Surgical Conditions of

Pleura
Kibrom Gebreselassie, MD, FCS-ECSA
Cardiovascular and Thoracic Surgeon
Pleural Disease
Pneumothorax
Presence of air in the pleural space.
Two main sources
Lung
Breached chest wall
 Air in the pleural space breaks the water seal that
sticks the two layers of pleura
A pneumothorax is evident on a CXR where there is
an absence of lung markings and a defined edge to
the lung.
 Simple pnemothorax
Tension
Open/sucking wound
 Primary
Secondary
Tension pneumothorax
Air entering in to the pleural space but not leaving
it.
Mediastinum will be pushed to the opposite side
Flat or inverted diaphragm
Urgent evacuation needed.
 Engorged neck veins
Low BP
Absent air entry
Hypertympanic
CXR features of pneumothorax

White line of visceral pleura parallel to chest wall

No lung markings lateral to the line
There may be associated rib fractures
Do not confuse the line with skin fold or with
scapula
The most sensitive test if in doubt is a CXR taken in
expiration
R
R

Right lung more translucent than left

Faint line just visible (zoomed view to follow)
Right pneumothorax

Pencil-thin white line

running parallel to chest wall
No lung markings lateral to
the line

Blade of right scapula

Types of Pneumothorax
Simple
Mediastinum remains central
Clinical condition stable
Can wait for CXR to confirm diagnosis
Tension
Progressive build up of air in the pleural space, causing a
shift of the heart and mediastinal structures away from
side of pneumothorax
Clinical condition unstable
Do not wait for CXR to confirm diagnosis
Simple Left Pneumothorax
Simple Left Pneumothorax

Visceral
pleural line
(zoomed view
on next slide)

Small pleural
No mediastinal shift effusion
(common
finding)
Note absence of
lung markings lateral
to this line
Pneumothorax with rib fractures
 Pneumothorax with rib fractures
Right pneumothorax

Surgical emphysema

Rib fractures
Tension right pneumothorax
Tension right pneumothorax

Mediastinal shift to
left
Causes of Pneumothorax
Spontaneous
Rupture of an apical bleb
Traumatic
With rib fractures
Penetrating chest trauma
Pre-existing lung abnormality
Pulmonary fibrosis
Asthma
Vasculitis
Pulmonary metastases close to edge of lung
Other causes of absent lung markings
Large emphysematous bullae
Large lung cysts
Pulmonary embolism
Treatment
Needle puncture
Chest tube
Treating the underlying cause
Effusion
Fluid in the pleural space
Evident by blunting of the costophrenic angle on
CXR
Causes
Intrathoracic
CHF
Infection
Neoplasm
Embolism, infarction
Trauma
 Extrathoracic
Hepatic failure
Nephrotic syndrome
Subphrenic abscess
Pancreatitis
Etiology
EXUDATE definition -one or more criteria:

o Pleural fluid protein to serum protein ratio >0.5

o Pleural fluid LDH to serum LDH ratio >0.6
o Pleural fluid LDH value >2/3 upper normal limit for serum LDH
(pleural fluid LDH >200U/L).
 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
Post-myocardial infarction (Dressler`s syndrome)
 TRANSUDATE:
o Pleural fluid protein to serum protein ratio < 0.5
o Pleural fluid LDH < 200U/L
 TRANSUDATE causes:
o Congestive heart failure (majority of cases);
o Cirrhosis with ascites;
o Nephrotic syndrome;
o Myxedema;
o Meigs`s syndrome (right side pleurisy, ascites, ovarian
cancer);
o Acute atelectasis;
o Constrictive pericarditis;
o Superior vena cava obstruction (mediastinal tumors)
Treatment
Chest tube
Treating the underlying cause
Pleurodesis
Empyema
Infection in the pleural space
The fluid may vary from turbid to thick pus and can
be very difficult to drain
Etiology
Approximately two-thirds of empyemas result from
spread of infection in contiguous organs, such as
Lung
Esophagus
Spine and ribs and
Sub-diaphragmatic viscera
 About one-third of empyemas result from direct
inoculation of the pleural space by penetrating
injuries of the chest, iatrogenic infections (chest
drains), percutaneous biopsies or thoracic surgery
(presenting as postoperative infection).
Bacteriology
The infecting organisms will reflect the etiology.
Empyemas secondary to pulmonary infections
often grow Staphylococcus aureus or Streptococcus
milleri.
 Empyemas resulting from esophageal perforations
or subdiaphragmatic infections often contain
anaerobes and Gram-negative bacilli.
Pathology
Empyema develops through a series of stages from
I to III.
Following a pulmonary infection, these take place
over a period of 34 weeks.
 Most empyemas occur in the posterior and inferior
parts of the pleural cavity.
Occasionally, they can be more localized as a
reflection of an underlying etiology or because the
development of loculi alters the distribution of the
empyema.
 Clinical features are often non-specific.
They may include:
Dyspnea
Cough
Pleuritic chest pain
Pyrexia.
Lab
Invariably show leukocytosis and elevation of
erythrocyte sedimentation rate and C-reactive
protein.
Persistent elevations of the latter with a normal
white blood cell count (common after antibiotic
usage) should raise the possibility of an empyema.
Radiology
Most empyemas are located, at least in the early
stages (I and II), in the posterior and inferior parts
of the pleural cavity and are visible on plain
radiographs of the chest.
 Ultrasound and/or CT scanning may be necessary
to locate fluid collections more precisely, especially
in the later (III) stages or if the empyema is
subpulmonic or to guide appropriate drainage
procedures.
Stages
Stage I -Parapneumonic effusion-
Sterile effusion or exudate
 Stage II -Fibropurulent
Bacterial invasion of effusion
Deposition of fibrin on pleural surfaces
Loculation begins
 Stage III Fibrous
Increased fibroblastic activity with
thickened fibrin layer and capillary
ingrowth
Management
Complete drainage of empyema
Thoracentesis
Intercostal drain
Rib resection
Thoracoscopy
 Obliteration of pleural space
Intercostal drain
Thoracoscopy/decortication
Thoracotomy/decortication
Thoracoplasty
Pedicled muscle flap
 Investigation/treatment of underlying cause
Antibiotics
Further investigations/treatment as indicated
Hemothorax
Presence of blood in the pleural cavity
As it organizes it behaves more like empyema than
a simple pleural effusion
History suggests either trauma or surgery
Long term complications are chronic pleural
thickening and heavy pleural calcification
CHYLOTHORAX
Mesothelioma
Malignant tumor of the pleura
Three types
Epitheloid
Adenomatoid
Mixed cellularity
Commonly due to asbestos exposure
CLINICAL PRESENTATION
Pleural effusion: 92%
Pleural tumors: 6%
Spontaneous pneumothorax: 0.5%
Empyema: 1%
 The futures that suggest malignant rather than
benign pleural thickening are
Thickness >1cm
Nodular or undulating surface
Involvement of the mediastinal pleura
Encasement of the lung
Chest wall invasion
Treatment
The treatment options for PM include surgery,
radiation, chemotherapy, immunotherapy, gene
therapy, supportive care, or some combination of
these modalities.