1. Pleural diseases
Pleural efffusion
Pneumothorax
Mesothelioma

2. Pleural effusion
 Abnormal accumulation of fluid in pleural
cavity (normal- ~20 ml)
 Pathogenesis-
 Increased production due to increased hydrostatic or decreased
oncotic pressure- transudates- CHF, nephrotic syndrome, CLD
 Increased production due to increased capillary permeability-
parapneumonic- commonest cause of pleural effusion
 Decreased lymphatic clearance- TB, cancer/lymphoma
 Infection in pleural cavity- empyema
 Bleeding in pleural cavity- hemothorax

3. Evaluation
 s/s-
 Dyspnea
 Cough- dry
 Chest-pain- pleuritic-worse on deep inspiration
 Stony dullness on percussion, decreased breath sounds
 CxR-
 PA- blunting of lateral CP sulcus- ~200 ml.
 Lateral- blunting of posterior CP sulcus- ~100 ml.
 Ultrasound- ~50 ml., to guide aspiration
 Ix- thoracentesis ± blind/thoracoscopic Bx

4. Pleural fluid appearance
Purulent- empyema
Milky/chylous- lymphatic obstruction
Hemorrhagic/bloody- trauma, malignant

5. Pleural fluid investigations
 Exudate
 Protein PF/S >0.5
 LDH PF/S >0.6
 PF LDH > 2/3rd
S LDH
 PF glucose < S glucose
 Cells >1000/µL-
neutrophilic- empyema
lymphocytic- TB
 pH <7.30
 Amylase increased
 Gram stain/Z-N stain +ve
 Malignant cells +ve
 Transudate
 No criterion for
exudate fulfilled

6. Treatment
 Transudative- treat underlying condition
 Exudative-
 Parapneumonic- treat underlying pneumonia,
chest-tube drainage if pH <7.2 or glucose <60
mg/dl
 Empyema & hemothorax- chest-tube drainage
 Malignancy- depends on symptoms-
infrequent- repeated thoracentesis
frequent-
chest-tube drainagepleurodesis
Pleurodesis- doxycycline, talc, bleomycin

7. Pneumothorax
 Air in pleural space
 Causes-
 Trauma- exogenous or iatrogenic
 Primary- rupture of subpleural blebs-
common in tall, thin, young, smoker males
 Secondary- complication of underlying lung disease
 Presentation-
 Symptom- chest-pain, dyspnea
 Signs- decreased movements, tracheal/mediastinal shift,
increased resonance, decreased breath sounds

8. Tension pneumothorax
 One-way valve making intra-pleural pressure
more than ambient pressure throughout the
respiratory cycle
 Common causes-
 Penetrating trauma, CPR
 Positive pressure mechanical ventilation
 s/s- marked tachycardia, hypotension in
patient with pneumothorax
 Complication- subcutaneous emphysema

9. Management
 Dx- clinical + CxR
 Rx-
 Small stable primary spontaneous pneumothorax-
<15% of a hemithorax- observe, oxygen, aspirate
 Other- chest-tube drainage
 Thoracoscopy/thoracotomy ± pleurodesis-
recurrent spontaneous pneumothorax,
B/L pneumothorax
 Surgery- if all else fails
 Quit smoking

10. Mesothelioma
 Rare, tumor of pleura
 More in elderly, males
 Asbestos exposure- crocidolite most
carcinogenic
 Symptom- dull pain, SOB, pleural effusion
 Ix- CxR, CT scan, thoracoscopy,
IHC-cytokeratin +ve
 Median survival- 9-21 months
 Rx- poor response- Sx/RT/CT-Pemetrexed