PLEURAL PATHOLOGIES
The Pleura
• The pleura is a serous membrane which
covers the surface of the lung and lines the
inner surface of the chest wall.
• The visceral pleura, over the lung, and the
parietal pleura, over the chest wall.
• The two layers of pleura are closely applied
to each other, being separated by a thin layer
of lubricating pleural fluid.
DISEASES OF THE PLEURA
PLEURAL EFFUSION
• Fluid will accumulate in the pleural space if the rate of its production exceeds
its rate of resorption.
• Pleural Effuion can be transudate, exudate, pus, blood or chyle.
Transudate
• Transudates contain less than 3 g/dl of protein.
• It is often bilateral.
• Causes of transudate are cardiac failure, hypoproteinemia, constrictive pericarditis,
myxoedema.
Exudate
• Exudates contain in excess of 3 g/dl of protein.
• The commonest causes of pleural exudate are bacterial pneumonia, pulmonary
tuberculosis, carcinoma of the lung, metastatic malignancy.
• Less commonly subphrenic infection, connective tissue disorders especially systemic
lupus erythematosus and rheumatoid disease are responsible.
• A purulent pleural effusion is termed an empyema.
Haemothorax
• Presence of blood in the pleural space.
• Bleeding into the pleural space is almost always secondary to open or closed
trauma to the chest.
Chylothorax
• Chylothorax may develop secondary to damage or obstruction of the thoracic
lymphatic vessels.
Radiological Findings :
X Ray :
• Fluid in pleural space can adopt several different appearance on both erect and
supine Chest X-rays.
• On Erect CXR, the commonest appearance is an opaque meniscus at a
costophrenic angle.
• It requires approximately 200 ml of pleural fluid to efface the normal sharp
recess between the diaphragm and the ribs.
• If the effusion is very large, then the entire hemithorax may be opaque and the
heart may be pushed towards the normal side.
On USG
• Ultrasound is an excellent method for locating loculated pleural fluid prior
to diagnostic or therapeutic aspiration.
• It is possible to visualise septations in loculated pleural effusion.
• Transudates are almost always anechoic but exudates may or may not
contain reflective material.
• The presence of pleural masses in association with an effusion is highly
suggestive of malignant disease
Other Patterns Of Pleural Fluid
• Encysted : loculation within a fissure
or elsewhere.
• An encysted effusion is often associated
with free pleural fluid or other pleural
shadowing, and may extend into a
fissure
• Lamellar Effusion : Fluid collection
between the lung surface and the
visceral pleura.
Pleural Thickening
• Pleural thickening usually occurs at one of the two sites :
• At costophrenic angle as a result of a previous pleural infection.
Occasionally it is consequent of haemorrhagic effusion following trauma.
• The appearance of fibrotic blunting of costophrenic angle may be very similar
to small pleural effusion.
• The overall clinical picture or
previous clinical history or a
previous chest X-ray will
usually help to make the
distinction.
• If there is doubt, a lateral
decubitus radiograph or
ultrasound will clarify.
• At Apex of one or both the lungs. The cause
is either old lung infection (tuberculosis) or
due to compression of lung and pleural tissue
by small apical bullae.
• If the apical thickening is unilateral then it
can appear similar to pancoast tumour.
• It is important to visualise the adjacent ribs
and spine because evidence of bone
involvement will almost certainly indicate a
carcinoma.
Pleural plaques
• Plaques are focal areas of thickening of parietal pleura due to previous exposure to
asbestos.
• Characteristically they appear as scattered islands of well circumscribed pleural
densities.
• Plaques are most commonly seen posteriorly and laterally, predominantly affecting
the lower third of the thorax.
• Plaques may be calcified, sometimes extensively.
PLEURAL CALCIFICATION
• Causes of unilateral pleural calcification are :
- Previous Empyema
- Haemothorax
- Pleurisy
• Causes of bilateral pleural calcification are :
- Asbestos exposure
• The calcification associated with
previous pleurisy, empyema or
haemothorax occurs in the visceral
pleura and it is almost always
associated with pleural thickening.
• The calcium may be in a continuous
sheet or in discrete plaques. usually
producing dense, coarse, irregular
shadows.
• The calcification associated with asbestos exposure is usually bilateral.
• It is frequently visible over the diaphragm and adjacent to the axillae.
• The most sensitive method for demonstrating a pleural plaque is high-
resolution CT (HRCT).
PNEUMOTHORAX
• Pneumothorax is the presence of air in the pleural cavity.
• Air enters this cavity through a defect in either the parietal or the visceral
pleura.
• If air can move freely in and out of the pleural space during respiration it is an
open pneumothorax.
• if no movement of air occurs it is closed.
• if air enters the pleural space on inspiration. but does not leave on expiration it
is tension pneumothorax.
Aetiology
• Spontaneous pneumothorax is the commonest type and typically occurs in
young men, due to rupture of a congenital pleural bleb. Such blebs are usually
present in the lung apex and may be bilateral.
• In older patients chronic bronchitis and emphysema are common factors.
• Traumatic pneumothorax may be the result of a penetrating chest wound, closed
chest trauma (particularly rupture of a bronchus in a road accident).
Radiological Findings
• A small pneumothorax in a free pleural
space in an erect patient collects at the
apex.
• The lung apex retracts towards the hilum
and on a frontal chest film the sharp white
line of the visceral pleura will be visible
separated from the chest wall by the
radiolucent pleural space which is devoid
of lung markings.
• The affected lung usually remains aerated: however perfusion is reduced in
proportion to ventilation.
• A large pneumothorax may lead to complete relaxation and retraction of the
lung, with some mediastinal shift toward the normal side, which increases
on expiration.
• Tension pneumothorax may lead to massive displacement of the
mediastinum, kinking of the great veins and acute cardiac and respiratory
embarrassment.
• Hyperexpanded radiolucent left
hemithorax is noted with absent
brochovascular markings.
• Significant widening of intercostal
space.
• Mediastinal shift on contralateral
side.
Supine Chest X-ray
• In supine position the highest part of pleural space is at the lung base under the
inferior surface of the lung.
• Look for : A hyperlucent upper quadrant of the abdomen, because air collecting at
the base of the lung overlies liver.
• Deep Sulcus Sign : A deep and lucent costophrenic angle that extends more
inferiorly than usual.
• A sharply outlined dome of diaphragm. This appearance may be particularly
prominent if there is adjacent lower lobe pulmonary disease.
Pleural Tumours
Benign tumours
• Benign tumours of the pleura include fibroma and lipoma.
• Fibromas are often asymptomatic presenting as an incidental finding
on a chest X-ray.
• They tend to grow slowly and are usually benign, but some show
malignant features.
• The radiographic appearance is of a well-
defined lobulated mass adjacent to the chest
wall, mediastinum, diaphragm or a pleural
fissure.
• The mass may be small or occupy most of
the hemithorax .
• Lipomas appear as well-defined
rounded masses.
• Being soft tumours, they may
change shape with respiration.
• CT scan is diagnostic.
Malignant Tumours
• The commonest malignant disease of the pleura is metastatic, the most
frequent primary tumours being of the bronchus and breast.
• Primary malignancy of the pleura (malignant mesothelioma) is usually
associated with asbestos exposure.
• The latent period between first exposure to asbestos and development
of mesothelioma is typically 20-40 years.
• The usual appearance is nodular
pleural thickening around all or
part of a lung.
• A haemorrhagic pleural effusion
may be present and it can obscure
the pleural masses.
• The extent of malignant
mesothelioma is best assessed by
CT or MRI.
• Features which suggest that pleural thickening is malignant rather than
benign are: thickening that is nodular rather than smooth, pleural
thickening that extends into fissures or over the mediastinal surface.
Pulmonary mass Vs Pleural mass
• Pulmonary mass : Interface between the pleura and the lesion forms an
acute angle.
• Margins are clear and well defined.
• Pleural mass : Interface between the pleura and the lesion forms an obtuse
angle.
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