Pleural diseases include pleural effusions, pneumothorax, and mesothelioma. Pleural effusions are abnormal fluid accumulations in the pleural space that can result from increased fluid production, decreased lymphatic drainage, infection, or bleeding. Evaluation involves symptoms, chest x-ray, ultrasound, and thoracentesis. Treatment depends on whether the effusion is transudative or exudative. Pneumothorax is the presence of air in the pleural space and can be caused by trauma, lung blebs, or underlying lung disease. Tension pneumothorax is life-threatening due to increased intra-pleural pressure. Management involves chest tube drainage or surgery depending on the situation

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