PLEURAL DISEASE

MUHAMMAD ILYAS

Departement Of Pulmonology and Respiratory medicine

Faculty of Medicine University of Hasanuddin
PLEURA
• The pleura is formed of two serosal
membranes, one covering the lung and
one covering the inner chest wall
• The pleural space is the space delimited
by two layers
• Normal condition, it contains only a
small amount of liquid that function as
a lubricator
• Composition of the thin layer of fluid
between the parietal and visceral pleura
is that of an ultrafiltrate of plasma

• The two lining act like semipermeable

membrane
• The Blood supply of the parietal pleura comes
exclusively from the systemic artery

• In contrast, visceral pleura is vascularized by

both the systemic and pulmonary circulation

• Venous blood is drained into the pulmonary

venous system
Composition of Normal Pleural fluid
• Volume : 0,1-0,2 ml/kg
• Cell per mm3 : 1000 – 5000
• Meshotelial cells 3-70%
• Monocytes 30-70 %
• Lymphocyte 2-30 %
• Granulocyte 10 %
• Protein : 1 – 2 g/dl
• Albumin : 50 – 70%
• Glucose < plasma level
• LDH < 50 % plasma level
• pH ≥ plasma
Initial Assesment
• Initial Assesment of patient with
suspected or proven pleural disease is
critical not only because history taking
and physical exm. may provide clues to
the diagnosis but also because they
may be useful in suggesting the cause
of underlying desease
• The typical symptom associated with
pleural disease are dyspnea and
“pleuritic” chest pain radiating to the
shoulder, back or neck are carried
through the sensory part of the phrenic
nerve.
• Chest pain made worse by breathing
and coughing
Diagnostic Procedures
• History and physical examination
• Conventional radiographic
• Computed Tomography
• Ultrasound
• Nuclear medicine
• Invasive prosudure :
– Thoracentesis
– Closed pleural needle biopsy
– Thoracoscopy
– Open thoracotomy
– Bronchoscopy
PLEURAL EFFUSION
 PLEURAL EFFUSION
• Defined ; Accumulation of fluid within the
visceral and parietal layers of the pleura when
there is an imbalance between formation and
absorption in various disease states.
• Caused by either excess fluid production or
decrease absorption
• Effusion are a common manifestation of both
systemic and intrathoracic disease
 Pleura Pleura
parietalis viseralis

Kapiler Kapiler
paru
sistemik

limfatik
limfatik
Cairan
pleura
 Physiology

• Normally : made from parietal pleura

capillary, 5-10 ml, 0.01 ml/kg BW/hr
• Absorption 20 times more than
production
• Fluid movement influence by
hydrostatic pressure and capillary
osmotic
 Dinding Rongga Paru
toraks pleura

Kapiler Kapiler
sistemik pulmonal
Tek koloid Tek koloid
osmotik osmotik
(cm H2O) (cm H2O)

Tek negatif
intrapleura

Tek
Tek
hidrostatik hidrostatik
(cm H2O) (cm H2O)

Pleura Pleura
parietalis viseralis
 Dinding Rongga Paru
toraks pleura

Kapiler Kapiler
sistemik pulmonal
Efusi
Tek koloid Pleura Tek koloid
osmotik osmotik
(cm H2O) (cm H2O)
Tek negatif
intrapleura

Tekanan
hidrostatik Tek
(cm H2O) hidrostatik
(cm H2O)

Pleura Pleura
parietalis viseralis
• Factors that determine whether pleural fluid
accumulates include :
• - oncotic pressure in the pleural fluid,
pleural microcirculation and lymphatics
• - permeability of the pleural microcirculation
• - pressure in the systemic and pulmonary
vein
Fluid direction,
posteroinferior
The mechanisms that lead to accumulation
of pleural fluid
l. Increased hydrostatic pressure in microvascular
circulation (CHF)
2. Decreased oncotic pressure in microvascular
circulation (severe hypoalbuminemia )
3. Increased permeability of the microvascular

circulation (pneumonia)
4. Impaired lymphatic drainage from the pleural
space (malignant effusion)
5. Movement of fluid from peritoneal space
( ascites )
Etiology
• Most common pathologyc of pleura
disease ; pleura, lung parenchym or
mediastinum
• Type of fluid effusion :
• - Transudate
• - Exudate
• - Emphyema
• - Haemorrhagyc/ haemothorax
• - Chylous / chyliform
Pleural effusion: Classification
• Transudates: due to diseases that
affect the filtration of pleural fluid: CHF &
hypoproteinemia

• Exudates: inflammation or injury

increases pleural membrane permeability to
proteins and various types of cells
Pleural effusion: Other Classification

• Purulent → Empyema
• Blood → Hemothorax
• Milky → Chylothorax
Criteria for “Exudative Effusion”
• criteria value
• 1. Pleural Protein : Serum Protein > 0.5
• 2. Pleural LDH : Serum LDH > 0.6
• 3. Pleural LDH > 200

• only need 1 critical value to establish the diagnosis

of exudate
 Two kinds of pleural effusions
Transudates and exudates

Transudate Exudate
Cause non-inflammatory
inflammatory,tumor
Apperance light yellow yellow,
purulent
Specific gravity <1.018 >1.018
Coagulability unable able
Revalta test negative positive
Protein content <30g/L >30g/L
ΘP. To serum Pre < 0.5 > 0.5
LDH < 200 I U/ L > 200 I U / L
Θ P. To s < 0.6 > 0.6
Cell count < 100×10 6/ L > 500×10 6 / L
Differential cell Lymphocyte Different
Pleural Effusion fluid
Tests Transudate Exudates Exudates
(tubercular) (Empyema)

Physical appearance Clear Straw Cloudy /

coloured Turbid
Microscopy <1000 >1000 >5000
Lympho/M Lymphocytes PMNs
Pus cells
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl

Pleural fluid Protein / <0.5 >0.5 >0.5

Serum protein

Pleural fluid LDH / <0.6 >0.6 >0.6

Serum LDH
Pleural fluid pH >7.3 <7.3 <7.2
Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
Clinical Manifestations
• Pain
• Cough
• Dyspnea
• Dullness to Percussion
• Diminished or Absent Vocal Resonance
• Diminished or Absent Tactile Vocal
Fremitus
• Friction Rub
Upright ..Meniscus
Supine…Unilateral
increased density
Decubitus…Effusion
layered on downside
Massive Pleural Effusion
• Large Effusions that prevent contact
between the Visceral & Parietal Pleura
during respiration are seldom
associated with pleuritic chest pain.

• Large effusions interfere with expansion

of the lung and produce dyspnea,
shortness of breath, and atelectasis
Treatment
• Transudative Effusion: focus on the
systemic cause
• Exudative Effusion: dependent on the exact
sub-type
• Consider Chest Thoracostomy
• Gross Pus / Empyema
• pH < 7.2
• Hemothorax
• Complicated Parapneumonic Processes
• Malignant Effusions…but remember the role of
pleurodesis!
 Purulent pleurisy / Empyema

• Pus or microorganism in pleural fluid

• Microorganism- by smear or culture
In the absence of these:
• pH of pleural fluid < 7.2
• Lactic dehydrogenase (LDH) >1000IU/L
• Glucose <than 40mg/dl
• Lactate > 45mg/ml
Empyema: Predisposing factors
• Pneumonia in ½ of cases
• Preceding H/O of pustules
• Blunt trauma to
chest/surgery/thoracocentesis
• Viral infections (chickenpox, measles)
• Severe malnutrition
• Neglected foreign body
• Extension from subphrenic, amoebic liver
abscess
• CHD
• Peridontal disease, steroid, immunodeficiency
Empyema: Etiology
• Staphylococcus aureus, epidermidis
• Streptococcus pneumoniae, viridans
• H influenzae
• Pseudomonas aeroginosa
• E. coli
• Klebsiella aerogenes
• Mycobacterium tuberculosis
• Fungal/ EH (rare)
Stages of Empyema

• Exudative (1 to 3 days):
parapneumonic effusion
• Fibrino purulent (4 to 14 days):
polymorpho nuclear & fibrin accumulation
• Organizing stage (after 14 days):
fibroblasts grow and producing an inelastic
membrane
Empyema: Clinical features
• Common in poor socioeconomic group
• Peak incidence 0-3 years
• Chills, fever, dyspnoea, chest pain,
referred pain, night sweat, malaise,
cough, ↑sputum production
• Pain abdomen & ileus
• Tachypnoeic, anxious, pleural rub
(disappear after fluid accumulates)
 Empyema: Clinical features...
• Large fluid- fullness of intercostal
spaces, diminished chest excursions
• Shift of mediastinum
• Dullness to percussion, decreased air
entry, decreased tactile & vocal fremitus
 Empyema: Treatment

Aims

• Control infection
• Drainage of pus
• Expansion of lungs
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
Pneumothorax
Pneumothorax

• Presence of gas in
the Pleural space
• Collection of air or gas in chest or
pleural space which causes collapsed
lung
Pneumothorax: Causes
• Rupture of pleural • Transthoracic
blebs aspiration needle
• Penetrating or non • Thoracentesis
penetrating injuries
• Central intravenous
• Pneumonia
catheters
• Asthma
• Mechanical Ventilation
• Cystic fibrosis
• COPD/ Bronchitis
• Resuscitative efforts
• Inhalation of some
toxic substances, most
notably crack cocaine
Pneumothorax: Classification
• Spontaneous pneumothorax :
Primary , Secondary
• Traumatic pneumothorax
• Iatrogenic pneumothorax
• Tension Pneumothorax
• Spontaneous Pneumothorax
• Primary - rupture of subpleural bleb
– “Jimmy is a tall, wiry, 21-year old male, who plays
trombone in the marching band….”
• Secondary : underlying lung/pleural disease
emphysema
• Chronic bronchitis, asthma, TB, …
• Traumatic Pneumothorax
• Open
– Chest wall is penetrated : outside air enters
pleural space
• Closed
• Chest wall is intact Ex. Fractured rib
• Tension Pneumothorax
– “Ball-valve mechanism”
– Injury to pleura creates a tissue flap that opens
on inspiration and closes on expiration
– One of our own patients
– Variations
= Hemo-thorax
= Chylo-thorax
@ Injury to thoracic duct
– Empyema
@ Parapneumonic effusions in community-acquired
pneumonia
Tension Pneumothorax
• If air continues to enter the pleural
space, a tension pneumothorax occurs.
• The air may compress the heart and
cause a fall in B.P.
• This is life-threatening and requires
immediate treatment to release the
pressure.
• Treatment can life-saving.
• A pneumothorax is a serious condition
that can be life-threatening.
•
• Symptoms of a tension pneumothorax
may include:
– Shift of the trachea
– Loss of consciousness
– Sweating
– Gasping
– Shock
– Rapid HR
Symptoms
Dyspnea
Pleuritic chest pain
– Nerve endings at pleural capsule
Sense of impending doom
Sudden onset
- Tension pneumothorax
- Spontaneous pneumothorax
 Tension Pneumothorax: Signs/Symptoms
• Clinical Presentation - Chest pain (90%), Dyspnea
(80%), Anxiety, Fatigue
• Physical examination - Respiratory distress and/or
arrest, Cyanosis, Tracheal deviation, Pulsus paradoxus,
Tachypnea, Tachycardia, Hypotension, Jugular venous
distension
• Hyperresonance of the chest wall on percussion
• Unilaterally decreased or absent lung sounds
• Increasing resistance to providing adequate ventilation
assistance
• Mental status changes, including decreased alertness
and/or consciousness
• Abdominal distension
Physical Exam - Signs
– Unstable patients vs. Stable patients
– Vital Signs
– Asymmetric chest expansion
– Deviated trachea
– Diminished breath sounds unilaterally
– Hyper-resonance unilaterally
– Decreased tactile fremitus
Diagnosis
– Unstable patient
Thoracentesis
@ Rapid release of air
@ Vital signs stabilize rapidly
– Stable patient
• CXR
• Monitor size by measuring distance from lateral
lung margin to chest wall
• Be sure that pneumothorax is not expanding
 Imaging
- Plain Radiographs
• Upright PA on inspiration
- Detect other pathologies: pneumonia, cardiac, etc.
- Partially collapsed lung
- Tension Pneumothorax
• Trachea and mediastinum deviate contralaterally
• Ipsilateral depressed hemi-diaphragm
- Chest CT
- Not routine
- Only to assess the need for surgery (thoracotomy)
 Treatment
• Small pneumothorax
Resolve over days to weeks
Supplemental oxygen and observation
Tension pneumothorax
– Immediate decompression via chest tube or
needle thoracostomy
Spontaneous pneumothorax
– Asymptomatic – outpatient, f/u with serial CXR
– Symptomatic – inpatient, chest tube
– Recurrent pneumothorax – CT to evaluate need
for thoracotomy
– Needle decompression
• Simple large-bore needle
• Mid, anterior chest
• 2nd or 3rd rib space
• NOT right next to Sternum

The “ Magic triangel”

Empyema: Inter Costal Drainage
(ICD)
Chest Tubes
Thank You