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Pleural Diseases

Melvin A. Pasay, MD, FPCP, FPCCP
Section of Pulmonary Medicine
De La Salle University Medical Center


• Pleural cavity contains approximately 10 mL on each side.

• Volume maintained by a balance between fluid production and


• 99% of pleural effusions classified into two general categories:

transudative - systemic perturbation

exudative - underlying local disease

• Estimates of the incidence of pleural effusions vary

• Annual incidence of up to one million in the United States

• Transudative effusions
– congestive heart failure

– hypoalbuminemic states (eg, cirrhosis)

• Exudative effusions
– malignancy

– infections (eg, pneumonia)

– pulmonary embolism



Elevation of hydrostatic pressure (congestive heart failure)
Decreased colloid osmotic pressure (cirrhosis, nephrotic
Increased capillary permeability (infection, neoplasm)
Passage of fluid through openings in diaphragm (cirrhosis with
Reduction of pleural space pressures (atelectasis)



Lymphatic obstruction
Elevation of systemic venous pressures [superior vena cava
(SVC) syndrome]

• Many patients are asymptomatic

• Symptoms are usually due to the underlying disease process

• Pleuritic chest pain indicates inflammation of the parietal pleura

• Other symptoms include dry, nonproductive cough and dyspnea

• Reduced tactile fremitus, dull or flat note on percussion, and

diminished/absent breath sounds on auscultation

• Presence of other clues (signs of heart failure, breast masses,


Chest Radiography

• Posteroanterior and lateral chest radiographs

• 50 mL of fluid - needed to be visible on the lateral


• 500 mL - the meniscus usually obscures the entire


• The lateral decubitus films


• Useful both as a diagnostic tool and as an aid in

performing thoracentesis

• differentiate between solid and liquid components

• Valuable in detecting subpulmonic or subphrenic


Computed Tomography

• distinguish anatomic compartments more clearly (the

pleural space from lung parenchyma)

• useful in distinguishing empyema (split pleura sign)

from lung abscess, in detecting pleural masses, and in
outlining loculated fluid collections

• Criteria of Light

– begin with a diagnostic thoracentesis

– classification of the pleural fluid into either a transudate or an exudate

• Pleural fluid protein/serum protein ratio greater than 0.5

• Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio
greater than 0.6
• Pleural fluid LDH greater than two-thirds the upper limit of
normal for serum LDH
– diagnostic sensitivity of 99% and specificity of 98% for an exudate

Additional Markers
• Cholesterol
– higher in exudates than transudates

– cannot be used as a substitute to measurements of protein

and LDH.

Additional Markers
• Serum-pleural Fluid Albumin Gradient
– with a cut-off of 12 g/L (exudates if below that level,
transudates if above)

– specificity of 100%

– use of this marker alone may result in

misclassification of many exudates as well.

Additional Markers
• Glucose
– Very low glucose levels (less than 25 mg/100 mL) are seen in a
few diseases. Rheumatoid arthritis, tuberculosis, empyema, and
tumors/malignancy with extensive involvement of the pleura

Additional Markers
• Amylase
– Elevated pleural fluid amylase is seen with pancreatitis and
esophageal rupture

– approximately 10% of malignant effusions

Additional Markers
• pH
– Normal pleural fluid pH estimated to be around 7.64

– pH below 7.30 suggests the presence of an

inflammatory or infiltrative process (parapneumonic
effusions, empyema, malignancy, connective tissue
diseases, tuberculosis, and esophageal rupture)

– Urinothorax is the only cause of a low pH

transudative effusion

Additional Markers
• Adenosine Deaminase
– higher in tuberculous pleural effusions than in other exudates

– level above 70 U/L is highly suggestive of tuberculous


– level below 40 U/L virtually rules tuberculous pleuritis

– high ADA levels may be seen are rheumatoid pleuritis and


Other Diagnostic
• Pleural Biopsy
– less frequent with the increasing availability of improved
serum markers and thoracoscopy

– used mainly to diagnose tuberculous pleuritis when other

markers (eg, ADA) are negative.

Other Diagnostic
• Thoracoscopy
– more popularity with the advent of video-assisted

– advantages of visual evaluation of the pleura, direct

tissue sampling, and therapeutic intervention (eg,
dissecting loculations and pleurodesis)

– diagnosis of pleural effusions that have remained

undiagnosed despite previous, less-invasive tests

(eg, thoracentesis)  
Therapeutic Thoracentesis:

• Drainage of a pleural effusion

• Complicated parapneumonic effusions or empyema

• Symptomatic relief of dyspnea
• Need for evaluation of underlying lung parenchyma
• categorize the risk for poor outcome as well as the need
for drainage of the effusion based on the pleural space
anatomy, pleural fluid bacteriology (culture and Gram's
stain), and pleural fluid chemistry (pH)
Therapeutic Thoracentesis

• may be repeated if indicated

• more definitive therapy is usually needed to treat recurrent,

symptomatic pleural effusions

• no more than 1 L to 1.5 L of fluid should be removed

• use of supplemental oxygen is probably of benefit

Pleural Sclerosis and Fibrinolytics

• indicated in recurrent, symptomatic malignant effusions

• talc, doxycycline, bleomycin, and quinacrine have been used

• use of fibrinolytics (urokinase or streptokinase instilled via a

tube thoracostomy) improved fluid drainage and chest
radiograph findings significantly

Surgical Therapy

• video-assisted thoracoscopic surgery (VATS) and thoracotomy

as acceptable approaches to managing patients with
complicated pleural effusions
• Parietal pleurectomy and decortication of the visceral pleura
are definitive procedures with excellent response rates
• morbidity and mortality rates remain high, and that the
patient's general medical condition, expected long-term
prognosis, and baseline lung function should be considered
before proceeding with surgery

Pleural Effusions in
Specific Diseases
• Collagen-vascular Diseases
– pleura is involved in a majority of patients with systemic lupus
erythematosus (SLE)
– pleural effusions are small and bilateral
– most common symptom is chest pain
– finding of LE cells and high antinuclear antibody titers in pleural
– SLE effusions are usually responsive to corticosteroids
– Pleural effusions occur less commonly in patients with rheumatoid
– occur more commonly in men
– low glucose level (less than 25 mg/dL)
– little evidence that corticosteroids are beneficial in treating
rheumatoid pleurisy

Pleural Effusions in
Specific Diseases
• Malignancy
– more commonly involved through metastasis
– Lung and breast cancer are the leading causes of
metastatic disease to the pleura
– less common causes are hematologic (eg, lymphoma and
leukemia), ovarian, and gastrointestinal tumors
– Cytologic examination of the pleural fluid is positive in
more than 50% of cases with pleural involvement
– Immunocytometry has been used to establish the

Pleural Effusions in
Specific Diseases
• Chylothorax
– Leakage of chyle from a disruption of the thoracic duct

– triglyceride level above 110 mg/dL confirms the diagnosis

– finding of chylomicrons in the effusion (using electrophoresis) also

establishes the diagnosis

– Treatment of a chylous effusion is aimed at preventing the

complications of malnutrition due to the continuous loss of protein,
fat, and electrolytes

– Definitive treatment modalities include thoracic duct ligation or

pleuroperitoneal shunt implantation

Pleural Effusions in
Specific Diseases
• Hemothorax
– gross appearance of pleural fluid is bloody

– hematocrit level should be determined

– Hemothorax most commonly results from chest trauma

– Nontraumatic hemothorax, although uncommon, must alert the

clinician to the possibility of malignancy or pulmonary embolism

– immediate chest tube thoracostomy

Pleural Effusions in
Specific Diseases
• Post-coronary Artery Bypass Graft
– Approximately one-half of patients who undergo coronary artery
bypass grafting develop pleural effusions
– related to pleural trauma during surgery or bleeding into the
pleural space
– Within 30 days of surgery, the fluid is bloody, eosinophilic, and
easily resolvable with drainage (thoracentesis)
– After 30 days, the fluid is clear-yellow and predominantly
lymphocytic, but these effusions are difficult to manage because
they frequently recur
– usually exudative.

Other Pleural Diseases
Asbestos-related Pleural Disease

AIDS-related Pleural Disease

• air leaks into the area between the lungs and
chest wall (pleural space)
• A lung collapses in proportion to the amount of
air that leaks into your chest cavity
• partial collapse is much more common
• tension pneumothorax, a life-threatening
condition, requires immediate medical care

• may have few signs or symptoms

• minimally collapsed lung is likely to cause some chest pain

• When your lung has collapsed 25 percent or more, you're likely to


• Sudden, sharp chest pain on the same side as the affected lung
• Shortness of breath, which may be more or less severe,
depending on how much of the lung is collapsed
• A feeling of tightness in your chest
• A rapid heart rate
• heart function may be impaired

Primary spontaneous pneumothorax
• usually occurs in otherwise healthy people
• most common in tall, thin men — many of them
smokers — between 20 and 40 years of age
• develop when a small air blister (bleb) on the lung
• genetic factors also may play a role
• usually mild because pressure from the collapsed
portion of the lung in turn collapses the bleb.

Secondary spontaneous pneumothorax

• develops in people who have existing lung disorders

• Other conditions causing secondary pneumothorax

include tuberculosis, pneumonia, cystic fibrosis and lung

• secondary pneumothorax can be more severe and even


Traumatic pneumothorax
• Any blunt or penetrating injury to the chest can cause
lung collapse
• Knife and gunshot wounds, a blow to the chest, even a
deployed air bag can cause a pneumothorax
• certain medical procedures such as the insertion of
chest tubes, cardiopulmonary resuscitation (CPR) and
lung or liver biopsies
• Pneumothorax is especially common in people whose
breathing is aided by a mechanical ventilator.

Tension pneumothorax
• The most serious type of pneumothorax
• pressure in the pleural space is greater than
the atmospheric pressure
• can cause the affected lung to collapse
• can also push the heart toward the
uncollapsed lung
• comes on suddenly, progresses rapidly and is
fatal if not treated quickly.

• The goal in treating a pneumothorax is to relieve the
pressure on the lung
• The best method for achieving this depends on the
severity of the lung collapse and sometimes on your
overall health:
• Observation

• Needle or chest tube insertion

Other Pleural Diseases
Air between the lung and chest wall (in the pleural space) is termed a
"pneumothorax".Table 5 lists the classification of pneumothoraces. Common
causes of pneumothoraces include trauma, iatrogenic factors (eg, thoracentesis,
mechanical ventilation), chronic obstructive pulmonary disease, infection, and
The incidence of primary spontaneous pneumothorax is higher in men less than
40 years old, and the relative risk rises with heavier smoking. Secondary
spontaneous pneumothorax is a more serious condition, since it further
compromises an already abnormal lung function. Most secondary spontaneous
pneumothoraces are related to chronic obstructive pulmonary disease or
infection (eg, Pneumocystis carinii). Trauma-related pneumothorax can result
either in an open (to the atmosphere) pneumothorax or a closed (tension)
pneumothorax, in which intrapleural pressures frequently exceed atmospheric
pressures. Table 6 summarizes the currently adopted guidelines by the ACCP
for the treatment of spontaneous pneumothorax. Traumatic pneumothorax
usually requires the placement of a tube thoracostomy until the air leak
resolves. The ACCP consensus statement also recommends surgical intervention
(thoracoscopy with bullectomy and a procedure to produce pleural symphysis)
in preventing the recurrence of secondary pneumothoraces.