Download PLEURAL DISEASE

PLEURAL DISEASE
Sevda Özdoğan MD,
Chest Diseases
 Pleural
effusions
 Emphyema
 Pleural malignancy
 Hemothorax
 Pneumothorax
Pleural Anatomy and Physiology
 Pleura
is a serous membrane formed from
mesenchyme that separates the lung
paranchym, mediastinum, diaphragm and
thoracic cage
 It


is composed of 2 layers as:
Parietal pleura
Visceral pleura
Pleural Cavity
 It
is the space between the visseral and
parietal pleura
 Normally contains a small amount of fluid
(10-20 ml in each pleural cavity)
 This pleural fluid is mainly produced by the
parietal pleural surface and reabsorbed by
the two layers (Mainly parietal pleura)
 The
production and reabsorbtion of the
pleural fluid is normaly in an equilibrium
accounted primarily by the forces
employed in Starling equation:
F=k[(Pcap-Ppl)-δ(πcap- πpl)]
F: The rate of fluid movement
P, π: Hydrostatic and oncotic pressures
k: The filtration coefficient
δ: Osmotic reflection coefficient
Pleural Effusion
 If
the physiologic balance between the
filtration and the drainage of the pleural
fluid is disturbed, pleural effusion
accumulate.
 Fluid
may accumulate in the pleural space
in response to the disease of the pleural
membranes or as a manifestation of a
systemic illness
The Mechanisms of Pleural
Effusion
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Increased hydrostatic pressure (Cardiac failure,
increased atrial pressure)
Decreased oncotic pressure (Protein deficiency)
Decreased pleural cavity negative pressure
(Atelectasis)
Increased permeability in microvascular
circulation (İnfections, inflammation)
Impaired lymphatic drainage of pleural space
(Tumor, fibrosis)
Transperitoneal route (Congenital defects,
ascite)
Symptoms
 Chest

pain (inspiratory)
Decreases when the fluid increases
 Dyspnea
 Cough
 Symptoms




of the underlying disease
Fever
Hemoptysis
Weight loss
...
Physical Examination
 No
physical signs can be detected when
the fluid is less than 300 ml
 İnspection


İncreased size of the affected hemithorax
Trachea is deviated away from the diseased
side

Palpation



Percussion


İpsilateral restriction of
chest wall motion
VT absent
Dullness (>300-400 ml)
Oscultation

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
Diminished breath sounds
or inaudible
Pleural friction rub
Bronchial sound over the
fluid level
Radiology

The fluid initially accumulates in the more
dependent recesses of the thoracic cavity
forming a Damoiseau Line
 200-300 ml of pleural effusion can be detected
on standard chest radiograph as blunting of the
costophrenic angle

Massive pleural fluid
often shifts the
mediastinum to the
opposite side

Unusual localized
pleural effusions can
be seen due to the
localized obliteration
of the pleural space
often by inflammatory
conditions
(adherence)
 Smaller
amounts of pleural fluid can be
detected on lateral decubitus radiography
as the free intrapleural fluid moves from
top of the diaphragm to the dependent
chest wall
Pleural effusion in a lateral decubitus
radiograph
 Ultrasound
is able to demonstrate smaller
amounts of fluid as 100 ml
 CT
has similar sensitivity to ultrasound,
not routine but can be performed to
evaluate concomitant paranchymal lesions
 CT
is sensitive in identifying pleural
thickening and calcification
Thoracenthesis and Pleural Fluid analysis
 Appereance

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Serous (light to dark yellow, clear)
Serosangineous (Blood tinged can be due to
thoracentesis itself)
Hemorrhagic (hemothorax if hct>50% of blood
hct)
Purulent (fetid odor in unaerobic infections)
Chylous (milky)
 Biochemical



evaluation
Exudative
Transudative
Some special hints
 Microbiological


evaluation
Cellular structure
Special stains and culture
 Cytologic
evaluation
Biochemical Evaluation

Routine

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
pH
Glucose
Lactate
dehydrogenase
Total protein
Albumine

Optional
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Htc
Cholesterol
Trigliserid
Bilirubine
Adenosin deaminase
Amylase
RF
LE cell
ANA
Hyaluronic ascite
Biochemical Evaluation

Exudate

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Dark yellow color
Total protein >3 gr/dl
Density >1016
Light Criteria:
• Protein pl/s >0.5
• LDH pl/s
>0.6
• LDH >200 or >2/3 of
normal upper value of
serum

Transudate
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
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Light yellow color
Total protein <3 gr/dl
Density <1016
Light Criteria:
• Protein pl/s
• LDH pl/s
• LDH <200
<0.5
<0.6
 Albumine



Gradient:
Serum albumine- Pleural fluid albumine
<1.2 gr/dl
Eksudate
>1.2 gr/dl
Transudate
 Pleural
Cholesterol >60 mg/dl: Eksudate
 Pl/S bilirubine >0.6:
Exudate

Transudative Pl. Eff.

Increased hydrostatic
pressure
•
•
•
•

Congestive heart failure
Constrictive pericarditis
Pericardial effusion
Pulmonary thromboemboli
Increased capillary
permeability
• Myxedema
• Pulmonary thromboemboli

Exudative Pl. Eff.

Transperitoneal transport
• Peritoneal dialysis
• Ascites
Infectious diseases
•
•
•
•

Decreased oncotic
pressure
• Cirrhosis
• Nephyrotic syndrome
• Malnutrition


Pnomonia, lung abscess
Tuberculosis
Fungal infections
Subphrenic abscess
Neoplastic diseases
• Metastatic
• Mesothelioma
• Lymphoma

Immunologic reactions
•
•
•
•
•
Dressler syndrome
Sistemic Lupus Er.
Rheumatoid artritis
Churg strauss syndrome
Wegener granulomatosis

Exudative Pl Eff

Gastrointestinal
disease
• Pancreatitis
• Causes of peritoneal
exuda

Drug induced
•
•
•
•
•
•
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Nitrofurantoin
Dantrolene
Methysergide
Bromocriptine
Procarbasine
Amiodorone
Postsurgical
Pulmonary
thromboembolism

Exudative Pl Eff

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Sarcoidosis
Uremic pleuritis
Asbestos exposure
Chylothorax
Hemothorax
 If
the effusion is transudative the main
cause should be treated
 If the effusion is exudative and not
emphyema further diagnostic procedures
should be considered
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Cytologic examination
Closed pleural needle biopsy
Thoracoscopy (VATS)
Thoracotomy
Special characteristics:
Milky appearance

Chylothorax
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Triglyceride >110
mg/dl
Pl TG/sTG>1
Cholesterol crystal (-)
Pl Ch/s Ch<1
Chylomicrons (+)

Pseudochylothorax
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Triglyseride <50 mg/dl
Pl TG/sTG<1
Cholesterol>250 mg/dl
Pl Ch/s Ch>1
Emphyema

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PH<7.20
Low Glucose
Microbiologic evaluation

RBC >100 000/mm3
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Trauma,
Pulmonary infarction
malignancy
WBC > 1000/mm3 : exudate
> 10 000/mm3 : emphyema, parapnomonic
effusion (PNL predominates)
Mesothelial cells<5%: tuberculosis possible
Lymphocytes >50% : tuberculosis, malignancy,
lymphoma, fungus, myxedema
 Gram
staining
 Ziehl-Neelsen staining
 Cultures for specific and nonspecific
infections
 PCR
Infectious pleuresy, emphyema
 Bacterial
pneumonia is associated with an
effusion in 40% of cases
 The effusion may be parapneumonic
without infection (uncomplicated) or
culture positive (complicated, emphyema)
 Parapneumonic effusions are treated with
appropiate antibiotics
 Tube drainage is indicated if emphyema
occurs
Other Pleural Diseases

Hemothorax
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Plevral fluid htc>50% of serum
Can be traumatic or nontraumatic:
•
•
•
•
•
•
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İatrogenic
Pulmonary infarction
Tumors
Rupture of aneurism
Anticoagulan treatment
Thoracic endometriosis
Treatment:
• intrapleural drainage
• thoracotomy
 Fibrothorax


A thick fibrous tissue formed on visceral
pleura
Cause:
• Empyema
• Tuberculosis
• Hemothorax

Treatment: Decortication
 Pneumothorax


Presence of free air between the visceral and
parietal pleura
Divided into 3
• Spontaneous


Primary idiopathic
Secondary
• Traumatic
• Iatrogenic
Primary Spontaneous
Pneumothorax
 Mostly
occurs in young, male, smokers
 There is no obvious underlying pulmonary
disease
 Subpleural blebs and bullae probably play
a role in pathogenesis
 Symptoms can be an acute unset of
dyspnea and unilateral chest pain but can
be absent also depending on the size of
the pneumothorax

Physical examination:
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Hypersonority on percusion
Reduced breath sounds, reduced VT, enlarged
hemithorax
Hypotension and cardiac tamponade may occur
depending on the size of the pneumothorax
Radiology:
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Pleural line
Hyperlucency at the periphery
Mediastinal shift
Expiration film can be used when the lesion is not
apparent
Quantification of the size of the pneumothorax is
helpfull in the decision of treatment
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Measurement of the average
diameters of the collapsed
lung and the affected
hemithorax can be used
100-(83/113)100=% 62
Simple observation with rest
and supplemental oxygen can
be used for asymptomatic
patients with a small (<20%)
px
Intercostal drainage is
indicated in large px
A recurrent spontaneous
pneumothorax (30-50% risk) is
an indication for surgery
Secondary Spontaneous
Pneumothorax

Patients have an underlying pulmonary disease:
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COPD
Asthma
Congenital cysts and bullae
Interstitial lung fibrosing diseases
Cystic fibrosis
Hystiocytosis X
Whooping cough
Lymphangiomyomatosis
Pleural endometriosis, catamenial pneumothorax
Pleural malignancy
Sarcoidosis
Bacterial pneumonia and Pneumocystis Pneumonia
Traumatic and Iatrogenic
Pneumothorax
 Iatrogenic
pneumothorax can be seen
during:
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Thorasentesis
Pleural needle biopsy
Transthoracic lung aspiration biopsy
Mechanical ventilation
Central venous catheterization
Tracheostomy
Cardiopulmonary resusitation
Pleural Neoplasms
 Benign:


Pleural lipoma
Local pleural fibroma (Fibrous mesothelioma)
 Malign:

Diffuse malign mesothelioma
Malign Pleural effusions
 Diffuse
Malign Mesothelioma
 Bronchial carcinoma (adenocarcinoma)
 Lymphoma
 Breast carcinoma
 Other adenocarcinomas
Malignant Mesothelioma

Primary tumour of pleural, pericardial, peritonial
mesothelium
 Etiology: 70-90% asbest exposure:
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Occupational: asbest is resistant to heat and friction
so used in building, water pipes, brakes, isolation
systems, textile
Environmental: Eskişehir, Kütahya, Bilecik, Yozgat,
Sivas, Diyarbakır
Latent period is 30-40 years in occupational
exposure
 Smoking dramaticaly increase the risk of cancer
in asbest exposure
Erionite is another fibrous zeolite found in soil,
high in Nevşehir: Tuzköy, Karain, Sarıhıdır
area in Turkey. It is more carcinogenic than
asbest.
49% of total deaths in the villages of Ürgüp are
due to DMM

The most common clinical presentations are
dyspnea, chest pain, unilateral decreased
volume of the affected hemithorax (frozen chest)
(inspite of fluid accumilation)

Nodular thickening of the pleura, irregular
thickening of the interlobar fissure, absence of
mediastinal shift with massive pleural effusion
(frozen chest)

Diagnosis by histologic examination
 Treatment oncologic and surgical if possible,
prognosis is poor
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