Outline Diseases of the Pleura

Physiology of the pleura Pleural effusions Neoplastic disease of the pleura Pneumothorax Chylothorax, pseudochylothorax, and hemothorax

Lecturer Catalina Lionte, M.D., PhD

Some important numbers
Size of pleural effusion to be seen on the chest film – 200cc Preferred size of effusion before thoracentesis - > 10 mm wide in the lateral decubitus view

Development of Pleural Effusion
pulmonary capillary pressure (CHF) capillary permeability (pneumonia, inflammation) intrapleural pressure (atelectasis) plasma oncotic pressure (hypoalbuminemia) pleural membrane permeability (malignancy) lymphatic obstruction (malignancy) diaphragmatic defect (hepatic hydrothorax) thoracic duct rupture (chylothorax) movement of fluids from extrathoracic site (pancreatitis)

Causes of pleural effusion

Pleural effusion - Other causes
•nephrotic syndrome •TB •Urinothorax •SVC syndrome •Meigs syndrome •rheumatoid arthritis •pancreatitis •drugs •yellow-nail syndrome yellow-

•collagen vascular disease

History: dyspnea pleuritic chest pain cough fever hemoptysis wt. loss trauma hx cancer cardiac surgery

Physical: Dullness to percussion Decreased breath sounds Absent tactile fremitus Other findings:
– – – – –

ascites jvd peripheral edema friction rub unilateral leg swelling

Diagnostic evaluation of the pleura
Radiography Ultrasound Computerized tomography, MRI Thoracentesis Video-assisted thoracic surgery (thoracoscopy) Closed pleural biopsy Open pleural biopsy - Thoracotomy

Diagnostic evaluation of the pleura

Pleural Effusion


Decubitus…Effusion layered on downside

Pleural Effusion Supine patient

Pleural Effusion

Semiupright…..Lung base opacity fades superiorly

Unilateral increased density

63-year-old man recovering from congestive heart failure…Effusion loculated in fissure

Massive Pleural Effusion or Total Lung Atelectasis

Pleural Effusion
Most sensitive way to show pleural effusion
– Decubitus chest radiograph

Least sensitive way to show pleural effusion
– Supine chest radiograph
Total Atelectasis Heart and mediastinum shifted toward whited out hemithorax Massive pleural effusion Heart and mediastinum shifted away from whited out hemithorax

Chest CT
Malignant pleural disease: pleural thickening (>1 cm), irregularity, nodules Pleural thickening: also seen in empyema Pleural nodules: only 17% in malignant effusions Other features: lung mass, chest wall involvement, mediastinal LAP, hepatic metastases

Chest CT

Indications for thoracentesis
Effusions larger than 1 cm height or unknown origin In heart failure:
– febrile/pleuritic pain, – unilateral, – no cardiomegaly, – no response to diuresis

Pleural fluid analysis
Bloody Appearance Hct <1% not significant, 1-20%= CA, PE, Trauma >50% serum Hct = hemothorax trig level >110mg/dl = chylothorax stain and culture = infection? Transudate vs Exudate? Exudate?

Differentiation of transudates and exudates
Transudates < 0.5 < 0.6 < 2/3 the upper limit for serum
Pleural Fluid Pleural/serum Protein Pleural/serum LDH Pleural LDH

Exudates > 0.5 > 0.6 >2/3 the upper limit for serum

Cloudy Putrid odor

Light’s Criteria
Pleural fluid is exudate if one or more: Pleural fluid protein/serum protein > 0.5 2. Pleural fluid LDH/serum LDH > 0.6 3. Pleural fluid LDH > 2/3 upper limit N serum LDH

Transudative Pleural Effusions
Congestive heart failure Pericardial disease Hepatic hydrothorax Nephrotic syndrome Urinothorax Myxedema Pulmonary embolism (sometimes) Sarcoidosis

Exudative Pleural Effusions
Parapneumonic effusions Tuberculous Fungal Viral Abdominal disease Parasitic Collagen vascular disease Pulmonary embolism
Post cardiac injury Post CABG Esophageal perforation

Exudative Pleural Effusions

Cell count - Neutrophil predom
- Lymphocytic predom

Exudative Effusion
acute pleural process (pneum., PE)

chronic process (Cancer, TB, CABGCoronary artery bypass graft)

Exudative Effusion

Exudative Effusion

Food-borne parasitic infection caused by Paragonimus westermani. Infection in humans mainly occurs by ingestion of raw or undercooked freshwater crabs or crayfishes. It is particularly common in East Asia.

Other Tests on the Pleural Fluid
– Esophageal Rupture – Pancreatitis

Triglycerides – for chylous effusions
– >110 highly likely – <50 highly unlikely

Unknown Etiology
15% of the time is no diagnosis made even after video assisted thoracic surgery (VATS)?

Parapneumonic Effusions
Parapneumonic effusions Complex Empyema Simple

Characteristics of a Complicated Parapneumonic Effusion
Glucose < 60 mg/dL pH < 7.2 Positive culture Pleural LDH > 3x the upper limit for serum Pleural fluid is loculated

Pus in pleura space Positive gram stain

Management of Parapneumonic Effusions Simple Complicated Empyema Antibiotics Antibiotics plus tube thoracostomy Tube thoracostomy and possible decortication

Management of Parapneumonic Effusions
Antibiotic selection should be based on the suspected causative microorganisms and the overall clinical picture. Various effective single agents and combination antimicrobial therapies exist. Coverage should generally include anaerobic organisms. Options may include clindamycin, extended-spectrum penicillins, and imipenem. Depending on the patient's clinical condition, infectious disease consultation may be appropriate.

Acute illness 2/3 of cases Chronic illness in 1/3 Unilateral effusion 1/3 will have parenchymal disease Exudative, lymphocyte predominant effusion

Tuberculous Pleuritis

Tuberculous pleurisy
Subpleural focus ruptures into the pleural space Usually younger adults, 3 to 7 months after primary tuberculous infection Abrupt or insidious onset. DDx: pneumonia, pulmonary infarct, tumor, others Natural history untreated: 65% of 141 patients developed active tbc.

Diagnosis of Tuberculous Pleuritis
PPD may be negative in up to 30% Culture

Diagnosis of Tuberculous Pleuritis
Pleural fluid for
– Adenosine deaminase > 40 – Interferon-gamma – Polymerase chain reaction (PCR) for tuberculous DNA


Treatment for Possible Tuberculous Pleuritis
Treat for tuberculosis
– If lymphocyte-predominant exudate and: The adensoine deaminase, polymerase chain reaction, or interferon gamma is positive in the absence of rheumatoid arthritis or empyema 1 PPD is positive 2

1.Light, RW, Broaddus, VC. Pleural Effusion. In Murray & Nadel: Textbook of Respiratory Medicine, 3rd ed. W.B. Saunders Company, 2000. 2. Ansari, T, Clin Chest Med, 1998

For severely ill patients with extensive or bilateral pleural effusions effusions and sputum positivity

Treatment of Tuberculous Pleuresy
INH 300 mg Rifampin 600 mg PZA 15-30 mg/kg Ethambutol 15-25 mg/kg or streptomycin 15 mg/kg

Four drug regimen for first 2 months:

Two drug regimen for next 4 months:
INH and rifampin Those with a solitary TB pleural effusion

2 months - isoniazid, rifampin, and pyrazinamide rifampin, followed by 4 months with - isoniazid and rifampin

Asbestos-related Pleural Disease AsbestosAsbestos-related Pleural Disease AsbestosBenign asbestos pleural effusion (10-20 year latency) Pleural plaques (20-30 year after latency) Mesothelioma (30-40 year latency) Diffuse pleural fibrosis Rounded atelectasis

Asbestos-related Pleural Plaques Asbestos-

Collagen-Vascular Disease of the CollagenPleura
Rheumatoid Arthritis Systemic Lupus Erythematosis Sarcoidosis Wegener’s Granulomatosis Sjogren’s syndrome

RA and SLE
Incidence Sex Effusion Glucose C4 Pleural immunology Treatment Response

Neoplastic disease of the pleura


3%-7% 15%-44% 80% male Female 80% with SQ nodules Exudate Exudate < 20 mg/dl – 63% > 70 mg/dl < 50 mg/dl – 83% Low Low RF + LE cells or + ANA NSAID/Steroids Steroids Variable response Excellent

Lung Breast Lymphoma Ovary Stomach Unknown

36% 25% 10% 5% 2% 7%
Sahn, SA: In Fishman, JA 9ed): Fishman’s Pulmonary Diseases and Disorders, 3rd ed. McGraw Hill, NY, 1998

Clinical Manifestations of Pleural Metastasis
Symptom Dyspnea Cough Weight loss Chest pain Malaise Fever Chills Asymptomatic Patients with symptom (%) 57 43 32 26 22 8 5 23
Chernow, B., Sahn, SA., Am J Med, 1977

Mechanism of malignancymalignancyassociated plural effusion
Direct metastasis Lymphatic obstruction Bronchial obstruction with atelect. Post obstructive pneumonia Thoracic duct involvement Pericardial disease Hypoproteinemia Pulmonary embolism Radiation therapy Chemotherapy (methotrexate, procarbazine, cyclophosphamide, mitomycin, bleomycin)
Sahn, SA, Clin Chest Med, 1998 Light, RW, Pleural Disease, Philadelphia, Lea&Febiger, 1983

Characteristics of Malignant Pleural Effusion
Usually exudative (though occasionally transudative) Mononuclear cell predominant (lymphocytes, macrophages, and mesothelial cells) 1/3 will have low pH (less than 7.3)
Sahn, SA, Clin Chest Med, 1998 Good, TJ, et al: American Review of Respiratory Disease, 1985

Pleural fluid cytology Pleural biopsy Thoracoscopy

Diagnosis of Malignant Pleural Effusion

Treatment of Malignant and Paramalignant Pleural Effusions
Serial thoracentesis Chest tube with pleurodesis Thoracoscopy with talc poudrage Pleuroperitoneal shunt Pleurectomy


Asbestos exposure (even very modest exposures) – Latency of 35-40 years No association with smoking Difficult diagnosis by cytology. Usually a biopsy is recommended VATS (Video-assisted thoracic surgery ) Three histological subtypes – Epithelial – Sarcomatous – Mixed


Video-assisted thoracic surgery

Treatment of Mesothelioma
Extrapleural pneumonectomy
– 5% surgical mortality – Median survival of 21 months (best with

Benign Mesothelioma
Localized pleural tumors of mesenchymal origin Clinical manifestations
– Asymptomatic in 50% – Cough, chest pain, dyspnea in 40% of symptomatic patients – 2 paraneoplastic syndromes
Hypoglycemia – caused by secretion of insulin-like growth factor II Hypertrophic pulmonary osteoarthropathy

epithelial histology)
– 5 year survival 22%

There may be a role for multimodality therapy using chemotherapy and radiation therapy

Solitary mass Usually cured by surgical removal

Pneumothorax - etiology
Primary spontaneous pneumothorax Secondary spontaneous pneumothorax occur due to an underlying lung disease such as COPD, cancer, Pneumocystis jerovici, cystic fibrosis, tuberculosis or other lung diseases

Iatrogenic pneumothorax
Traumatic Catamenial (pneumothorax occurring in conjunction with menstrual periods)

Primary Spontaneous Pneumothorax
Felt to arise from sub pleural blebs Associated with smoking Patients tend to be taller and thinner Usually occurs when the patient is at rest Diagnosis confirmed by chest x ray Recurrence rate of 39% on ipsilateral side and 15% on contralateral side
– Second recurrence rate of 50%

Pneumothorax Displaced Visceral Pleura

Skin Fold

Pneumothorax Displaced pleura (arrows)

Skin fold extends outside ribs

Look for displaced Visceral Pleura

Tension Pneumothorax

Supine Patient Medial Pneumothorax

TENSION PNEUMOTHORAX ** Examine patient * Look for deviated heart and mediastinum, depressed hemidiaphragm * Compare to previous radiographs

Is there a pneumothorax or isn’t there?
Order a Lateral Decubitus chest radiograph
– With the side of the chest in question as the upside
Possible left pneumothorax get right lateral decubitus chest
– Look for displaced visceral pleura along upside lateral chest wall

Treatment of Primary Spontaneous Pneumothorax
Observation Supplemental oxygen Simple aspiration Chest tube Thoracoscopy, bleb resection, and pleurodesis (usually reserved for recurrent disease)
– Recurrence rates of 3-4 % after thoracoscopy

Order Upright Expiratory chest radiograph
– Look for pneumothorax at lung apex

Secondary Spontaneous Pneumothorax
COPD Cystic fibrosis Interstitial lung disease such as sarcoidosis or eosinophilic granuloma Pneumocystis

Chest tube Pleurodesis with first event with or without thoracoscopy

Treatment of Secondary Pneumothorax

Recurrence rates higher that for primary spontaneous pneumothorax

Iatrogenic Pneumothorax
Transthroacic needle aspiration – 20% Mechanical ventilation Thoracentesis Central line placement Transbronchial lung biopsy

Treatment of Iatrogenic Pneumothorax
Minimal symptoms and less that 15% pneumothorax: observe Symptomatic or > 15 % : aspiration or chest tube For patients on mechanical ventilation: chest tube

Traumatic Pneumothorax
Penetrating or non-penetrating trauma 40% are occult to plain chest film and are discovered with CT Consider rare but catastrophic diagnoses that require immediate thoracotomy
– Rupture of the trachea – Rupture of the esophagus

Treatment is usually with a chest tube. If the pneumothorax is small and the patient is not in the ventilator, observation may be considered

Chylous Pleural Effusion
Defined by the presence of chyle (lymph) in the pleural space. Diagnosis
– Appearance often milky. Must differentiate chylous from chyliform effusion – Chemical confirmation
Triglyceride > 110 mg/dL If triglyceride is between 50-110 mg/dL, send fluid for lipoprotein electrophoresis. Chylomicrons confirms a chylothorax If triglyceride is < 50, it is not chylous

Causes of Chylous Effusion
– Lymphoma

54% 25%

– Surgical – Other

– Chyliform effusion has elevated cholesterol and occurs in long standing effusions.

Idiopathic 15% Miscellaneous 6%

Treatment of Traumatic Chylous Effusion
Pleuro-peritoneal shunts Chest tube: Caution that the patient may become malnourished. Therefore, chyle flow is reduced by GI rest and the use of parenteral nutrition Chemical pleurodesis Thoracotomy or thoracoscopy and ligation of the thoracic duct.

Treatment of Non-traumatic NonChylous Effusions
Treat underlying lymphoma or carcinoma If ineffective, then insert a pleuro-peritoneal shunt

Chyliform Effusions
Milky pleural fluid due to elevated cholesterol of lecithin-globulin complexes Most commonly associated with tuberculosis, rheumatoid arthritis, therapeutic pneumothorax

Pleural fluid hematocrit greater that 50% that of peripheral blood Causes
– Traumatic (penetrating or non-penetrating) – Iatrogenic (thoracic surgery or line placement) – Non traumatic (from metastatic pleural disease), spontaneous rupture of an intrathoracic vessel, bleeding disorders – Complication of anticoagulant therapy

Complications of Hemothorax
Retention of clotted blood in the thorax (causing restriction) Infection Effusion (usually self limited) Fibrothorax (occurs in less that 1% of hemothoraces. Decortication is necessary)

Treatment is immediate chest tube (both to evacuate the fluid and monitor for additional bleeding)


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