Pleural Cavity

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Pleural Cavity
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Mechanism of fluid formation
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Pleural Diseases

• Pleuritis Dry pleurisy
• Pleural effusion Hydrothorax
• Hemothorax
• Pyothorax empyema
• Chylothorax
• Pneumothorax
• Hydro-pneumothorax
• Pyo-pneumothorax
• Fibrothorax Pleural thickening

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Pleural Effusion Causes

• Exudative effusion
• Tuberculosis
• Bacterial Synpneumonic
• Post pneumonic
• Malignant
• Connective tissue disorders
• Pulmonary thromboembolism
• Transudative CHF, constrictive pericarditis,
  Nephrotic syndrome, hypoproteinemia, cirrhosis

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Symptoms and signs

• Chest pain or heaviness
• Breathlessness and cough
• General weakness, fatigue, night-sweats, fever
• Signs
• Tracheal and mediastinal shift
• Bulging of hemithorax
• Movements diminished
• P. note impaired / dull/ stony dull
• Br. Sounds Decreased / absent
• Pl. rub, Egophony, etc.
• Symptoms signs of underlying disease

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Diagnosis

• Physical examination
• Chest radiology
• CXR Opacity, rising level, or massive
• CT chest to see the underlying lungs,
• mediastinal LN etc.
• Sputum, if available
• Tuberculin skin test
• Pleural fluid aspiration (Pleurocentesis)
• pleural biopsy / thoracoscopy

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Examination of pleural fluid

• Pleural fluid chemistry pH, Fluid LDH level
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  Fluid total protein and corresponding serum
  protein
• Fluid
  glucose and corresponding serum glucose
• Special chemistry Fluid Amylase, Triglycerides,
  Cholesterol
• Total and differential cell count
• Cytological examination Special stains for
  malignancy, fungal infections
• Immunological studies Fluid ANA, Rheumatoid
  factor, Adenosine deaminae
• Special immuno-Cytology
• Flow Cytometry for diagnosis of lymphoma
• Tumor markers for diagnosis of malignant pl
  effusion

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Pleural Biopsy

• Pleural biopsy
• Closed bx with Abrams needle
• Thoracoscopic
• (Biopsy exam. May reveal granulomas or other
  histopath. Depending upon the cause)
• Thoracoscopy Gold standard procedure
  examination and biopsy

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Pleural fluid appearance in unique effusions
Appearance Underlying Disease
Pale yellow Most transudates
Turbid Inflammatory exudates
Pus Empyema
Hemothorax Trauma, malignancy, Pulmonary embolism, Thoracic endometriosis
Milky fluid Chylothorax
Brown Amebic liver abscess
Black Fungal infection (aspergillus niger)
Yellow to green Rheumatoid pleurisy
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Causes of pleural effusion

• Common causes of Transudative Pleural Effusion
• Heart failure (left and bi-ventricular failure)
• Cirrhosis of liver, Nephrotic syndrome
• Hypoalbuminemia, Constrictive pericarditis
• Peritoneal dialysis Subclavian vein thrombosis
• Common causes of Exudative Pleural Effusion
• Tuberculosis
• Non-tubercular infections (Bacterial, Fungal)
• Malignancies (Lung, pleura, metastases)
• Connective tissue diseases (RA, SLE)
• Pulmonary thromboembolism

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Causes for asymptomatic pleural effusion

• Atlectasis
• Benign asbestos pleural effusion
• Hypoalbuminemia
• Nephrotic syndrome
• Peritoneal dialysis
• Rheumatoid effusion
• Trapped lung
• Urinothorax
• Yellow Nail syndrome

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Causes of amylase rich pleural effusion
Pancreatic Type Amylase Salivary Type Amylase
Acute pancreatitis Adenocarcinoma of lung Squamous cell lung cancer
Chronic pancreatitis Undifferentiated lung cancer Ovarian Cancer
Pancreatic pleural fistula Multiple myeloma Lymphoma Lymphatic leukemia Pneumonia Tuberculosis
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Causes of chylothorax
Traumatic Non-traumatic
Mediastinal, lung and cardiac surgery Benign Lyphangioieiomyomatosis
Neck surgery especially on left side Tuberous sclerosis
Central line placement aspecially on left side Filariasis Amylodosis Benign mediastinal tumors
Endoscopic sclerotherapy Malignant
Penetrating surgery to neck and thorax Lymphoma Mediastinal metastasis
Post delivery Primary lung cancer Kaposis Sarcoma
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Treatment

• Fluid aspiration therapeutic
• Chest-tube drainage (empyema, pneumothorax,
  hemothorax)
• Treatment of underlying disease
• - Tuberculosis
• - Bacterial/ fungal infections
• - Malignancy etc.
• (Tmt of transudative effusion mostly consists of
  tmt of the cause of effusion)

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Complications

• Depend upon the underlying etiology
• Increase in fluid causes breathlessness and
  respiratory distress
• Broncho-pleural fistula formation
• Hydropneumothorax may occur
• Empyema and pyo-pneumothorax
• Pleural fibrosis, thickening, chest deformity
• Chest movement restriction long term
• May lead to chronic cor pulmonale

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Empyema

• Pus in the pleural cavity
• Commonly occurs as a complication of pneumonia
• Sometimes, iatrogenic following
  aspiration, trauma
• Symptoms Signs Fever, rigors, sweating,
  malaise
• Tender hemithorax, Signs of bulging (Acute) or
  retraction (chronic empyema)
• Diagnosis History, Chest X Ray, CT Chest, TLC,
  DLC, CRP, ESR etc
• Pl fluid/ pus examination Grams stain, culture

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Bacterial parapneumonic effusion

• Staphylococcus aureus, MRSA, S. epidermidis
• Streptococcus intermedius, St pneumoniae, St
  pyogenes, Streptococcus milleria
• Anaerobes Fusobacterium, Bacteriods
  Peptosteptococcus, Prevotella spp., Clostridium
  spp.
• Klebsiella pneumoniae
• Pseudomonas aeruginosa
• Escherichia coli
• Enterobacter supp.
• Mycobacterium tuberculosis
• Actinomyces spp.

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Treatment of empyema

• Drainage ICTD
• Antibiotics change according to causative
  organism and sensitivity reports
• Surgical intervention Adhesiolysis
• Decortication
• Lung resection

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Pleurodesis

• Therapeutic closure of pleural cavity through
  adhesion of pleural membranes
• Done in case of recurrent effusion
• Total drainage of fluid with ICTD following by
  administration of pleurodesic agent such as
• - Tetracycline, doxycyclkine, mepacrine
• - Talc powder or slurry
• - Betadine
• - Cytotoxic agents Bleomycin

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Pneumothorax
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Spontaneous Pneumothorax

• Primary Cause unidentified
• Secondary Identifiable cause
• Obstructive airway disease/ Bullous emphysema,
  Asthma
• Infections Tuberculosis
• Pneumonias Staphylococcal
• Fungal infections
• Lung cancer
• Connective tissue diseases
• Interstitial lung disease
• Miscellaneous Lymphangioleimyomatosis
• Histiocytosis, Morfans Syndrome

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Clinical Features

• Acute Sudden onset chest pain, breathlessness
• Chronic/ Loculated Heaviness, pain,
  breathlessness
• Symptoms of underlying illness
• Signs
• - Bulge of hemithorax
• - Shift of mediastinum to opposite side
• - Movements diminished
• - Percussion note hyper-resonant
• - Breath sounds diminished
• - Bronchial breathing/ egophony

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Types of Pneumothorax

• Clinical features also depend upon the type of
  pneumothorax
• Communicating (Open) Pt may be comfortable at
  rest, breathless on exertion. Sign of BP Fistula
  may be present
• Non-communicating (Closed) Subacute or chronic.
  May be loculated.
• Tension pneumothorax (Expanding) Acute with
  respiratoy distress.

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Diagnosis

• History physical examination
• Chest X-Ray, CT scanning
• Investigations for cause of pneumothorax
• Thoracoscopic examination

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B
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Pleural line
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Complications

• Tension pneumothorax
• Respiratory distress, shock
• Leakage of air to mediastinum and pericardial
  cavity (pneumomediastinum), subcutaneous tissues
  (subcutaneous emphysema), peritoneal cavity
  (pneumoperitoneum) etc.
• Cardiac compression cardiac temponade
• Infection in the pleural cavity, hydro and
  pyo-pneumothorax, fistula etc.

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Treatment

• 1. Drainage with a pig-tail catheter/ chest-tube
  under water-seal
• Acute and tension pneumothorax
• Immediate drainage is required.
• 2. Supportive tmt Oxygenation
• Treatment of underlying etiology
• 3. Surgery depending upon the cause
• (Bullectomy, lobar or lung resection etc)
• 4. Recurrent pneumothorax Pleurodesis

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