Pleural disease

Department of Pulmonary Medicine
PLEURAL DISEASES
Dr. Rahul Magazine
M.D. (Medicine), D.T.C.D.

ANATOMY
• The pleura is the serous membrane that
covers the lung parenchyma (visceral
pleura) , the mediastinum, the diaphragm,
and the rib cage (parietal pleura).
• visceral pleura: blood supply from low-
pressure pulmonary circulation, and has
no sensory nerves
• parietal pleura: from the systemic
circulation and contains sensory nerves

PHYSIOLOGY
The two layers of the pleura are separated
by a virtual cavity, which is lubricated by 5 to
10 mL of fluid, facilitates lung expansion,
and helps maintain lung inflation by coupling
the lungs with the chest wall.

PNEUMOTHORAX

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

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

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.

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)

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-to-1 to 3-to-1.
– 20 and 40 years of age
– taller and thinner
– Occurs almost exclusively in smokers

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

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.

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 rare

Secondary Spontaneous
Pneumothorax
Incidence and Patient Demographics:
• 6.3/100,000/year for males and
2.0/100,000/year 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 %

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

• Infection
Tuberculosis
P. jerovici pneumonia
Acute bacterial pneumonia (i.e.
staphylococcus)
• Malignancy
Primary lung carcinoma
Pulmonary metastasis (especially
sarcomas)Department of Pulmonary Medicine

• Connective tissue disease
Rheumatoid arthritis
Ankylosing spondylitis
• Other
Catamenial pneumothorax
Pulmonary infarction

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.

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

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.

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
visceral or parietal pleura in such a
manner that a one-way valve develops.

• A tension pneumothorax can occur after any
type of pneumothorax; it is independent of the
etiology. It can sometimes occur after a
spontaneous pneumothorax but is more
common after a traumatic pneumothorax,
with mechanical ventilation, or during
cardiopulmonary resuscitation.

• Clinical picture:
The patient will appear acutely ill
Severe dyspnea, Profuse diaphoresis
Cyanosis
On physical examination:
Profound hypotension and hypoxemia
Distended neck veins
Tracheal deviations to the side opposite,
Subcutaneous emphysema
Unilateral chest hyperinflation.

• If the tension in the pleural space is not
relieved, the patient is likely to die from
inadequate cardiac output or marked
hypoxemia.
• A large-bore needle should be inserted into
the pleural space through the second anterior
intercostal space. If large amounts of gas
escape from the needle, the diagnosis is
confirmed. The needle should be left in place
until a thoracostomy tube can be inserted.

Re-expansion Pulmonary Edema:
• Re-expansion pulmonary edema is a rare
but potentially lethal condition that can
occur with the rapid reexpansion 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

PLEURAL EFFUSION

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)

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

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

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

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.

• 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.

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

Signs
• Hemithorax will be larger, and the usual
concavity of the intercostal spaces will be
blunted or even convex
• Tactile fremitus is absent or attenuated
because the fluid absorbs the vibrations
emanating from the lung.
• Medisatinal Shift (Tracheal and apical
impulse shift to opposite side)

• Percussion note is dull
• Shifting dullness (free fluid)
• Auscultation: reveals decreased or absent
breath sounds. Sometimes pleural rub

Clues to the origin are often present elsewhere.
• Cardiomegaly, neck vein distension, or
peripheral edema(CHF).
• Signs of joint disease or subcutaneous
nodules (rheumatoid disease or lupus
erythematosus).
• An enlarged, nontender 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
subdiaphragmatic process, whereas tense
ascites suggests cirrhosis
• Lymphadenopathy suggests lymphoma,
metastatic disease, or sarcoidosis.

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.

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.

• USG
• CT Thorax
• Pleural aspiration

Ultrasound image of the left hemithorax

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

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.

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.

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

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)

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

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

THANK YOU

Pleural disease

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