Diseases of pleura

Pleural cavity
Pleural space
 Diseases of pleura

• Inflammation = pleurisy
• Pneumothorax
• Tumor (primary and
secondary)
 PATHOPHYSIOLOGY

• Transudate:
• increase in hydrostatic pressure and/or reduction in
plasma oncotic pressure.
• pleura usually remains normal.

• Exudate:
• various pathologic condition in pleura, resulting in
increased vascular permeability and/or impaired fluid
reabsorption(e.g. lymphatic obstruction).

• Extrapleural sources:
• Transdiaphragmatic migration of peritoneal fluid;
• Abnormal communication between pleural cavity and the
thoracic duct (chylothorax)
 Epidemic pleurodynia (Bornholm’s
disease)
• Any age but more in children
• Enterovirus (Coxacie B also?)
• Severe, intermittent pain of pleuritic type
• begins suddenly in the epigastrium, abdomen, or lower
anterior chest
• Fever, headache, sore throat, malaise
• involved truncal muscles may become swollen and
tender.
• subside in 2 to 4 days, may reoccur within a few days
and persist or recur for several weeks.
 Pleural effusion
An accumulation of fluid between the
layers of the membrane lining the lung
and the chest cavity
Can be of inflammatory (excudate),
non-inflammatory (transsudate) and
neoplastic (primary=mesothelioma and
secondary=metastatic) origin
 Pathophysiologic Principles
• Pleural fluid produced from systemic
capillaries at parietal pleura – absorbed
into pulmonary capillaries at visceral
pleura.
• Fluid governed by Starlings law –
difference between hydrostatic pressure of
systemic and pulmonic circulations
• When influx exceeds outflux, effusion
develops 10
 ANATOMY

Sheep lung
Clinics in chest medicine
2006
 HISTOLOGY

Clinics in chest medicine 2006

 PHYSIOLOGY OF PLEURAL SPACE

•The pleural cavity contains

a small amount of pleural
fluid (<10ml in a 70 kg man)
•Normal rate of production is
app. 17ml/day
•Estimated maximal
absorptive capacity of 0.2-
0.3ml/kg/hr into the lymphatic
channels
• 2. Pleural effusion syndrome:
Symptomes
• Chest pain of pleuritic type; then - heaviness
(fluid is more and more accumulated)
• Dyspnoe of inspiratory type
Physical examination
• Percussion: dull
• Auscultation: diminished/absent breath sounds
X-ray
• Small fluid: blunting of costo-phrenic angle
• Larger volume (>300 ml):homogenous
shadow
Pleural effusion
Pleural effusion
Pleural effusion
Pulmonary embolism
 Transudative Pleural Effusions
• Transudates – ultrafiltrates of plasma with
little protein
• Due to increases in hydrostatic pressure
• Primary cause is CHF (90%)
• Cirrhosis and nephrotic syndrome are
remaining primary causes (although also
have hypoproteinemia)

19
 Causes of transudates
■ Congestive heart failure
■ Cirrhosis with ascites
■ Nephrotic Syndrome
■ Hypoalbuminemia
■ Hypothyrosis (myxedema)
■ Peritoneal dialysis
■ Superior vena cava obstruction
■ Coronary artery bypass surgery
■ Pulmonary embolism (transudate + excudate)
20
• CHF: increases of capillary wedge pressure
• Low serum albumin: decreased oncotic
pressure in microvessels
• Fibrosis: impaired lymphatic drainage from
pleural space
 Excudate pathophysiology

• Inflammation/mediators: ↑
permeability of capillars
• Pneumonia: Occlusion of parietal
pleura communications with fibrin,
debris and mesothelial swellings
• Malignancy: production of fluid by
malignant mesothelial or metastatic
cells
 Exudative Pleural Effusions
■ Contain high amounts of protein
■ Reflect an abnormality of the pleura itself
(increased membrane permeability or lymphatic
drainage)
■ Any pulmonary or pleural process may result in
exudate
■ Parapneumonic effusion is most common
■ Massive effusions (1/5-2 L) generally due to
malignancy

23
 Causes of Pleural Effusions
■Exudates
■ Infections
■ Bacterial pneumonia
■ Lung abscess
■ Tuberculosis
■ Viral illness
■ Subphrenic abscess
24
 Non-infectious causes
Autoimmune inflammation (SLE, scleroderma,
rheumatoid arthritis, post-infarction Dressler
syndrome, DRESS syndrome etc)

Malignancy (mesothelioma, metastases)

Pulmonary embolism (excudate+transsudate due to

hypoxia and shift to lactate metabolism in the affected
zone leading to increased capillaries permeability)
 Other non-infectious causes
■
■ Abdominal/Gastrointestinal Disorders
■ Pancreatitis (injury by pancreatic enzymes coming
by lymphatic system)
■ Esophageal rupture
■ Abdominal surgery
■ Miscellaneous
■ Uremia (injury by uremic toxins)
■ Postpartum
■ Chylothorax (trauma or metastatic injury of
thoracic duct or lymphatic vessels,
lymphangioleiomyomatosis)
26
 Clinical manifestations
• Small pleural effusions – often asymptomatic
• Leading syndrome is the pleural chest pain
• As fluid accumulates, heaviness appear together
with squeezing syndrome (vena cava superior
congestion, cough due to trachea pressure)
• Large effusion (> 500 ml) dyspnea on exertion
or rest
• Acute pleuritic pain – think pleurisy or
pulmonary infarction
 Physical signs
• Depend on size of effusion
• Often dominated or obscured by underlying
disease process
• Classic Physical Findings
– Diminished breath sounds
– Dullness to percussion
– Decreased tactile fremitus
– Sometimes a localized pleural friction rub
– With massive effusions – may see signs of
mediastinal shift
28
 Clinical Features of Pleural
Effusion – X-Ray Findings
• Classic finding – blunting of the costophrenic
angle in upright chest
• 250-500 ml of fluid necessary to visualize on AP
or PA CXR
• < 250 ml – possibility to view on lateral upright
• >500 ml – obscured hemidiaphram with upright
meniscus
• Massive effusion – total hemithoracic
opacification

30
 Loculated effusion

Effusion localized between

adhezions
In almost all cases is the result of
empyema
 Clinical Features of Pleural
Effusion – X-Ray Findings
• Recumbent Patients
– Pleural fluid gravitates superiorly, laterally, and
posteriorly
– Large effusion may show diffuse haziness
– Cross table lateral in supine position – posterior
layering of effusion
– Lateral decubitus (better) for detection of small
effusions
– Lateral decubitus w/slight Trendelenburg (best) can
show as little as 5-15 ml pleural fluid

41
!!! Dif.diagnosis with diaphragm
relaxation
 INDICATIONS FOR DIAGNOSTIC
THORACENTHESIS

• Presence of a clinically
significant pleural effusion of
unknown cause.
> 10mm thick on US or Lateral decub. CXR

• Unilateral Pleural effusion.

• Effusion persists for > 3 days
 Thoracocentesis
Definition: A procedure to remove fluid from the
space between the lungs and the wall of the
chest.
How to prepare for the test: No special preparation
is needed before the procedure. A chest X-ray is
may be performed before and after the test. Do not
cough, breathe deeply, or move during the test to
avoid injury to the lung.
Risks: pneumothorax, fluid re-accumulation,
pulmonary edema, bleeding,infection, and
respiratory distress.
Thoracocentesis
Ultrasonic control of the procedure
 Pleural effusion: analysis
• Quantity
• Quality: color, density, opacity
• Lab. analysis
– Chemical
– Cytological
– Bacteriological: culture
• Spec
• Aspec.
 Lab. analysis of pleural effussion
Exsudate Transudate
3%↑ protein 3%↓
+ Rivalta -
0.5 ↑ Protein in pl. eff./ 0.5 ↓
Se protein
0.6 ↑ LDH in pl.eff/Se 0.6 ↓
LDH
1014 ↑ Specific gravity 1014 ↓

inflammation Cause ↑ syst./pulm.

venous pressure
 Common features of Exudative Effusion
Tuberculosis Unilateral; lymphocytic
Lung cancer Bloody, large, parenchymal lesion on
the X-ray, rapid accumulation
Pneumonia neutrophilic
i

Pulm. Infarction RBC

Lymphoma lymphocytes, atypical cells
Metastatic tumor Large, rapidly accumilates; RBC,
atypical cells
Mesothelioma RBC, atypical cells, rapid
accumulation
Trauma RBC, case history
PARAPNEUMONIC EFFUSIONS

Exudative

Fibropuru-
lent

Organized/
Fibrous
 Common Causes of Transudative
Effusion
Congestive Bilateral; case history
heart failure

Cirrhosis Ascites, protein low, usually on the right

side

Nephrotic Hypoproteinaemia,
syndrome Generalized oedema, ascites; urine
analysis changes
Hypothyrosis very viscous fluid with minimum cells
 Medications associated with pleural effusions

Medication Comment
Nitrofurantoin Pleural effusion: 25% of cases
CXR with B/L interstitial infiltrates

Methylsergide B/L pleural effusions in 50% of cases

Dantrolene Similar to nitrofurantoin

Bromocriptine B/L pleural effusions and pleural
thickening
Procarbazine B/L pleural effusions and infiltrates. Rare

Amiodarone Pulmonary infiltrate more common than

effusions
 CHYLOTHORAX

Mechanism:
1. Disruption of thoracic duct: Large amounts of
cholesterol or lecithin globulin complexes
accumulate to produce pseudochylothorax.
2. Traumatic: Secondary to cardiac surgery,
penetrating injuries.
3. Tumors: Lymphomas, pulmonary
lymphangiomyomatosis, filariasis, lymphangitis
of the thoracic duct.
4. Idiopathic.
 CHYLOTHORAX

• Large pleural effusion, no odor, no chest

pain

• Triglycerides > 110mg/dl; 50-110 mg/dl,

lipoprotein analysis; + chylomicrons
diagnostic < 50 mg/dl R/O chylothorax.

• Repeat thoracenthesis leads to

 CHYLOTHRAX
TREATMENT

• Pleuroperitoneal shunt
• Surgical exploration with ligation of the
thoracic duct.
• Radiation therapy.
• Chemical pleurodesis.
• Empyema = pus in the pleural space
– Causes:bacteria: Streptococcus pneumoniae,
Staphylococcus aureus, Klebsiella pn, E. Coli, Mycobact. Tb,
anaerobic bact.
– Risk factors: alcoholism, drug use, HIV infection, neoplasm,
pre-existent pulmonary disease
– Appear: as the complication of bacterial pneumonia,
subdiaphragmatic abscess, oesophageal perforation, following
thoracic surgery
–
 Clinical manifestations of
empyema
Intoxication - intermittent fever,
perspiration, weight loss if long time
intensive pleural pain
physical signs of excudative pleurisy
Possible loculated effusions (more
likely as an outcome)
 Empyema diagnosis

– WBC, neutrophils increase with left shift

– ESR, CRP
– Thoracocentesis: pus!
Empyema
 Treatment

broad spectrum antibiotics

drainage
surgery
Chest tube drainage
Fistulae
Pneumothorax
 II. Pneumothorax

• Air in the pleural space causing partial or complete

lung collapse.
• It can occur spontaneously or result from trauma or
medical procedures.
• Diagnosis is based on clinical criteria and chest x-
ray.
• Symptomes: chest pain, dyspnoe depending on the
size of pneumothorax
• Physical signs
– Percussion note:Hyperresonance
– Breath sounds: diminished/absent
Potential causes of pneumothorax
• Air: from the • Air: outside the
airways chest wall
– Idiopathic – Trauma
– Rupture of – Thoracocentesis,
oesophagus pleural biopsy, TTB
– COPD
– Insertion of venous
– IPF
catheter
– Any cystic or
– Acupuncture
cavitary lesion
 Spontaneous Pneumothorax
Spontaneous pneumothorax – occurs in the
absence of any precipitating factor (traumatic or
iatrogenic
• Primary spontaneous pneumothorax – no
clinically apparent lung disease
• Secondary spontaneous pneumothorax –
underlying pulmonary disease

68
 Primary Spontaneous
Pneumothorax
• 15/100,000/year for men
• 5/100,000/year for women
• Generally young men of taller than average height
• Cigarette smoking and changes in ambient
pressure associated factors
• Marfan’s Syndrome and Mitral Valve Prolapse
higher frequency
• Unrelated to physical exertion

69
 Secondary Spontaneous
Pneumothorax
■ 1/3rd of all pneumothoraces
■ Incidence is three times higher in men
■ High association with COPD (incidence of 0.8%
in hospitalized patients), cavitary and cystic
lesions
■ Occurs in 2% of patients with HIV/AIDS,
generally in setting of Pneumocystis carinii
pneumonia
■ In any patient with cancer, pulmonary metastasis
likely
70
 Causes of Secondary
Pneumothorax
■ Airway Disease
■ COPD
■ Asthma
■ Cystic fibrosis
■ Infections
■ Necrotizing bacterial pneumonia/lung abscess
■ Pneumocystis carinii pneumonia
■ Tuberculosis
■ Interstitial Lung Disease
■ Sarcoidosis
■ Idiopathic pulmonary fibrosis
■ Lymphoangiomyomatosis
■ Tuberous sclerosis
■ Pneumoconiosis 71
 Causes of Secondary
Pneumothorax
■ Neoplasms
■ Primary lung cancers
■ Pulmonary/pleural metastasis
■ Miscellaneous
■ Connective tissue diseases
■ Pulmonary infarction
■ Endometriosis/catamenial pneumothorax

72
 Catamenial Pneumothorax
■ Rarely seen but hypothesized pathophysiology is
rather groovy
■ Recurrent spontaneous pneumothorax occurs in
association with menses (generally within 72
hours)
■ Also known as thoracic endometriosis syndrome
■ Exact etiology unknown, but often responds to
ovulation suppressing medications

73
 Clinical Features of
Pneumothorax - Symptoms
■ Ipsilateral chest pain and dyspnea
■ Symptoms generally begin suddenly and
while at rest
■ Pain worsens w/inspiration
■ Mild dyspnea, but extreme dyspnea
uncommon (unless tension or underlying
lung disease)

74
Pneumothorax - General Physical
Findings
• Physical findings correlate with degree of symptoms and
size
• Mild sinus tachycardia
• Decreased or absence breath sounds
• Hyperresonance to percussion
• Unilateral enlargement of the hemithorax
• Decreased excursions with respirations
• Absent tactile fremitus
• Inferior displacement of the liver or spleen
• NOTE – Absence of all or any of these does not exclude
pneumothorax (always do a chest x-ray if you’re remotely
thinking of this diagnosis)
75
 Tension PTX
A tension PTX is a life-threatening condition that
requires immediate intervention.

Causes: penetrating chest injuries, fractures of the

trachea or bronchi, a ruptured esophagus, the
presence of an occlusive dressing over an open
PTX, and PPV.
 Symptoms
Pain syndrome - pleural pain
Physical manifestations of “air in pleural
cavity syndrome” (hyperresonant sound,
no respiration) with mediastenum and
trachea displacement to the healthy side
Increasing respiratory failure due to lung
compression by increasing air volume
Shock due to squeezing of major vessels,
mediastenum displacement
Tension ptx X-ray

Deviation of the
trachea away from the
side of the tension.
Shift of the
mediastinum.
Depression of the
hemi-diaphragm
Pneumothorax
Pneumothorax
 Management –
Tension Pneumothorax
• One of our true emergency diagnoses where rapid
recognition and treat truly can make a difference
• Condition worsens with each passing moment and each
additional breath
• Do not delay treating for x-ray
• Decompress immediately – whether needle or tube
depends on your skills set and where you’re at
• Needle thoracostomy is not definitive – always needs to be
followed by prompt tube thoracostomy.

86
 Tension PTX therapy
Don’t forget: Life-threatening condition!

Emergent chest decompression with needle thoracostomy.

A 14-16G intravenous cannula is inserted into the second rib space
in the mid-clavicular line.
The needle is advanced until air can be aspirated into a syringe connected to the
needle.
Later : Constant tube drainage
 Management –
Spontaneous Pneumothorax
■ Primary spontaneous pneumothorax
greater than 20%
■ IV catheter aspiration or chest tube drainage
■ IV catheter
■ Low morbidity, cost savings lack of invasiveness
■ Success rates of 45-70%
■ Observe for 6 hrs and DC
■ If failure, may attach catheter to water seal
device, or go to chest tube drainage

88
 Pneumothorax Management -
Tube Thoracostomy
■ Widely used and treatment of choice in
many circumstances
■ Indicated for:
■ Large primary spontaneous pneumothoraces
■ Secondary spontaneous pneumothoraces
■ All tension pneumothoraces
■ All patients likely to need ventilation

89
Ptx tube drainage
 III. Pleural tumors
Primary: malignant Metastatic pleural tumor
mesothelioma
Asbestosis as a preceding condition
 Asbestosis vs mesothelioma
(difficult to diff at early stage)
asbestosis mesothelioma
Benign asbestosis lesions
Benign asbestosis calcifications
asbestosis mesothelioma
Advanced: typical massive
hemorrhagic effusions
 III. Pleural tumors
•
Localised form: solitary growth on pleural surface (can
be resected at early stage)

Diffuse mesothelioma: Malignant , aggressive tumour

originating in the serosal membranes that line the
thoracic and abdominal cavities.

Symptomes: Chest pain, especially when taking a deep

breath, Cough, General discomfort, uneasiness, or ill
feeling (malaise), Shortness of breath, Weight loss
• Diagnosis:

– Chest X-ray: rapidly reproducated

pleural effusion
– CT scan of the chest; PET scan
– Thoracentesis: Pleural fluid analysis:
cytology, histology,
immunhistochemistry
– Open pleural biopsy
– Pleural needle biopsy
locacized
Advanced
PET scan
Adenocar
cinoma
 Metastatic pleural tumor
• Metastatic tumor: malignant pleural effusion caused by
primery tumor of the body: breast c., lung c., ovarian
cancer, kidney c,
• Symptomes: symptomes of pleural effusion+symptomes of
primary tumor
• Pleural fluid reproduction is rapid
• Diagnosis: Anamnesis! X-ray, ultrasonography, CT, lab.
– Thoracocentesis: cytology, histology, immunhistochemistry
• Therapy: therapy of primary tumor + palliative care
(thoracocentesis, pleurodesis, painkiller)
 Malignant
nodules

Breast
cancer
 MESOTHELIOMA

• Rare neoplasm that commonly arises from

the mesothelial surfaces of the pleural
cavity.
• Extremely poor prognosis
• The median survival: 4-13 months for
untreated patients, 6-18 months for
treated patients.
• There are limited data from randomized
trials.
• Treatment recommendations are
somewhat empiric.
 Mesothelioma therapy
• Surgery: Depending on the location and stage of the cancer, and the
health of the patient, tumors may be able to be removed through
surgery.
• Chemotherapy: pemetrexed
• Radiation therapy: One of the oldest mesothelioma treatments,
radiation techniques can target and shrink tumors to make other
treatments more effective.
• Experimental Treatment: Clinical trials that test newer therapies like
immunotherapy can prove effective if other options are exhausted.
• Palliative Treatment: Additional techniques and therapies can treat
the symptoms of mesothelioma to help ease patient pain and
suffering.: painkiller, thoracocentesis, pleurodesis, tube drainage
 THERAPEUTIC APPROACH
1 Year 3 Year 5 Year Median
% % % (months)

Thoracotomy 41 0 - 7

Pleurectomy 38 24 - 8.8

EPP 39 16 11 10.2

Medical 24 0 - 5.8

EPP: Extrapleural
 SCLEROSING AGENT
MALIGNANT PLEURAL EFFUSIONS
Walker-Renard PB Ann Internal Med 1994;120(1):56-64

Sclerosing agent Success rate

n/n(%)
Bleomycin 108/199(54%)

Tetracycline 240/359(67%)

Doxycycline 43/60(72%)

Minocycline 6/7(86%)