DETAILS OF DISEASES OF PLEURA AND THEIR MANAGEMENT. PROCEDURES OF PUTTING A CHEST DRAIN AND EMERGENCY MANAGEMENT OF PNEUMOTHORAX

1. PLEURAL DISEASE
Presenters:
Twesiime Enock
Oriba Dan Langoya
Tutor:
MR. MWAMBU.T.

2. OUTLINE
• Anatomy
• Physiology
• Pneumothorax
• Pleural Effusion
• Empyema Thoracis
• Chylothorax/ Chylous Effusion

3. PLEURA AND PLEURAL CAVITY

4. PLEURA AND PLEURAL CAVITY

5. FIBRINOUS (DRY) PLEURISY

6. DEFINITION
–Inflammation of the pleura characterized by
fibrinous exudation and no significant
degree of effusion.

7. 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.

8. CLINICAL FEATURES
• SYMPTOMS:
1. Pleuritic pain (sudden, stitching chest pain, increasing
with inspiration, coughing and movements);
o 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).
2. Pleuritic cough – dry, due to irritation of pleura;
3. Dyspnea – due to:
o Restriction of respiratory movements;
o Underlying lung disease or development of effusion.
4. Specific etiological and general features: fever,
headache, and malaise.

9. CLINICAL FEATURES
• SIGNS:
1. Inspection
o Limitation of movements on the affected side.
2. Palpation
o Sometimes palpable pleural rub.
3. Percussion
o Tenderness .
4. Auscultation
o PLEURAL RUB

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

11. Pneumothorax
• Pneumothorax is the presence of air outside the lung,
within the pleural space.
• Spontaneous pneumothorax occurs when the visceral
pleura ruptures without an external traumatic or
iatrogenic cause.
• Primary spontaneous pneumothorax is a disease in its
own right.
• Secondary spontaneous pneumothorax occurs when
the visceral pleura leaks as part of an underlying lung
disease e.g tuberculosis, any degenerative or cavitating
lung disease and necrotising tumours.

12. • Tension pneumothorax is when there is a build-up of
positive pressure within the hemithorax, to the extent
that the lung is completely collapsed, the diaphragm is
flattened and the mediastinum is distorted and,
eventually, the venous return to the heart is
compromised.
• Any pleural breach is inherently valve-like because air
will find its way out through the alveoli but cannot be
drawn back in because the lung tissue collapses around
the hole in the pleura

13. • In thoracocentesis, a poorly managed chest
drain with intermittent build-up of pressure
allows air to track into the chest wall through the
point where the drain breaches the parietal
pleura.
• Other iatrogenic causes; insertion of central line
for CVP monitoring, i.v feeding or cardiac
pacing,liver biopsy and patients on mechanical
ventilation following trauma.

15. Primary spontaneous pneumothorax
• This is characteristically seen in young people from
their mid-teens to late-20s. Mainly males, smokers and
the condition runs in families.
• It is due to leaks from small blebs, vesicles or bullae,
which may become pedunculated, typically at the apex
of the upper lobe or on the upper border of the lower
or middle lobes.
• Usually, pneumothorax presents with sharp pleuritic
pain and breathlessness.
• Bleeding and tension pneumothorax can occur. If the
patient is not in respiratory distress or hypoxia there is
no urgency.

16. Inserting and managing a chest drain
• An intercostal tube connected to an
underwater seal is central to the management
of chest disease;
• The safest site for insertion of a drain is in
the triangle that lies:
-anterior to the mid-axillary line;
- above the level of the nipple;
- below and lateral to the pectoralis
major muscle.
This will ideally find the fifth intercostal space.

17. PLEURAL EFFUSION

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

19. Pleural Effusion

20. PLEURAL EFFUSION

21. ETIOLOGY. PATHOGENESIS
• EXUDATE
• TRANSUDATE
The term “pleural effusion”, by general consent, is applied
only to serous effusions.

22. ETIOLOGY. PATHOGENESIS
• EXUDATE – definition -one or more criteria:
o Pleural fluid protein to serum protein ratio >0.5
o Pleural fluid LDH to serum LDH ratio >0.6
o Pleural fluid LDH value >2/3 upper normal limit for
serum LDH (pleural fluid LDH >200U/L).
Mechanisms: increased permeability of the pleural surface (due to inflammation)
or by obstruction of the lymphatic (carcinoma).

23. 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 (Dressler`s syndrome)

24. ETIOLOGY. PATHOGENESIS
• TRANSUDATE:
o Pleural fluid protein to serum protein ratio < 0.5
o Pleural fluid LDH < 200U/L
Mechanisms:
o Increased in hydrostatic pressure (congestive heart failure);
o Decreased oncotic pressure (hypoalbuminemia);
o Greater negative intrapleural pressure (acute atelectasis).

25. ETIOLOGY. PATHOGENESIS
• TRANSUDATE – causes:
o Congestive heart failure (majority of cases);
o Cirrhosis with ascites;
o Nephrotic syndrome;
o Myxedema;
o Meigs`s syndrome (right side pleurisy, ascitis, ovarian
cancer);
o Acute atelectasis;
o Constrictive pericarditis;
o Superior vena cava obstruction (mediastinal tumors).

26. 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.

27. CLINICAL FINDINGS
• SIGNS:
– INSPECTION
o limitation of movements on the affected side
– PALPATION
o large effusions shift the mediastinum to the opposite side (if it is not fixed
by malignancy)
o decreased vocal tactile fremitus
– PERCUSSION
o basal stony dullness rising to the axilla (Damoisseau line)
o hyper-resonance above the level of effusion (compensatory emphysema)
– AUSCULTATION
o Absent or reduced breath sounds over the area of the effusion
o 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.

28. Pleural Effusion

29. 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”).

30. LABORATORY FINDINGS
• DIAGNOSTIC THORACENTESIS
• Pleural fluid is examined for:
• physical,
• chemical,
• bacteriological,
• and cytological
characteristics.

31. Analysing pleural fluid
• Appearance
– Bloody
• (e.g. trauma, malignancy, infection, infarction)
– Straw-coloured
• (e.g. cardiac failure, hypoalbuminaemia)
– Turbid/Milky
• (e.g. empyema, chylothorax)
– Foul smelling
• (Anaerobic empyema)
– Viscous
• (e.g. mesothelioma)
– Food particles
• (oesophageal rupture)

32. ASSESSMENT OF PLEURAL FLUID

33. 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.

34. Emmet E. McGrath, Diagnosis of Pleural
Effusion: A Systematic Approach, AJJC

35. 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.

36. 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.

37. COMPLICATIONS
• Respiratory chronic distress;
• Secondary infection causing empyema;
• Fibrosis – pachypleuritis (fibrous “peel”);
• Permanent lung collapse.

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

39. MESOTHELIOMA OF PLEURA

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

41. CHARACTERISTICS OF PARAPNEUMONIC PLEURAL
EFFUSION
BTS guidelines for the management of pleural infection, Thorax 2003

42. OTHER MAJOR TYPES OF PLEURAL EFFUSION
• EMPYEMA
o Is an exudative pleural effusion caused by direct
infection (usually bacterial) of the pleural space
(frank pus pleural fluid);
o The main causes: bacterial pneumonia and lung
abscess;
o Pleural fluid PH < 7.2;
o Milky in appearance pleural fluid, clearing the
supernatant after centrifugation.

43. OTHER MAJOR TYPES OF PLEURAL EFFUSION
• HEMOTHORAX
o Is the presence of frank blood in the pleural space;
o If the hematocrit of pleural fluid is more than 50%
of the hematocrit of peripheral blood,
hemothorax is present;
o Causes: chest trauma, cancer, or pulmonary
embolism (less commonly).

44. HEMOTHORAX

45. OTHER MAJOR TYPES OF PLEURAL EFFUSION
• CHYLOUS PLEURAL EFFUSION
o Occurs in chylothorax as a result of disruption of the
thoracic duct, traumatically or by cancer invasion;
o The pleural fluid is turbid post centrifugation;
o Triglyceride > 110 mg/dl.

46. CHYLOTHORAX

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

48. 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

49. 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.

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

51. 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.

52. 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.

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

54. 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.

55. 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.

56. 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.