Pleural diseases define a group of diseases that affect the coverings of the lungs. These may be primary or secondary in origin. Relevant references are provided in the slides for further reading. Note that this information must be used not to replace your lecturer but to supplement and provided a basis for further reading.

1. Pleural diseases
Presented by;
1. Nelson Ssewante MBChB V
2. Ronald Mujuni MBChB V

2. Introduction
• The pleura is the mesothelial lining between
the chest wall and the lung
• Divided into 2 layers; Parietal and the Visceral
pleura
• Parietal pleura is the outermost layer lining
the rib cage, mediastinum and the diaphragm

3. Continued…
• The Visceral pleura is the inner layer invested
on the lung surface
• The parietal and visceral pleura are separated
by the pleural cavity
• Normally, this cavity contains a thin lubricated
fluid about 10-20ml

5. Pleurisy
• Also known as Pleuritis is inflammation of the pleura

6. 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, pulmonary Embolism;
2. Mediastinal disease: pericarditis, mediastinitis or malignancy;
3. Subdiaphragmatic disease: amoebic or subphrenic abscess.

7. Clinical presentation
• Chest Pain. It is characteristically sharp, localized and worsened by deep inspiration or coughing.
• Evidence of infection; fever, malaise, cough, dyspnea
• Intercostal tenderness on palpation
• Pleural rub on auscultation

8. Diagnosis
• Lab investigations: CBC, D-dimer test, arterial blood gases and culture
• Imaging: Chest x-ray, ECG, CT scan depending on your differentials
• Findings on chest x-ray may include; infiltrations (i.e., pneumonia), effusions (i.e., pulmonary
embolism, malignancy), or lack of identifiable lung markings (i.e., pneumothorax)

9. Management
• The goal of initial management is to find the underlying etiology and symptomatic treatment
• Prescribe appropriate analgesics(WHO analgesic ladder)
• Supplemental oxygen may be necessary
• Patient monitoring
• Inflammation resolves once the underlying cause is treated

10. Complications of pleurisy
• Severe pleural effusion
• Atelectasis due to shallow breathing caused by pain

11. Pneumothorax
• Pneumothorax is the presence of air outside the lung, within the pleural space which can impair
oxygenation or ventilation.
• Air can enter the intrapleural space through a communication from the chest wall (ie, trauma) or
through the lung parenchyma across the visceral pleura(i.e spontaneous pneumothorax)
• 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 necrotizing tumors

12. Clinical features
Spontaneous pneumothorax
• May be asymptomatic. Symptomatic cases are associated with acute onset of chest pain and
shortness of breath
Iatrogenic pneumothorax
• Symptoms similar to those of spontaneous pneumothorax
Tension pneumothorax
• Hypotension, hypoxia, chest pain, dyspnea
Pneumomediastinum
• May or may not have symptoms; chest pain, persistent cough, sore throat, dysphagia, shortness of
breath, or nausea/vomiting

13. Diagnostic evaluation
• Diagnosis is majorly clinical
• Imaging provides additional information and
should be performed;
Extent of pneumothorax, potential
causes, and assistance with the
therapeutic plan.

14. PLEURAL EFFUSION
• The collection of excess fluid in the pleural
spaces.
• Normally, this space contains about 10-20mls
of serous fluid

15. Continued
• Normal vs Excessive fluids • Pleural fluid normally seeps from
parietal pleural capillaries into
the space
• It is then drained by visceral
capillaries and lymphatics
• Any interferences in both
production and drainage leads
to Pleural effusion.
Production of
pleural fluid
Drainage of
pleural fluid

16. Transudative effusion
• Also known as hydrothoraces occurs in non-inflammatory conditions.
• There is no associated increase in capillary permeability and therefore low protein and Cell counts
• May be due to increased hydrostatic pressure, as in cardiac failure
• OR: A decrease in oncotic pressure as happens in hypoalbuminemia(Liver Cirrhosis or renal
disease)

17. Exudative effusion
• It occurs in inflammatory conditions and results in a protein rich fluid
• Common conditions include;
• Pulmonary infections(Pneumonia, TB, etc)
• Pulmonary Embolism
• Malignancies

18. Pathophysiology
• Transudative • Exudative
Hydrostatic pressure or Oncotic pressure
Leakage of the fluid into the pleural space
Pleural Effusion
Initiation of an Inflammatory reaction
Vasodilation Increased Capillary permeability
Invasion of microbes
Proteins leaks Decreased Oncotic pressure
Fluid shift into the pleural cavity
Pleural Effusion

19. Clinical presentations
• Depend on underlying cause
• Pneumonias; fevers, malaise, pleuritic chest pain
• Malignant effusions may be associated with weight loss, dyspnea, coughing, hemoptysis.
• Dullness to percussion
• Reduced or absent breath sounds on auscultation

21. Diagnostic evaluation
• Complete Blood count
• Chest X-ray or Ultrasound detects
fluid collection
• Biochemical, cytological and
bacteriological analysis
• Light’s Criteria

22. Analyzing pleural fluid
• Appearance
 Bloody
e.g. trauma, malignancy, infection, infarction
 Straw-coloured
e.g. cardiac failure, hypoalbuminemia
 Turbid/Milky
e.g. empyema, chylothorax
 Foul smelling
Anaerobic empyema
 Viscous
e.g. mesothelioma
 Food particles; esophageal rupture

24. Management
• Identify and treat the cause
• Relive discomfort, dyspnea and respiratory compromise
• Thoracentesis to remove the excess fluid
• A chest drain may be necessary in malignant effusions

26. Empyema
• Collection of purulent material (pus) from a lung infection in the pleural space
• It is commonly a consequence of pneumonia, injury, or chest surgery
• 20% to 57% of people with pneumonia develop a parapneumonic effusion, of
whom some can progress to pleural empyema
• Commonly S. aureus, S. pneumoniae, S. pyogens

27. Stages
• Stage I (1-3 days): An exudative phase characterized by a clear, thin and
sterile pleural effusion.
It is a simple parapneumonic effusion with normal glucose levels and
pH
• Stage II (4-14 days): Fibrinopurulent phase where the fluid becomes thick,
infected and purulent
There is accumulation of neutrophils and fibrin

28. Stage III(beyond 14 days)
• An organizing or consolidative phase where granulation tissue
is formed and encases the lung.
The thickened pleural can resist lung movement(trapped lung)

29. Clinical features
• Features of pneumonia
Fever, dyspnea, cough, chest pain
• Abdominal pain, vomiting
• Splinting of the affected side

30. Diagnostic evaluation
Laboratory
• CBC
• Pleural fluid analysis(biochemical, bacteriological)
A positive culture is the definitive test
Imaging
• Ultrasound(pleural loculations and septations)
• Chest X ray(Pleural effusion)
• CT scan(pleural thickening and enhancement)
A: Air B: Fluid

31. Management
• Antibiotic use alone is curative in stage I
• In Stage II &III, drainage of the effusion is necessary to supplement antibiotics
• Drainage techniques may be surgical or non-surgical
• Non-surgical interventions
Thoracentesis(through a needle)
 Thoracostomy(through a chest tube)

32. Management continued…
Surgical interventions include
• Video‐assisted thoracoscopic surgery (VATS)
Enables visualization of the pleural cavity for drainage of pus and disruption of septations
A temporary chest tube is left in place for postoperative drainage of any re‐accumulated
effusions
• Open thoracotomy
Involves surgical exploration of the pleural space and drainage of the empyema

33. Other forms of pleural effusions
• Hemothorax
Accumulation of blood in the pleural cavities
• Chylothorax
Accumulation of chile in the pleural cavities due to rupture of the thoracic duct
• Urinothorax
Rare condition in which there's accumulation of urine in the pleural cavities. It can be
obstructive or traumatic

34. Mesothelioma
• Malignancy involving mesothelial cells that normally line the body
cavities
• It affects pleura in 87% of cases but may also involve peritoneum,
pericardium, and testis
• 3 major histologic types are sarcomatous, epithelial, and mixed

35. Malignant pleural mesothelioma
• Tumor growth usually starts at the lower part of the chest
• The tumor may invade the diaphragm and encase the surface of the
lung and interlobar fissures

36. Etiology
• Asbestos is the principal carcinogen implicated
• Others
• Age: Risk increases with age; rare under 45 years
• Gender: More common in males
• Smoking
• Radiatiion
• Genetic mutation: BAP1 gene

37. Clinical presentation
Classical symptoms ;-
• Non pleuritic chest pain .
• Dyspnoea
• Systemic symptoms; Fatigue, Weight loss, Sweating & fever
Physical Examination
• Finger clubbing .
• Signs of pleural effusion or sold pleural tumor .
Signs of advanced disease ;-
• Palpable chest mass
• Hoarse voice , vocal cord palsy .
• SVC Obstruction
• Horner's syndrome
• Ascites due to involvement of the peritoneum

38. Diagnosis
• Imaging(CXR, CT, MRI)
Pleural thickening, pleural effusion, contraction of ipsilateral hemithorax
• Invasive techniques
aspiration cytology
Blind biopsy
CT guided biopsy
Thoracoscopy & biopsy

39. Staging

40. Treatment

41. References
1. Frank W. Sellke, Pedro J. del Nido, and Scott J. Swanson. Sabiston and Spencer Surgery of the
Chest; 9th Edition(2016). Chapters 27-31 pages 462-518
2. F. Charles Brunicardi, Katie S. Nason, Rose B. Ganim, and James D. Luketich. Schwartz’s Principles
of Surgery; 11th edition volume 1 (2019). Chapter 19 pages 736-744
3. Sriram Bhat M; SRB’s Manual of Surgery 5th Edition. Chapter 28 Pages 1116-1120

42. The End!