A 22-year-old male presented with a 14-day history of fever and right-sided chest pain that worsened with deep breathing and coughing. On examination, he was febrile and tachycardic with dullness on percussion of the right infraaxillary area and diminished breath sounds. The document discusses various pleural diseases including pneumothorax, pleural effusion, and fibrous pleurisy. It outlines their etiologies, clinical features, investigations, and management. Primary spontaneous pneumothorax commonly affects young, thin males and smokers due to rupture of subpleural blebs. Pleural effusions can be transudative such as in heart failure or exudative including those

1. PLEURAL DISEASES
Dr Rohit Rajeevan

2. CASE SCENARIO
 22yr male
 C/c – fever x 14 days
 Right side chest pain x 14 days
 HOPI - High grade fever assoc with right side stabbing chest pain that
is intensified by deep inspiration/cough.
 Cough with whitish sputum and 1 episode of hemoptysis 10 days ago

3.  On examination
 Thin, BMI 19.5 Kg/m2
 Febrile - 101ᵒF
 PR – 110/mt, BP 96/60mmHg
 RR – 30/min
 Tenderness on palpation Rt side of chest
 Dullness + Rt Infraaxillary area on percussion
 Diminished breath sounds in the right infraaxillary area

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

5. PLEURA AND PLEURAL CAVITY

6. FIBRINOUS (DRY) PLEURISY

7. DEFINITION
 Inflammation of the pleura characterizedby fibrinous exudation and no
significant degree of effusion.

8. 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).

9.  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.

10. CLINICAL FEATURES
 Pleuritic pain ( sudden , stitching chest pain, increasing with inspiration, coughing
and movements)
In diaphragmatic pleurisy, the pain is referred to the shoulder (via phrenic nerve) or
to the epigastrium and lumbar region ( thru 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

11. • 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

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

13. PNEUMOTHORAX

14. • Pneumothorax is the presence of air outside the lung, within the
pleural space.

15. CLASSIFICATION
1. Spontaneous
 Primary (e.g. rupture of pleural bleb)
Secondary (e.g.TB, COPD)
2. Traumatic
 Iatrogenic (e.g. following thoracic surgery/biopsy) Non-iatrogenic

16.  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.

17. • 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

18. CLINICAL FEATURES
 Symptoms:
 Sudden-onset unilateral chest pain ranging from minimal to severe on
the affected side.
 Dyspnea occur in nearly all patients.
 May present with life-threatening respiratory failure if underlying
diseased lung

19.  Signs:
 If pneumothorax is small : (<15% of a hemithorax), physical findings are
unimpressive.
 If pneumothorax is large: signs of mediastinal shift to opposite side, ↓ed movement,
↓ed tactile fremitus and diminished breath sounds
 Tension pneumothorax should be suspected in the presence of marked tachycardia
and hypotension

20. INVESTIGATION
 Chest X-ray shows the sharply defined edge of the deflated lung with
complete translucency (no lung markings) between this and the chest
wall
 CT Thorax if in doubt
 Investigations aimed at finding the cause (e.g. Pulmonary TB, COPD)

21. PRIMARY SPONTANEOUS
PNEUMOTHORAX
 Incidence and Patient Demographics:
 7.4/100,000/year for males and 1.2/100,000/year for females.
 The male-to-female predominance ranges from 6:1 to 3:1.
 20 and 40 years of age
 Taller and thinner
 Occurs almost exclusively in smokers

22.  Etiology:
 Rupture of subpleural blebs or bullae on the apical portion of the upper lobes
 Airway inflammation secondary to cigarette smoking may contribute to the
development of these blebs
 Other etiologies include abnormalities of connective tissue (e.g.,Marfan’s syndrome)
 Genetic risk factors

23. RECURRENCE:
 Approximately one-half of patients
 Usually occurs within 1 to 2 years after the first episode.
 No predilection for the right or left hemithorax with the initial episode,
75 percent of recurrences occur on the same side as the first
pneumothorax

24.  Treatment:
 Simple aspiration
 If the lung does not expand with aspiration, or if the patient has a recurrent
pneumothorax, thoracoscopy with stapling of blebs and pleural abrasion is indicated.
Thoracoscopy or thoracotomy with pleural abrasion is almost 100% successful in
preventing recurrences.
 Prognosis – death is rare

25. SECONDARY SPONTANEOUS
PNEUMOTHORAX
 Incidence and Patient Demographics:
 6.3/100,000/yr for males and 2.0/100,000/yr for females
 Patients with secondary spontaneous pneumothorax are 15 to 20
years older than patients with primary spontaneous pneumothorax.
 The risks of recurrence vary from 40 to 80 %

26.  Etiology:
 Obstructive lung disease
 Chronic obstructive lung disease (COPD) Asthma
 Interstitial lung disease
 Idiopathic pulmonary fibrosis
 Eosinophillic granuloma
 Lymphangioleiomyomatosis

27.  Infection
 Tuberculosis
 P. jerovici pneumonia
 Acute bacterial pneumonia (i.e. staphylococcus)
 Malignancy
 Primary lung carcinoma Pulmonary metastasis (especially sarcomas)

28.  Connective tissue disease
 Rheumatoid arthritis
 Ankylosing spondylitis
 Other
 Catamenial pneumothorax
 Pulmonary infarction

29. TREATMENT
 Nearly all patients – treated with tube thoracostomy.
 Most should also be treated with thoracoscopy or thoracotomy with the stapling of blebs and
pleural abrasion.
 If the patient not a good operative candidate or refuses surgery, then pleurodesis to be done by
intrapleural injection of sclerosing agent such as doxycycline.

30.  Prognosis:
 In contrast to the low mortality rate in PSP, in patients with SSP, there
is a much higher risk of mortality.

31. TRAUMATIC PNEUMOTHORAX
 Trauma is the most common cause of pneumothorax
 Both penetrating and nonpenetrating chest trauma
 Treatment is tube thoracostomy unless very small. If hemopneumothorax is present,
one chest tube placed in the superior part of the hemithorax to evacuate air, and
another placed in the inferior part of the hemithorax to remove blood.

32. COMPLICATIONS
 TENSION PNEUMOTHORAX
 Is a pneumothorax in which the pressure in the pleural space is
positive throughout the respiratory cycle.
 The mechanism responsible for tension pneumothorax is the disruption
of the parietal pleura in such a manner that a one-way valve happens

33.  Can occur after any type of pneumothorax
 Independent of etiology
 More common after a traumatic pneumothorax, with mechanical ventilation, or during
cardiopulmonary resuscitation

34. CLINICAL PICTURE
 The patient will appear acutely ill - Severe dyspnea, Profuse
diaphoresis and cyanosis
On physical examination:
 Profound hypotension and hypoxemia
 Distended neck veins
 Tracheal deviations to the side opposite, Subcutaneous emphysema
 Unilateral chest hyperinflation.

35.  If tension in pleural space not relieved, pt is likely to die from inadequate cardiac output
or marked hypoxemia
 Large-bore needle inserted into pleural space through 2nd anterior ICS. If large amount
of gas escapes from needle, diagnosis – confirmed.
 Needle to be left in place till thoracostomy tube can be inserted.

36. RE-EXPANSION PULMONARY EDEMA
 Re-expansion pulmonary edema is a rare but potentially lethal
condition that can occur with the rapid re-expansion of a collapsed
lung (after a varied period of time) after tube thoracostomy is used to
drain air (pneumothorax) or fluid (pleural effusion) from the pleural
space.
 Bronchopleural fistula

41. PLEURAL EFFUSION

42. MECHANISMS OF PLEURAL FLUID ACCUMULATION
Increased hydrostatic
pressure in the
microvascular circulation
(heart failure)
Decreased oncotic
pressure in the
microvascular circulation
(severe hypoalbuminemia)
Decreased pressure in the
pleural space (lung
collapse)
Increased permeability of
the microvascular
circulation (pneumonia)
Impaired lymphatic
drainage from the pleural
space (malignant effusion)
Movement of fluid from
the peritoneal space
(ascites)

43. ETIOLOGY
 Transudative Pleural Effusions
 Congestive heart failure
 Cirrhosis
 Peritoneal dialysis
 Nephrotic syndrome
 Superior vena cava obstruction
 Myxedema
 Pulmonary thromboemboli

44.  Exudative pleural effusions:
 Infectious diseases
 Tuberculosis, Bacterial infections, Fungal, Viral, Parasitic
 Neoplasms
 Pulmonary thromboembolization
 Gastrointestinal disease
 Pancreatitis, Esophageal perforation, Intra-abdominal abscesses
 Collagen vascular diseases
 Rheumatoid arthritis, Lupus erythematosus

45.  Drug-induced pleural disease Nitrofurantoin, Amiodarone
 Asbestos exposure
 Chylothorax
 Hemothorax
 Postsurgical
 Sarcoidosis
 Uremic pleuritis
 Yellow nail syndrome

46. CLINICAL FEATURES
 Symptoms
 Many patients have no symptoms referable to the effusion.
 Pleuritic chest pain indicates inflammation of the pleura
 Some patients with pleural effusions experience a dull, aching
chest pain rather than pleuritic chest pain. This symptom is very
suggestive that the patient has pleural malignancy.

47.  The presence of either pleuritic chest pain or dull, aching chest pain indicates that the
parietal pleura is probably involved and that the patient has an exudative pleural
effusion.
 Dry, nonproductive cough. It may be related to pleural inflammation. or lung compression
by the fluid may bring opposing bronchial walls into contact, stimulating the cough reflex.

48.  Dyspnea. A pleural effusion acts as a space- occupying process in the
thoracic cavity and therefore reduces all subdivisions of lung volumes.

49. SIGNS
 Hemithorax will be larger, usual concavity of intercostal spaces – blunted or
even convex
 Tactile fremitus – absent/attenuated (fluid absorbs vibrations emanating from
lung)
 Mediastinal shift ( Trachea and apical impulse shift to opp side)
 Percussion note – dull
 Shifting dullness ( free fluid)
 Auscultation : Decreased/absent breath sounds. Pleural rub +/-

50. CLUES TO ORIGIN ??
 Cardiomegaly, neck vein distension, or peripheral edema(CHF).
 Signs of joint disease or subcutaneous nodules (rheumatoid disease or lupus
erythematosus)
 An enlarged, non-tender nodular liver or the presence of hypertrophic osteoarthropathy
suggests metastatic disease, as do breast masses or the absence of a breast.
 Abdominal tenderness suggests a sub-diaphragmatic process, whereas tense ascites
suggests cirrhosis
 Lymphadenopathy suggests lymphoma, metastatic disease, or sarcoidosis.

51. INVESTIGATIONS
 Chest X-ray:
 Blunting of the sharp costophrenic angle.
 Fluid accumulation between the lung and the diaphragm (subpulmonic effusion) is
suspected if there is apparent elevation of the hemidiaphragm or widening of the
shadow between the gas-containing stomach and the lower left lung margin.

52.  Chest X-ray:
 Up to 300 mL of fluid may fail to be seen on a PA chest radiograph, whereas as little as
150 mL may be seen on a lateral decubitus view.
 A supine film (e.g. in ICU patients) may obscure the diagnosis because the fluid layers
posteriorly.
 A pseudotumor occurs when fluid loculates in an interlobar fissure, a clue to the
diagnosis is the presence of pleural fluid elsewhere and a biconvex lenticular
configuration of the mass.

53.  USG
 CT Thorax
 Pleural aspiration

55. Ultrasound image of the left hemithorax

56. Computed tomography: Bilateral pleural effusions
are present as a result of pneumonia

57. PLEURAL EFFUSION.: A, Blood-stained pleural aspirate. This patient
had pleural metastases from carcinoma of the breast.
B, Chylous pleural effusion. This patient had bronchial carcinoma that
had invaded and obstructed the thoracic duct.
C, Pleural transudate. This pale effusion is typically found in patients
with heart failure or other causes of generalized edema.

60. EMPYEMA
• Is pus in the pleural space
Etiology:
• Empyema is always secondary to infection in a neighbouring
structure, usually the lung. The principal infections liable to
produce empyema are the bacterial pneumonias and TB.

61. • Pathophysiology: parapneumonic pleural effusion
exudative stage
↓
fibropurulent stage
↓
organization stage

62. CLINICAL FEATURES
Symptoms:
• Pyrexia, usually high and remittent
• Rigors, sweating, malaise and weight loss
• Pleural pain
• Breathlessness
• Cough and sputum usually because of underlying
lung disease;
• Copious purulent sputum (bronchopleural fistula)

63. Signs:
• Clinical signs of fluid in the pleural space
• Intercostal tenderness

64. TREATMENT
• Antibiotics OR anti tubercular drugs
• Intercostal tube drainage
• Decortication if gross thickening of the visceral pleura has
developed and is preventing re-expansion of the lung

65. THANK YOU

66. REFERENCES
 Harrisons Textbook of Medicine 20th ed
 Davidsons’ Principles and Practice of Medicine
 Fishman’s Pulmonary Diseases and Disorders 5th ed
 Murray and Nadel’s Textbook of Respiratory Medicine 6th ed