DISEASES OF THE PLEURA

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DISEASES OF THE PLEURA
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PLEURA AND PLEURAL CAVITY
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PLEURA AND PLEURAL CAVITY
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FIBRINOUS (DRY) PLEURISY
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DEFINITION

• Inflammation of the pleura characterized by
  fibrinous exudation and no significant degree of
  effusion.

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ETIOLOGY

• A. Primary pleural disease
• 1. Tuberculosis
• 2. Rheumatic fever
• 3. Viral disease Coxsackie B virus may cause a
  recurrent pleuromyositis, named Pleurodynia or
  Bernholm disease
• 4. Malignant (mesothelioma).
• B. Secondary to
• 1. Lung disease pneumonia, tuberculosis, lung
  abscess or pulmonary infarction
• 2. Mediastinal disease pericarditis,
  mediastinitis or malignancy
• 3. Subdiaphragmatic disease amoebic or
  subphrenic abscess.

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CLINICAL FEATURES

• SYMPTOMS
• Pleuritic pain (sudden, stitching chest pain,
  increasing with inspiration, coughing and
  movements)
• In diaphragmatic pleurisy the pain is referred
  to the shoulder (through the phrenic nerve) or to
  the epigastrium and lumbar region (through the
  lower intercostal nerves).
• Pleuritic cough dry, due to irritation of
  pleura
• Dyspnea due to
• Restriction of respiratory movements
• Underlying lung disease or development of
  effusion.
• Specific etiological and general features fever,
  headache, and malaise.

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CLINICAL FEATURES

• SIGNS
• Inspection
• Limitation of movements on the affected side.
• Palpation
• Sometimes palpable pleural rub.
• Percussion
• Tenderness .
• Auscultation
• PLEURAL RUB

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• Chest X-ray must be performed in every case for
  detecting a thoracic cause for the pleurisy.

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PLEURAL EFFUSION
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DEFINITION

• Abnormal (excessive) accumulation of fluid inside
  the pleural space.

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Pleural Effusion
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PLEURAL EFFUSION
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ETIOLOGY. PATHOGENESIS

• EXUDATE
• TRANSUDATE

The term pleural effusion, by general consent,
is applied only to serous effusions.
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ETIOLOGY. PATHOGENESIS

• EXUDATE definition -one or more criteria
• Pleural fluid protein to serum protein ratio gt0.5
• Pleural fluid LDH to serum LDH ratio gt0.6
• Pleural fluid LDH value gt2/3 upper normal limit
  for serum LDH (pleural fluid LDH gt200U/L).

Mechanisms increased permeability of the pleural
surface (due to inflammation) or by obstruction
of the lymphatics (carcinoma).
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ETIOLOGY. PATHOGENESIS

• EXUDATE causes
• Pneumonia (parapneumonic effusions)
• Cancer (especially mediastinal)
• Pulmonary embolism
• Rheumatic fever
• Empyema
• Tuberculosis
• Conective tissue disease
• Viral pleurisy
• Acute pancreatitis
• Uremia
• Chronic atelectasis
• Sarcoidosis
• Drug-related
• Post-myocardial infarction (Dresslers syndrome)

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ETIOLOGY. PATHOGENESIS

• TRANSUDATE
• Pleural fluid protein to serum protein ratio lt
  0.5
• Pleural fluid LDH lt 200U/L

• Mechanisms
• Increased in hydrostatic pressure (congestive
  heart failure)
• Decreased oncotic pressure (hypoalbuminemia)
• Greater negative intrapleural pressure (acute
  atelectasis).

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ETIOLOGY. PATHOGENESIS

• TRANSUDATE causes
• Congestive heart failure (majority of cases)
• Cirrhosis with ascites
• Nephrotic syndrome
• Myxedema
• Meigss syndrome (right side pleurisy, ascitis,
  ovarian cancer)
• Acute atelectasis
• Constrictive pericarditis
• Superior vena cava obstruction (mediastinal
  tumors).

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CLINICAL FINDINGS

• SYMPTOMS
• Pleuritic pain, pleural rub, irritative dry cough
  (a dry pleurisy often precedes the development of
  effusion)
• Dyspnea (its severity increases with the size of
  the effusion)
• General symptoms (due to the cause)
• Fever, night sweat, loss of weight, loss of
  appetite.

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CLINICAL FINDINGS

• SIGNS
• INSPECTION
• limitation of movements on the affected side
• PALPATION
• large effusions shift the mediastinum to the
  opposite side (if it is not fixed by malignancy)
• decreased vocal tactile fremitus
• PERCUSSION
• basal stony dullness rising to the axilla
  (Damoisseau line)
• hyper-resonance above the level of effusion
  (compensatory emphysema)
• AUSCULTATION
• Absent or reduced breath sounds over the area of
  the effusion
• Bronchial breathing and egophony may be heard
  over the upper level of effusion

Physical findings are absent if less than 200-300
ml of pleural fluid is present.
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Pleural Effusion
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LABORATORY FINDINGS

• CHEST X- RAY
• obliteration of the costophrenic angle by a
  homogenous, intense opacity rising laterally to
  the axilla
• mediastinal displacement to the opposite side
• may indicate the possible etiology of the
  pleurisy (tuberculosis, lung cancer, lymphoma)
  showing the primary mediastinal lesion.

Pleural fluid may become trapped (loculated) by
pleural adhesions, forming unusual collections
along the chest wall or in the lung fissures
(pseudotumors).
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LABORATORY FINDINGS

• DIAGNOSTIC THORACENTESIS

• Pleural fluid is examined for
• physical,
• chemical,
• bacteriological,
• and cytological

characteristics.
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ASSESSMENT OF PLEURAL FLUID
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LABORATORY FINDINGS

• PLEURAL BIOPSY (blind or image guided)
• should be considered whenever malignancy or
  tuberculosis is accounted in the differential
  diagnosis of a pleural effusion.
• OTHER INVESTIGATIONS
• ultrasonography
• contrast enhanced computed tomography of thorax
• bronchoscopy (if is a high index of suspicion of
  bronchial
• obstruction)
• medical/surgical thoracoscopy.

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Emmet E. McGrath, Diagnosis of Pleural Effusion
A Systematic Approach, AJJC
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POSITIVE DIAGNOSIS

• Pleuritic chest pain, dyspnea, pleural rub
• Decreased TVF, stony dullness to percussion,
  distant breath sounds, egophony (large effusion)
• Radiographic evidence of pleural effusion
• Etiological diagnosis is based mainly on
  thoracentesis and fluid laboratory examination.

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DIFFERENTIAL DIAGNOSIS

• Basal lung lesions
• Basal consolidation
• Collapse
• Subdiaphragmatic diseases
• Amoebic liver abscess
• Subphrenic abscess

Differentiation between various causes of
effusion is based especially upon the laboratory
examination of the fluid, in direct relationship
with the clinical and imagistic data.
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COMPLICATIONS

• Respiratory chronic distress
• Secondary infection causing empyema
• Fibrosis pachypleuritis (fibrous peel)
• Permanent lung collapse.

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SPECIAL FORMS OF PLEURAL EFFUSION

• Malignant Pleural Effusion
• An effusion developed due to a pleural cancer
  (mesothelioma), the pleural surface being
  directly involved and invaded by malignant cells
  
• Pleural fluid cytology or pleural tissue biopsy
  reveals evidence of malignancy
• The pleural fluid is hemorrhagic with a rapid
  reaccumulation.
• Paramalignant Pleural Effusion
• An unapparent cancer or visible but not pleural,
  the pleural space being not directly invaded by
  tumor.

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MESOTHELIOMA OF PLEURA
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SPECIAL FORMS OF PLEURAL EFFUSION

• Parapneumonic Pleural Effusion
• In uncomplicated parapneumonic effusion, the
  pleural fluid is not infected (the pleural fluid
  glucose and PH are normal) usually this
  effusion solve spontaneously
• In complicated parapneumonic effusion, pleural
  fluid is either frank empyema or has the
  potential to organize into a fibrous peel
• Tube thoracostomy is required for parapneumonic
  effusion if any of the following is present
• The fluid resembles frank pus
• Pleural fluid glucose is lt 40 mg/dl
• Pleural fluid PH is lt 7.2.
• A pneumonic effusion that does not respond to
  drainage within 24 hours may have become
  loculated.

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CHARACTERISTICS OF PARAPNEUMONIC PLEURAL EFFUSION
BTS guidelines for the management of pleural
infection, Thorax 2003
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OTHER MAJOR TYPES OF PLEURAL EFFUSION

• EMPYEMA
• Is an exudative pleural effusion caused by direct
  infection (usually bacterial) of the pleural
  space (frank pus pleural fluid)
• The main causes bacterial pneumonia and lung
  abscess
• Pleural fluid PH lt 7.2
• Milky in appearance pleural fluid, clearing the
  supernatant after centrifugation.

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OTHER MAJOR TYPES OF PLEURAL EFFUSION

• HEMOTHORAX
• Is the presence of frank blood in the pleural
  space
• If the hematocrit of pleural fluid is more than
  50 of the hematocrit of peripheral blood,
  hemothorax is present
• Causes chest trauma, cancer, or pulmonary
  embolism (less commonly).

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HEMOTHORAX
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OTHER MAJOR TYPES OF PLEURAL EFFUSION

• CHYLOUS PLEURAL EFFUSION
• Occurs in chylothorax as a result of disruption
  of the thoracic duct, traumatically or by cancer
  invasion
• The pleural fluid is turbid post centrifugation
• Triglyceride gt 110 mg/dl.

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CHYLOTHORAX
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PROGNOSIS

• Depends on the etiology and the prognosis of the
  underlying disease
• In malignant pleural effusion the prognosis is
  poor
• The rheumatic fever or viral pleural effusions
  have usually a better prognosis, often solving
  spontaneously.

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TREATMENT

• Treatment of the underlying medical condition
  that is causing pleural effusion
• Thoracentesis (therapeutic and diagnostic)
• Tube Thoracostomy (Chest Tube)
• Pleural Catheter (for reoccurring pleural
  effusion )
• Pleural Sclerosis (Pleurodesis) - Doxycycline or
  talc
• Surgery
• Video-assisted thoracoscopic surgery (VATS)
• Thoracotomy

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ANTIBIOTICS

• If are indicated should be guided by bacterial
  culture results.
• Where cultures are negative, antibiotics should
  cover community acquired bacterial pathogens and
  anaerobic organisms.
• Hospital acquired empyema requires broader
  spectrum antibiotic cover.

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ANTIBIOTIC REGIMENS FOR THE INITIAL TREATMENT OF
CULTURE NEGATIVE PLEURAL INFECTION
BTS guidelines for the management of pleural
infection, Thorax 2003
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THERAPEUTIC THORACENTESIS

• Any pleural effusion large enough to cause severe
  respiratory symptoms should be drained regardless
  of the cause and regardless of concomitant
  disease-specific treatment.
• Relief of symptoms is the main goal of
  therapeutic drainage in these patients.
• Absolute contraindication - active cutaneous
  infection at the puncture site.
• Relative contraindications include severe
  bleeding diathesis, systemic anticoagulation, and
  a small volume of fluid.
• Possible complications bleeding, pneumothorax,
  infections, laceration of intra-abdominal organs,
  hypotension, and pulmonary edema.

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TUBE THORACOSTOMY (CHEST TUBE)

• Tube thoracostomy allows continuous, large volume
  drainage of air or liquid from the pleural space.
• Specific indications
• spontaneous or iatrogenic pneumothorax
• hemothorax
• penetrating chest trauma
• complicated parapneumonic effusion or empyema
• chylothorax
• pleurodesis of symptomatic pleural effusions.

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Chest computed tomographic scan with a split
pleural sign (arrow), seen in empyema. This
patient needed drainage with tube thoracostomy.
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PLEURAL SCLEROSIS

• is considered for patients with uncontrolled and
  recurrent symptomatic malignant effusions, and
  rarely, in cases of benign effusions after
  failure of medical treatment.
• a sclerosing agent (talc, doxycycline, or
  tetracycline) is instilled into the pleural
  cavity via a tube thoracostomy to produce a
  chemical serositis and subsequent fibrosis of the
  pleura.

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VIDEO-ASSISTED THORACOSCOPIC SURGERY (VATS)

• is very useful in managing incompletely drained
  parapneumonic effusions.
• with thoracoscopy, the loculi in the pleura can
  be disrupted, the pleural space can be completely
  drained, and the chest tube can be optimally
  placed.

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THORACOTOMY

• In cases of empyema with uncontrolled sepsis or
  progression to the fibroproliferative phase a
  full thoracotomy with decortication is performed
  with removal of all the fibrous tissue and
  evacuation of all the pus from the pleural space.