Dr.

Ahmed Al-Azzawi Lec 4

DISEASES OF THE PLEURA #237

ANATOMY AND PHYSIOLOGY OF THE PLEURAL SPACE
 The pleura consists of a visceral and parietal layer.

 The visceral pleura covers the lungs and interlobar fissures,

whereas the parietal pleura lines the ribs, diaphragm, and
mediastinum.

 A double fold of pleura extends from the hilum to the

diaphragm to form the inferior pulmonary ligament..

 There is no communication between the two pleural cavities. The

pleural space is a potential space that contains 2 to 10 mL of

pleural fluid in the normal individual.

 The parietal pleura lines the chest wall, mediastinum,

diaphragm, and form the cupola or pleura dome at the thoracic
inlet bilaterally.

 The diaphragmatic pleura adheres tightly to the diaphragm.

The mediastinal pleura adherent tightly to pericardium. The
cupola, costal pleura can dissected from the underlying tissue.

Anatomy of the Pleura (Blood supply)

 Visceral pleura arterial supply is from the bronchial and pulmonary arterial systems.

 The veinous drainage is to the Pulmonary veins.

 The parietal pleura arterial supply is from various systemic arterial supply of the chest
wall, diaphragm, and mediastinum.

 Veinous drainage is directly into the superior vena cava.

Prepared by: Kizhe Kamaran Surgery｜1

Anatomy of the Pleura (Lymphatics)
 The lymphatic drainage of the visceral is to the pulmonary plexus located in the interlobar
and peribronchial space. A direct subplerual lymphatic connection to mediastinal node is
possible in 22-25% of people.

 Lymphatic drainage of the parietal pleural is to the parietal pleural lymphatic channels,
the stomata and around the Kampmeier’s foci.

 The lymphatic network of the chest wall drain into internal mammary chain anteriorly and
intercostals chain posteriorly.

 The drainage of the diaphragmatic pleura is to retrosternal and mediastinal and celiac
lymph node.

Anatomy of the Pleura (Nerve supply)

 Parietal pleura is innervated by both somatic, sympathetic and parasympathetic fiber via
the intercostal nerve.

 The diaphragmatic pleura is supplied by phrenic* nerve.

 The visceral pleura is devoid of any somatic nerve supply.

The main manifestations of disease in the pleura include

 Pleural effusion.

 Pleural thickening (which may or may not be calcified).

 Pleural air (i.e., pneumothorax).

 Pleural neoplasms.

 Primary disease of the pleura is rare. Most pleural abnormalities result from disease
processes in other organs.

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Fibrinous (Dry) Pleurisy
DEFINITION: Inflammation of the pleura characterized by fibrinous exudation
and no significant degree of effusion.
ETIOLOGY
A. 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.

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SIGNS:

1. Inspection 3. Percussion

o Limitation of movements on the o Tenderness .

affected side.
4. Auscultation
2. Palpation
o PLEURAL RUB
o Sometimes palpable pleural rub.

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

Pleural plaques and Calcification

 Discrete areas of thickened parietal pleura

 Often bilateral

 More common on lower half of thorax

 Do not occur at apex of chest

 Do not cause adhesions

 Appear smooth and ivory white (may be nodular and greyish brown)

 Histologically uniformly arranged, densely laminated collagen

 Relationship with mesothelioma uncertain

 Common finding on CXR

 Differential diagnosis - any pleural tumour

Pleural Cysts
 Most common at pleuropericardial  Typical water density on CXR
angle, 70% on right
 Slow growing, Rarely symptomatic
 Unilocular, up to 10cm in diameter
 Removed for diagnostic purposes

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Pleural Masses
 Benign: Lipomas, & pleural fibromas, and rounded atelectasis.

 Malignant: Metastasis* (most common), other less common causes Lymphoma, thymomas &
asbestos related Malignant mesothelioma

* 39-year old female with no significant past medical history Benign pleural fibroma

 Pleural lipomas are benign soft-tissue neoplasms that originate from the submesothelial
layers of parietal pleura and extend into the subpleural, pleural or extrapleural space.

 Are soft, encapsulated fatty slow growing tumors.

 CT may demonstrate fat attenuation

(approximately -100 HU) . If lesion is close to diaphragm may be mistaken for a hernias
(Morgagni & Bochedalek)

* 70-year-old man patient admitted with chest pains, dyspnea, and cough Pleural lipoma

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Mesothelioma
 Primary tumour usually carry high mortality

 Caused by asbestos exposure

o 5-7% of all individuals exposed to asbestos

o latent period 20-40 years

o 50% of patients no history of asbestos exposure

 Asbestos + cigarettes increases lung Ca risk

 Malignant pleural mesothelioma is tumor that develops from the protective lining covering
the outer lining of the lungs and internal chest wall due to exposure to asbestos.

 CXR may show unilateral, concentric, plaque like, or nodular pleural thickening.

 CT shows in detail involvement of mediastinum and diaphragm and chest wall.

 MRI shows the plagues as hyperintense < muscles.

 Usually found incidentally by chest radiography

 Common in 4th to 6th decade, +/- hx of asbestos exposure, no gender distribution.

 Presenting symptoms (~50-60% asymptomatic),others symptoms (dyspnea, chest pain,

hemoptysis).

 Most behave as slowly growing, painless masses.

 Associated hypertrophic pulmonary osteoarthropathy and episodic hypoglycaemia (due to

production of insulin-like growth factor) may be present in 4-5% of cases.

 80% arise from visceral pleura and 20% from parietal pleura.

 Calcification present in ≤5%, central necrosis is common in the larger tumors.

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Investigations
• CXR • Pleural biopsy

• CT scan – closed

• Pleural aspiration – open

• Bronchoscopy – VATS

* 49-year old Pxt presented with no symptoms of tightening chest pain.

Management
• Surgical • Intracavity radiotherapy

• Brachytherapy • Chemotherapy

• External radiotherapy • Combination therapy

All are usually considered palliative

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PLEURAL EFFUSION
DEFINITION: Abnormal (excessive) accumulation of fluid inside the pleural space.
(normal- ~20 ml)

 Definition - increase in fluid in the pleural space

 Shows on CXR if >300ml

 Detected clinically if >500ml

 Exudates - protein content = < 30g/l

 Blood stained effusions usually malignant

 50% of malignant effusions are serous

Physiologic Mechanisms in the development of Pleural Effusions

 Increase in hydrostatic pressure in microvascular circulation (congestive heart failure)

 Decrease in osmotic pressure in microvascular circulation (Hypoalbuminemia, Cirrhosis).

 Decrease in pleural pressure (Atelectasis).

 Increase in permeability of microvascular circulation (Inflammatory conditions, Neoplasms).

 Impaired lymphatic drainage (Tumor, Fibrosis).

 Transport of fluid from abdomen (Ascites).

ETIOLOG & .PATHOGENESIS

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

EXUDATE – definition -one or more criteria: Mechanisms: increased permeability of the

pleural surface (due to inflammation) or by
 Pleural fluid protein to serum protein ratio >0.5
obstruction of the lymphatics (carcinoma).
 Pleural fluid LDH to serum LDH ratio >0.6

 Pleural fluid LDH value >2/3 upper normal limit for serum LDH (pleural fluid LDH
>200U/L).

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EXUDATE – causes:

 Pneumonia (parapneumonic effusions)  Acute pancreatitis

 Cancer (especially mediastinal)  Uremia

 Pulmonary embolism  Chronic atelectasis

 Rheumatic fever  Sarcoidosis

 Empyema  Drug-related

 Tuberculosis  Post-myocardial infarction (Dressler`s

syndrome)
 Conective tissue disease
 Mesothelioma
 Viral pleurisy

Mechanisms:
TRANSUDATE: • Increased in hydrostatic pressure

 Pleural fluid protein to serum protein ratio < 0.5 (congestive heart failure);

 Pleural fluid LDH < 200U/L • Decreased oncotic pressure

(hypoalbuminemia);
TRANSUDATE – causes:
• Greater negative intrapleural
 Congestive heart failure (majority of cases); pressure (acute atelectasis).

 Cirrhosis with ascites;

 Nephrotic syndrome;  Acute atelectasis;

 Myxedema;  Constrictive pericarditis;

 Meigs`s syndrome (right side pleurisy,  Superior vena cava obstruction

ascitis, ovarian cancer); (mediastinal tumors).

Surgery｜9
 Dr. Ahmed Al-Azzawi
Pleural effusion - Clinical features
 Shortness of breath  Stony dull to percussion

 Decreased chest wall movement  Reduced or absent breath sounds

 Tracheal shifting.  Signs of underlying cause

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.

SIGNS:
 INSPECTION

o limitation of movements on the affected side

 PALPATION

o large effusions shift the mediastinum to the opposite side (if it is not fixed by
malignancy)

o decreased vocal tactile fremitus

 PERCUSSION

o basal stony dullness rising to the axilla (Damoisseau line)

o hyper-resonance above the level of effusion (compensatory emphysema)

 AUSCULTATION

o Absent or reduced breath sounds over the area of the effusion

o 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

Prepared by: Kizhe Kamaran Surgery｜10

Radiologic Features
Standard Radiography: Free pleural effusion demonstrates a meniscus sign, which is a
concave, upward-sloping interface with the lung that causes sharp or indistinct blunting of the
costophrenic angle.

A massive effusion produces a

complete or nearly complete
opacification of a hemithorax,
with displacement of the
mediastinum to the opposite
side

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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”).

DIAGNOSTIC THORACENTESIS

Pleural fluid is examined for these characteristics:

• physical, • bacteriological,

• chemical, • and cytological

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.

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DIFFERENTIAL DIAGNOSIS
 Basal lung lesions  Subdiaphragmatic diseases

• Basal consolidation • Amoebic liver abscess

• Collapse • 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;  Fibrosis – pachypleuritis (fibrous “peel”);

 Secondary infection causing empyema;  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.

 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”;

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 o Tube thoracostomy is required for parapneumonic effusion if any of the following is
present:

• The fluid resembles frank pus;

• Pleural fluid glucose is < 40 mg/dl;

• Pleural fluid PH is < 7.2.

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

OTHER MAJOR TYPES OF PLEURAL EFFUSION

 EMPYEMA

o 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;

o Milky in appearance pleural fluid, clearing the supernatant after centrifugation.

 HEMOTHORAX

o 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).

 CHYLOUS PLEURAL EFFUSION

o 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; Triglyceride > 110 mg/dl.

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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
Transudative - treat underlying condition
Exudative -
Treatment of the underlying medical condition that is causing pleural effusion;

 Thoracentesis (therapeutic and diagnostic) - Parapneumonic- treat underlying

pneumonia, chest-tube drainage if
 Tube Thoracostomy (Chest Tube) pH <7.2 or glucose <60 mg/dl
- Empyema & hemothorax- chest-t
 Pleural Catheter (for reoccurring pleural effusion ) ube drainage
- Malignancy depends on sympto
 Pleural Sclerosis (Pleurodesis) - Doxycycline or talc ms-
- infrequent- repeated thorace
 Surgery
ntesis
– Video-assisted thoracoscopic surgery (VATS) - frequent- chest-tube drainage
pleurodesis
– 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.

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Pleurodesis
 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.

Empyema Drainage
 Inter costal drainage (ICD), under water seal, large catheter inserted in the site of pus
accumulation

 Loculated fluid/pus- drainage continued for 1 week

 Chest tube kept till drainage is nil or < 30 ml/day

Pyopneumothorax

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 Classification
Pneumothorax
- Spontaneous pneumothorax
Presence of gas in the Pleural space Primary , Secondary
- Traumatic pneumothorax
Pneumothorax: Causes - Iatrogenic pneumothorax
 Rupture of pleural blebs - Tension Pneumothorax

 Penetrating or non penetrating

injuries
 Transthoracic aspiration needle
 Pneumonia
 Thoracentesis
 Asthma
 Central intravenous catheters
 Cystic fibrosis
 Mechanical Ventilation
 COPD/ Bronchitis

 Inhalation of some toxic substances,

most notably crack cocaine
 Resuscitative efforts

Tension Pneumothorax

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 One-way valve making intra-pleural pressure more than ambient pressure throughout the
respiratory cycle

 Common causes-

– Penetrating trauma, CPR

– Positive pressure mechanical ventilation

 s/s- marked tachycardia, hypotension in patient with pneumothorax

 Complication- subcutaneous emphysema

Management
 Dx- clinical + CxR

 Rx-

 Small stable primary spontaneous pneumothorax- <15% of a hemithorax- observe,

oxygen, aspirate

 Other- chest-tube drainage

 Thoracoscopy/thoracotomy ± pleurodesis- recurrent spontaneous pneumothorax,

B/L pneumothorax

 Surgery- if all else fails *Quit Smoking

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