PLEURA AND PLEURAL CAVITY

PLEURA AND PLEURAL CAVITY

 Inflammation of the pleura characterized
by fibrinous exudation and no significant
degree of effusion.
 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.
 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.
 SIGNS:
1. Inspection
o Limitation of movements on the affected side.
2. Palpation
o Sometimes palpable pleural rub.
3. Percussion
o Tenderness .
4. Auscultation
o PLEURAL RUB
 Chest X-ray must be performed in
every case for detecting a thoracic
cause for the pleurisy.
PLEURAL EFFUSION
 DEFINITION

 Abnormal (excessive)
accumulation of fluid inside the
pleural space.
Pleural Effusion
PLEURAL EFFUSION
 ETIOLOGY. PATHOGENESIS

 EXUDATE
 TRANSUDATE

The term “pleural effusion”, by general consent, is applied

only to serous effusions.
 ETIOLOGY. PATHOGENESIS

 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).

Mechanisms: increased permeability of the pleural surface (due to inflammation)

or by obstruction of the lymphatics (carcinoma).
 ETIOLOGY. PATHOGENESIS
 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
 Drug-related
 Post-myocardial infarction (Dressler`s syndrome)
 ETIOLOGY. PATHOGENESIS
 TRANSUDATE:
o Pleural fluid protein to serum protein ratio < 0.5
o Pleural fluid LDH < 200U/L

Mechanisms:
o Increased in hydrostatic pressure (congestive heart failure);
o Decreased oncotic pressure (hypoalbuminemia);
o Greater negative intrapleural pressure (acute atelectasis).
 ETIOLOGY. PATHOGENESIS
 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, ascitis, ovarian
cancer);
o Acute atelectasis;
o Constrictive pericarditis;
o Superior vena cava obstruction (mediastinal tumors).
 CLINICAL FINDINGS

 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.
 CLINICAL FINDINGS
 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.
Pleural Effusion
 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”).
 LABORATORY FINDINGS
 DIAGNOSTIC THORACENTESIS

• Pleural fluid is examined for:

• physical,
• chemical,
characteristics.
• bacteriological,
• and cytological
ASSESSMENT OF PLEURAL FLUID
 LABORATORY FINDINGS
 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.
Emmet E. McGrath, Diagnosis of Pleural
Effusion: A Systematic Approach, AJJC
 POSITIVE DIAGNOSIS

 Pleuritic chest pain, dyspnea, pleural rub;

 Decreased TVF, stony dullness to percussion, distant
breath sounds, egophony (large effusion);
 Radiographic evidence of pleural effusion;
 Etiological diagnosis is based mainly on thoracentesis
and fluid laboratory examination.
 DIFFERENTIAL DIAGNOSIS
 Basal lung lesions
 Basal consolidation
 Collapse
 Subdiaphragmatic diseases
 Amoebic liver abscess
 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;

 Secondary infection causing empyema;
 Fibrosis – pachypleuritis (fibrous “peel”);
 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.
MESOTHELIOMA OF PLEURA
 SPECIAL FORMS OF PLEURAL EFFUSION
 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”;
o Tube thoracostomy is required for parapneumonic
effusion if any of the following is present:
o The fluid resembles frank pus;
o Pleural fluid glucose is < 40 mg/dl;
o Pleural fluid PH is < 7.2.
o A pneumonic effusion that does not respond to drainage
within 24 hours may have become loculated.
CHARACTERISTICS OF PARAPNEUMONIC PLEURAL
EFFUSION

BTS guidelines for the management of pleural infection, Thorax 2003

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.
OTHER MAJOR TYPES OF PLEURAL EFFUSION

 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).
HEMOTHORAX
OTHER MAJOR TYPES OF PLEURAL EFFUSION

 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;
o Triglyceride > 110 mg/dl.
CHYLOTHORAX
 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
 Treatment of the underlying medical condition that is
causing pleural effusion;
 Thoracentesis (therapeutic and diagnostic)
 Tube Thoracostomy (Chest Tube)
 Pleural Catheter (for reoccurring pleural effusion )
 Pleural Sclerosis (Pleurodesis) - Doxycycline or talc
 Surgery
 Video-assisted thoracoscopic surgery (VATS)
 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.
ANTIBIOTIC REGIMENS FOR THE INITIAL TREATMENT OF
CULTURE NEGATIVE PLEURAL INFECTION

BTS guidelines for the management of pleural infection, Thorax 2003

 THERAPEUTIC THORACENTESIS
 Any pleural effusion large enough to cause severe respiratory
symptoms should be drained regardless of the cause and
regardless of concomitant disease-specific treatment.
 Relief of symptoms is the main goal of therapeutic drainage in
these patients.
 Absolute contraindication - active cutaneous infection at the
puncture site.
 Relative contraindications include: severe bleeding diathesis,
systemic anticoagulation, and a small volume of fluid.
 Possible complications: bleeding, pneumothorax, infections,
laceration of intra-abdominal organs, hypotension, and
pulmonary edema.
 TUBE THORACOSTOMY (CHEST TUBE)

 Tube thoracostomy allows continuous, large volume

drainage of air or liquid from the pleural space.

 Specific indications:
 spontaneous or iatrogenic pneumothorax;
 hemothorax;
 penetrating chest trauma;
 complicated parapneumonic effusion or empyema;
 chylothorax;
 pleurodesis of symptomatic pleural effusions.
Chest computed tomographic scan with a “split pleural sign” (arrow),
seen in empyema. This patient needed drainage with tube thoracostomy.
 PLEURAL SCLEROSIS
 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.
VIDEO-ASSISTED THORACOSCOPIC SURGERY
(VATS)
 is very useful in managing incompletely drained
parapneumonic effusions.

 with thoracoscopy, the loculi in the pleura can be

disrupted, the pleural space can be completely
drained, and the chest tube can be optimally placed.
 THORACOTOMY

 In cases of empyema with uncontrolled sepsis or

progression to the fibroproliferative phase a full
thoracotomy with decortication is performed with
removal of all the fibrous tissue and evacuation of all the
pus from the pleural space.