  be absorbed well--> pleural effusion
‧usually bilateral 80%, if unilateral, the Rt. side pleural effusion is the most.
decrease oncotic pressure-- liver cirrhosis, Nephortic syndrome


Effusion
Parapneumonic effusion
Defintion:  accumlation of  exudative pleural space and associated ipsilateral pulmonary infection 

Classification
-->Uncomplicated: are not infected and usually not need the chest drainage
-->Complicated: are usually associated with plueral infection, and require tube thoracostomy and sometimes decortication of their resolution.
-->empyema: a pus accumlation in the pleural space
 
plueral effusion state
1. pleuritis sicca stage: 
-->the sensitive pain innervation of the adjacent parietal pleura

2. the exudative stage:
--> increase the influx of pulmonary interstitial fluid in local microvascular exudate
--> the metabolic state: LDH > 1,000 IU/ml and PH < 7.2

3. the fibropurulent stage:
--> the bacterial infection from lung parenchyma 
--> develop quickly in p't who are not received the antibiotic   
-->  the deposition of fibrin clots and fibrin membranes in the plueral space, which lead to lobulation
--> the metabolic state: LDH > 1,000 IU/ml and PH < 7.2

4.  the organizational stage
--> final stage-->invasion by fibroblast-->taransformation the interpleural fibrin membrane--> web of thickness and nonelastic

Treatment
Antibiotic: empritic agents 
--> CAP: usually give beta-lactam/beta-lactamase inhibitor, 2nd and 3 rd generation of cephalosporin, or metronidazole and clindamycin

Thoracentesis: for plueral examination, and used Light's criteria
Drainage ( see Table in my book, the poor outcome of parapneumonic effusion)

Fibrolytic agents
--> Streptokinase(250,000 IU) and Urokinase(100,000 IU)
--> step 1: dilute with normal saline 100 ml
--> step 2 :instilled via chest tube and cramped for 1-4 hrs
--> repeated once daily and last for 2 wks

SURGERY TREATMENT
Therapeutic thoracoscopy
Thoracotomy with decortication
Open drainage