5/24/2011

Pemeriksaan dan Interpretasi Cairan Pleura

Cairan Pleura
- Berada pada rongga Pleura, sbg pelicin gesekan antara pleura visceralis dan pleura parietalis - Normal : cairan sedikit, Vol. 1-10 mL -Dihasilkan secara kontinu berdasarkan : * tekanan hidrostatik kapiler * tekanan onkotik plasma * permeabilitas kapiler. - Direabsorbsi melalui limfatik dan venule - Akumulasi cairan disebut efusi, terjadi karena imbalance produksi dan reabsorbsi - Berdasarkan penyebabnya, efusi pleura biasanya diklasifikasikan atas Transudat dan Eksudat

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Transudasi adalah akumulasi cairan akibat : - Peningkatan tek. hidrostatik dalam paru - Penurunan tek. onkotik Mis. Albumin plasma menurun atau tek. vena meninggi (CHF, hipoproteinemia, sirosis, neprotik sindrom, dll) Eksudasi adalah akumulasi cairan akibat : - Proses inflamasi yg menyebabkan perubahan permeabilitas membran pleura atau - Penurunan reabsorbsi limfatik - Penyebab a.l : Infeksi TBC, infeksi bakteri atau jamur, Neoplasma, rheumatoid disease, SLE. Cairan juga dapat berasal dari : - Pancreatitis (amilase tinggi) - Rupture esophagus (pH rendah dan amilase tinggi) - Urine ( pH rendah dan creatinine tinggi)

Indikasi pengambilan cairan pleura

1. Pemeriksaan lab. (mengetahui etiologi efusi transudat atau eksudat) 2. Mengurangi gejala klinik (mis.sesak, sakit) 3. Menghindari terjadinya kumpulan darah atau nanah (hemitoraks, empiema) 4. Mengurangi cairan dalam rongga pleura untuk diganti dgn obat kedlm rongga tsb

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Indikasi pemeriksaan cairan pleura

1. Mengetahui penyebab (diagnosis) 2. Penunjang diagnosis 3. Follow up penyakit, komplikasi dll 4. Follow up terapi

Pemeriksaan yg dianjurkan:
Rutin : 1. Makroskopis 2. Mikroskopis : Hitung sel, Hitung jenis 3. Analisa kimia : Protein, Glucose Pemeriksaan Cairan Pleura: Berguna utk sbgn besar pasien : 1. Pulasan langsung dan kultur m.o 2. Sitologi Perlu utk kasus tertentu : 1. Cholesterol atau ratio fluid/serum 2. Albumin gradient 3. pH 4. CRP 5. Tumor marker 6. Enzymes (Amylase, LD) 7. Lactate 8. Alkaline Phosphatase, dll

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Kriteria Lab utk Eksudat :

- Secara Umum : * Total Protein * Lights Criteria - Khusus Pleural fluid :
1. 2. 3. 4. Cholesterol > 45 mg/dL Pleural fluid/serum cholesterol ratio = atau > 0,30 serum-pleural fluid albumin gradient = atau < 1,2 g/dL Pleural fluid/serum bilirubin ratio = atau > 0,6

- Sens 98%, spec 80%

Pembedaan transudat dan exudat secara umum Total Protein (TP) : exudat jika TP > 3.0 g/dL Lights Criteria Rasio TP TP Cairan (E > 0.5) TP Serum Rasio LDH : LDH cairan LDH serum (E > 0.6)

Rasio LDH : LDH cairan (E > 0.67) nilai tertinggi LDH serum normal

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PLEURAL EFFUSION : PLEURAL FLIUD PROFILES IN VARIOUS DISEASE STATES

Diagnosis Gross Appearan ce
Clear

Protei n (g/dL)
1.0-1.5

Glucose (mg/dL)

WBC & Differenti al (per mcL)

1000, mostly MN

RBC (per mcL)

0 or few

Microscopic Exam

Culture

Comments

Normal

Equal to serum

Neg

Neg

TRANSUDATES Congestive heart failure serous <3: some times 3 <3 Equal to serum <1000 <10.000 neg Neg Most common cause of pleural effusion. Effusion right-sided in 55-70% of patients Occurs in 20 % of patiens. Cause is low protein osmotic pressure From movement of ascites diaphragm. Treatment of underlying ascites usually sufficient.

Nefrotic syndrome

Serous

Equal to serum

<1000

<1000

neg

Neg

Hepatic cirrhosis

serous

<3

Equal to serum

<1000

<1000

Neg

Neg

EXUDATES Tuberculosis Usually serous; can be bloody 90% 3; mey exceed 5 g/dL 90% 3 Equal to serum ; 0 cc <60 50010.000, mostly MN < 10.000 Concentrate Pos for AFB in <50% May tield MTb PPD usually positive; pleural biopsy positive; eosinophils (>10%) or mesothelial cells (>5%) make diagnosis unlikely Eosinophils uncommon; fluid tends to reaaccumulate after removal.

Malignancy

Usually turbid, bloody; 0cc serous

Equal to serum; <60 in 15% of cases

100010.000 mostly MN

>100.00 0

Post cytology in 50%

Neg

Diagnosis

Gross Appearanc e
Turbid to purulent

Protei n (g/dL)
3

Glucose (mg/dL)

WBC & Differential (per mcL)

25.000-100.00 mostly PMN

RBC (per mcL)

<5000

Micro scopi c Exam

Pos

Cult ure

Comments

Empyema

Less then serum, often <20

Pos

Drainage necessary; putrid odor suggest anaerobic infection Tube thoracostomy unnecessary; associated infiltrate on chest X-ray; fluid pH 7,2 Variable findings; 25% are transudates

Parapneumo nic-effusion, uncomplicate d Pulmonary embolism, infarction

Clear to turbid

Equal to serum

5000-25.000 mostly PMN

<5000

Neg

Neg

Serous to grossy bloody

Equal to serum

1000-50.000 mostly PMN

100->
100.000

Neg

Neg

Rheumatiod athritis or other collagenvascular disease Pancreatitis

Turbid or yelloy-green

Very low (<40 in most); in Ra, 5-20 mg/dL

1000-20.000 mostly PMN

<1000

Neg

Neg

Rapid clotting time; secondary empyema common

Turbid to serosanguin eous Turbid to purulent; redbrown

Equal to serum

1000-50.000 mostly PMN

100010.000

Neg

Neg

Effusion usually left-sided; highamylase level

Esophageal Rupture

Usually low

<5000- over 50.000, mostly PMN

<5000

Pos

Pos

Effusion usually left-sided; high fluid amylase level (salivary); pneumothorax in 25% of cases; pH <6.0 strongly suggest diagnosis

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TERIMA KASIH