Signs of the lobar consolidation of lung tissue

Visual examination: It is severe condition of the patient. He has redness in cheek at the affected side, herpes on his lips, sometimes prefers to lie on the affected side. There is tachypnea, cyanosis.

Visual examination of the chest: There is limitation of the chest moving at the affected side. Auxiliary muscles take part in breathing.

Palpation of the chest

There is a tenderness of the pleural points, positive Potendzher symptom, because large part of lung with pleura is involved to inflammatory process and surrounded tissues react to this. It is obtained amplifying of voice resonance according to the affected lobe or segments, because consolidated lung tissue conducts acoustic waves better than normal one.

Percussion of the chest

Comparative percussion: Over the consolidated lobe the percussion sound is dull because only solid components of infiltrated lung tissue get to percussion sphere.

Topographic percussion: Thelower border of the affected lung lifts up if pathological process localizes in lower lobe. The height of lung apex pulls down. But size of the lung doesn’t change. It is obtaining due to increasing of solidity of lung tissue. There is dimension of lower lung border excursion.

Auscultation of the lung

There is pathological bronchial breathing because all alveoli are filled up with inflammatory exudates, whispering pectoriloquy. There is pleural rub due to inflamed pleura rubbing against each other. You can hear depressed vesicular or bronchial breathing and crepitations in the beginning or end of pathological process.

X-ray signs of lobar pulmonary consolidation: There is intensive and homogeneous infiltration of lobe or segments.

A pleural effusion results from the accumulation of abnormal volumes (>10-20 ml) of fluid in the pleural space. According to causes of pleural effusion and content of pleural fluid there are two types – exudates and transudates.

Causes of the pleural effusion:

1. Cardiac failure

2. Pneumonia

3. Tuberculosis

4. Malignancy

5. Pulmonary embolism

6. Chest injury

7. Liver cirrhosis, pancreatitis and other

Symptoms of the pleural effusion:

It may be asymptomatic if little quantity of fluid accumulates in pleural space.

It is associated with breathlessness, dry cough, chest pain (suggesting pleural inflammation), chest “heaviness”, palpitation, if quantity of fluid is large (more than 400-500 ml).

Signs of the pleural effusion:

Visual examination

It is a severe condition of the patient. There is tachypnea, cyanosis and limitation of the chest moving at the affected side. Patient prefers to lie on the affected side because it facilitates his breathing.

Palpation of the chest

It is obtained reduced or absent tactile vocal fremitus, because fluid damps acoustic waves, and increased chest resistance. Sometimes, may be positive Potendzher symptom.

Percussion of the chest

Comparative percussion: It is dullness over fluid.

Topographic percussion: Lower lung border has shape named Ellis-Damuazo line which begins near column and rises to scapular then descends to axillary region and continues horizontally. This shape of line makes conditional upon different property of lung tissue to be squeezed.

Auscultation of the lung

There are no any sounds over the fluid. But sometimes may be diminished vesicular breathing if it is little quantity of fluid. You can hear diminished bronchial breathing if quantity of fluid much and squeezed lung has similar density as fluid. Above the fluid it is diminished vesicular breathing and, sometimes, pleural rub.

X-ray signs of the pleural effusion: It is usually detected effusion volumes of 200 ml or more by posterior-anterior position. Lateral chest X-ray is more sensitive and may detect as little as 50 ml pleural fluid. Classical chest X-ray appearance is of basal opacity obscuring hemidiaphragm, with concave upper border. Massive effusion may result in a ‘white-out’ of the hemithorax, with mediastinal displacement away from the effusion. Lack of the mediastinal shift in such cases raises the possibility of associated volume loss due to bronchial obstruction from a primary lung cancer.

Ultrasound is extremely sensitive at detecting fluid volumes of 100 ml or more, and is useful for distinguishing pleural fluid from pleural masses or thickening, and for demonstrating loculation.

Laboratory assessment of pleural fluid:

1. Common – visual assessment, comparative density, Rivalt test

2. Biochemistry for measurement of protein, LDH, glucose, cholesterol, triglycerides, amylase, depending on the clinical circumstances.

3. Cytology for examination for malignant cells and differential cell count

4. Microbiology for Gram stain and microscopy, culture, MBT examination

Is the pleural effusion a transudates or exudates?

Sign	transudates	exudates
comparative density	< 1,015-1,018	>1,018
Rivalt test	negative	positive
protein	<30 g/l	>30 g/l
Pleural fluid protein/serum protein ratio	<0,5	>0,5
LDH	<1,6 mMol/l	>1,6 mMol/l
Pleural fluid LDG/serum LDG ratio	<0,6	>0,6
erythrocytes	<10*10^9/l	>100*10^9/l
leucocytes	<1*10^9/l	>1*10^9/l
pH	>7,3	<7,3
glucose	3,3-5,5 mMol/l	<3,3 mMol/l

A pneumothorax is anair in the pleural space; may occur with apparently normal lungs (primary pneumothorax) or in the presence of underlying lung disease (secondary pneumothorax); may occur spontaneously or following trauma.

Causes of pneumothorax:

1. It occurs following an air leak from apical bullae.
2. Underlying diseases: COPD, asthma, interstitial lung disease, necrotizing pneumonia, tuberculosis, Pneumocystis carinii pneumonia, cystic fibrosis, Langerhans’cell histiocytosis, lymphangioleiomyomatosis, Marfan’s syndrome, oesophageal rupture, lung cancer, catamenial pneumothorax, pulmonary infarction.

Spontaneous – due to rupture of blebs, usually in thin tall young males with history of smoking

Traumatic – iatragenic (i.e. subclavian central line insertion, excessive PPV, thoracic surgery, transbronchial lung biopsy) or penetrating chest trauma (knife, bullet).

Tension – most serious: air enters on inspiration but cannot escape on expiration = pneumothorax size increases with each breath. Lung eventually collapses under increasing pressures.

Symptoms of pneumothorax:

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