Pleural diseases

PLEURAL DISEASE

Presenters: Twesiime Enock

Oriba Dan Langoya

Tutor: MR. MWAMBU.T.

OUTLINE

• Anatomy• Physiology• Pneumothorax• Pleural Effusion • Empyema Thoracis• Chylothorax/ Chylous Effusion

PLEURA AND PLEURAL CAVITY

PLEURA AND PLEURAL CAVITY

FIBRINOUS (DRY) PLEURISY

DEFINITION

– Inflammation of the pleura characterized by fibrinous exudation and no significant degree of effusion.

ETIOLOGYA. 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).

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.

CLINICAL FEATURES

• SYMPTOMS:1. Pleuritic pain (sudden, stitching chest pain, increasing with

inspiration, coughing and movements);o In diaphragmatic pleurisy the pain is referred to the shoulder

(through the phrenic nerve) or to the epigastrium and lumbar region (through the lower intercostal nerves).

2. Pleuritic cough – dry, due to irritation of pleura;3. Dyspnea – due to:

o Restriction of respiratory movements;o Underlying lung disease or development of effusion.

4. Specific etiological and general features: fever, headache, and malaise.

CLINICAL FEATURES

• SIGNS:1. Inspectiono Limitation of movements on the affected side.

2. Palpationo Sometimes palpable pleural rub.

3. Percussiono Tenderness .

4. Auscultationo PLEURAL RUB

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

Pneumothorax

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

• 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.

• 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

• In thoracocentesis, a poorly managed chest drain with intermittent build-up of pressure allows air to track into the chest wall through the point where the drain breaches the parietal pleura.

• Other iatrogenic causes; insertion of central line for CVP monitoring, i.v feeding or cardiac pacing,liver biopsy and patients on mechanical ventilation following trauma.

Primary spontaneous pneumothorax

• This is characteristically seen in young people from their mid-teens to late-20s. Mainly males, smokers and the condition runs in families.

• It is due to leaks from small blebs, vesicles or bullae, which may become pedunculated, typically at the apex of the upper lobe or on the upper border of the lower or middle lobes.

• Usually, pneumothorax presents with sharp pleuritic pain and breathlessness.

• Bleeding and tension pneumothorax can occur. If the patient is not in respiratory distress or hypoxia there is no urgency.

Inserting and managing a chest drain

• An intercostal tube connected to an underwater seal is central to the management of chest disease;

• The safest site for insertion of a drain is in the triangle that lies:

-anterior to the mid-axillary line; - above the level of the nipple; - below and lateral to the pectoralis major muscle.This will ideally find the fifth intercostal space.

PLEURAL EFFUSION

DEFINITION

• Abnormal (excessive) accumulation of fluid inside the pleural space.

Pleural Effusion

PLEURAL EFFUSION

ETIOLOGY. PATHOGENESIS

• EXUDATE• TRANSUDATE

The term “pleural effusion”, by general consent, is applied only to serous effusions.

ETIOLOGY. PATHOGENESIS

• EXUDATE – definition -one or more criteria:

oPleural fluid protein to serum protein ratio >0.5oPleural fluid LDH to serum LDH ratio >0.6oPleural fluid LDH value >2/3 upper normal limit for

serum LDH (pleural fluid LDH >200U/L).

Mechanisms: increased permeability of the pleural surface (due to inflammation) or by obstruction of the lymphatic (carcinoma).

ETIOLOGY. PATHOGENESIS• EXUDATE – causes:

– Pneumonia (parapneumonic effusions)– Cancer (especially mediastinal)– Pulmonary embolism– Rheumatic fever– Empyema– Tuberculosis – Conective tissue disease– Viral pleurisy– Acute pancreatitis– Uremia – Chronic atelectasis– Sarcoidosis– Drug-related– Post-myocardial infarction (Dressler`s syndrome)

ETIOLOGY. PATHOGENESIS• TRANSUDATE:

o Pleural fluid protein to serum protein ratio < 0.5o Pleural fluid LDH < 200U/L

Mechanisms:o Increased in hydrostatic pressure (congestive heart failure);o Decreased oncotic pressure (hypoalbuminemia);o Greater negative intrapleural pressure (acute atelectasis).

ETIOLOGY. PATHOGENESIS• TRANSUDATE – causes:

o Congestive heart failure (majority of cases);o Cirrhosis with ascites;oNephrotic syndrome;oMyxedema;oMeigs`s syndrome (right side pleurisy, ascitis, ovarian

cancer);o Acute atelectasis;o Constrictive pericarditis;o Superior vena cava obstruction (mediastinal tumors).

CLINICAL FINDINGS

• SYMPTOMS:– Pleuritic pain, pleural rub, irritative dry cough (a dry

pleurisy often precedes the development of effusion);– Dyspnea (its severity increases with the size of the

effusion);– General symptoms (due to the cause):

• Fever, night sweat, loss of weight, loss of appetite.

CLINICAL FINDINGS• SIGNS:

– INSPECTIONo limitation of movements on the affected side

– PALPATIONo large effusions shift the mediastinum to the opposite side (if it is not

fixed by malignancy)o decreased vocal tactile fremitus

– PERCUSSIONo basal stony dullness rising to the axilla (Damoisseau line)o hyper-resonance above the level of effusion (compensatory emphysema)

– AUSCULTATIONo Absent or reduced breath sounds over the area of the effusiono Bronchial breathing and egophony may be heard over the upper level of

effusion

Physical findings are absent if less than 200-300 ml of pleural fluid is present.

Pleural Effusion

LABORATORY FINDINGS• CHEST X- RAY

– obliteration of the costophrenic angle by a homogenous, intense opacity rising laterally to the axilla;

– mediastinal displacement to the opposite side;– may indicate the possible etiology of the pleurisy

(tuberculosis, lung cancer, lymphoma) showing the primary mediastinal lesion.

Pleural fluid may become trapped (”loculated”) by pleural adhesions, forming unusual collections along the chest wall or in the lung fissures (“pseudotumors”).

LABORATORY FINDINGS• DIAGNOSTIC THORACENTESIS

• Pleural fluid is examined for:• physical,• chemical,• bacteriological,• and cytological

characteristics.

Analysing pleural fluid

• Appearance– Bloody

• (e.g. trauma, malignancy, infection, infarction)– Straw-coloured

• (e.g. cardiac failure, hypoalbuminaemia)– Turbid/Milky

• (e.g. empyema, chylothorax)– Foul smelling

• (Anaerobic empyema)– Viscous

• (e.g. mesothelioma)– Food particles

• (oesophageal rupture)

ASSESSMENT OF PLEURAL FLUID

LABORATORY FINDINGS

• PLEURAL BIOPSY (blind or image guided)– should be considered whenever malignancy or tuberculosis is

accounted in the differential diagnosis of a pleural effusion.• OTHER INVESTIGATIONS

– ultrasonography;– contrast enhanced computed tomography of thorax;– bronchoscopy (if is a high index of suspicion of bronchial

obstruction);– medical/surgical thoracoscopy.

Emmet E. McGrath, Diagnosis of Pleural Effusion: A Systematic Approach, AJJC

POSITIVE DIAGNOSIS• Pleuritic chest pain, dyspnea, pleural rub;• Decreased TVF, stony dullness to percussion,

distant breath sounds, egophony (large effusion);

• Radiographic evidence of pleural effusion;• Etiological diagnosis is based mainly on

thoracentesis and fluid laboratory examination.

DIFFERENTIAL DIAGNOSIS• Basal lung lesions

– Basal consolidation– Collapse

• Subdiaphragmatic diseases– Amoebic liver abscess– Subphrenic abscess

Differentiation between various causes of effusion is based especially upon the laboratory examination of the fluid, in direct relationship with the clinical and imagistic data.

COMPLICATIONS

• Respiratory chronic distress;

• Secondary infection causing empyema;

• Fibrosis – pachypleuritis (fibrous “peel”);

• Permanent lung collapse.

SPECIAL FORMS OF PLEURAL EFFUSION

• Malignant Pleural Effusion:o An effusion developed due to a pleural cancer

(mesothelioma), the pleural surface being directly involved and invaded by malignant cells;

o Pleural fluid cytology or pleural tissue biopsy reveals evidence of malignancy;

o The pleural fluid is hemorrhagic with a rapid reaccumulation.• Paramalignant Pleural Effusion:

o An unapparent cancer or visible but not pleural, the pleural space being not directly invaded by tumor.

MESOTHELIOMA OF PLEURA

SPECIAL FORMS OF PLEURAL EFFUSION

• Parapneumonic Pleural Effusion:o In “uncomplicated” parapneumonic effusion, the pleural fluid

is not infected (the pleural fluid glucose and PH are normal) – usually this effusion solve spontaneously;

o In “complicated” parapneumonic effusion, pleural fluid is either frank empyema or has the potential to organize into a fibrous “peel”;

o Tube thoracostomy is required for parapneumonic effusion if any of the following is present:o The fluid resembles frank pus;o Pleural fluid glucose is < 40 mg/dl;o Pleural fluid PH is < 7.2.

o A pneumonic effusion that does not respond to drainage within 24 hours may have become loculated.

CHARACTERISTICS OF PARAPNEUMONIC PLEURAL EFFUSION

BTS guidelines for the management of pleural infection, Thorax 2003

OTHER MAJOR TYPES OF PLEURAL EFFUSION

• EMPYEMAo Is an exudative pleural effusion caused by direct

infection (usually bacterial) of the pleural space (frank pus pleural fluid);

o The main causes: bacterial pneumonia and lung abscess;

o Pleural fluid PH < 7.2;oMilky in appearance pleural fluid, clearing the

supernatant after centrifugation.

OTHER MAJOR TYPES OF PLEURAL EFFUSION

• HEMOTHORAXo Is the presence of frank blood in the pleural space;o If the hematocrit of pleural fluid is more than 50%

of the hematocrit of peripheral blood, hemothorax is present;

o Causes: chest trauma, cancer, or pulmonary embolism (less commonly).

HEMOTHORAX

OTHER MAJOR TYPES OF PLEURAL EFFUSION

• CHYLOUS PLEURAL EFFUSIONo Occurs in chylothorax as a result of disruption of the thoracic

duct, traumatically or by cancer invasion;o The pleural fluid is turbid post centrifugation;o Triglyceride > 110 mg/dl.

CHYLOTHORAX

PROGNOSIS

• Depends on the etiology and the prognosis of the underlying disease:o In malignant pleural effusion – the prognosis is poor;o The rheumatic fever or viral pleural effusions have

usually a better prognosis, often solving spontaneously.

TREATMENT• Treatment of the underlying medical condition

that is causing pleural effusion;• Thoracentesis (therapeutic and diagnostic)• Tube Thoracostomy (Chest Tube)• Pleural Catheter (for reoccurring pleural effusion )• Pleural Sclerosis (Pleurodesis) - Doxycycline or talc • Surgery

– Video-assisted thoracoscopic surgery (VATS) – Thoracotomy

ANTIBIOTICS

• If are indicated should be guided by bacterial culture results.

• Where cultures are negative, antibiotics should cover community acquired bacterial pathogens and anaerobic organisms.

• Hospital acquired empyema requires broader spectrum antibiotic cover.

ANTIBIOTIC REGIMENS FOR THE INITIAL TREATMENT OF CULTURE NEGATIVE PLEURAL INFECTION

BTS guidelines for the management of pleural infection, Thorax 2003

THERAPEUTIC THORACENTESIS• Any pleural effusion large enough to cause severe respiratory

symptoms should be drained regardless of the cause and regardless of concomitant disease-specific treatment.

• Relief of symptoms is the main goal of therapeutic drainage in these patients.

• Absolute contraindication - active cutaneous infection at the puncture site.

• Relative contraindications include: severe bleeding diathesis, systemic anticoagulation, and a small volume of fluid.

• Possible complications: bleeding, pneumothorax, infections, laceration of intra-abdominal organs, hypotension, and pulmonary edema.

TUBE THORACOSTOMY (CHEST TUBE)

• Tube thoracostomy allows continuous, large volume drainage of air or liquid from the pleural space.

• Specific indications:– spontaneous or iatrogenic pneumothorax;– hemothorax;– penetrating chest trauma;– complicated parapneumonic effusion or empyema;– chylothorax;– pleurodesis of symptomatic pleural effusions.

Chest computed tomographic scan with a “split pleural sign” (arrow),seen in empyema. This patient needed drainage with tube thoracostomy.

PLEURAL SCLEROSIS• is considered for patients with uncontrolled

and recurrent symptomatic malignant effusions, and rarely, in cases of benign effusions after failure of medical treatment.

• a sclerosing agent (talc, doxycycline, or tetracycline) is instilled into the pleural cavity via a tube thoracostomy to produce a chemical serositis and subsequent fibrosis of the pleura.

VIDEO-ASSISTED THORACOSCOPIC SURGERY (VATS) • is very useful in managing incompletely

drained parapneumonic effusions.

• with thoracoscopy, the loculi in the pleura can be disrupted, the pleural space can be completely drained, and the chest tube can be optimally placed.

THORACOTOMY

• In cases of empyema with uncontrolled sepsis or progression to the fibroproliferative phase a full thoracotomy with decortication is performed with removal of all the fibrous tissue and evacuation of all the pus from the pleural space.