Anatomy Pleura Visceral Layer outer surface of lung Separates lobes of lung from each other Parietal Layer inner surface chest wall Pleural linings Co

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1 Pleural diseases Dr. JM Nel Department of Pulmonology Pleural diseases Anatomy Empyema Physiology Pleurisy Pleural effusion Spontaneous Pneumothorax Asbestos- related pleural disease 1

2 Anatomy Pleura Visceral Layer outer surface of lung Separates lobes of lung from each other Parietal Layer inner surface chest wall Pleural linings Costal Mediastinal Diaphragmatic Anatomy 2

3 Pleura Thin membrane Anatomy Lining cells: mesothelial cells Connective tissue beneath mesothelial layer Blood vessels and lymphatic vessels Liquid formation and resorption in pleural space Parietal pleura Stomas (openings) between mesothelial cells Stomas lead to lymphatic channels Liquid moves from pleural space to lymphatic system Anatomy 3

4 Physiology Pleural space 10ml liquid Lubricates apposing surfaces Pleural fluid formation and resorption Ongoing formation Parietal pleura Resorption Stomas Lymphatic channels of parietal pleura Pleural fluid Ultrafiltrate from pleural capillaries Fluid filtration Forces Net movement from capillaries to pleural space Hydrostatic pressure Fluid into pleural space Colloid osmotic pressure Fluid into capillaries Physiology 4

5 Pleurisy Not a diagnosis Describes the result of a disease process involving the pleura Etiology Pulmonary infection Pulmonary infarction Malignancy Clinical features Pleuritic chest pain Pleural rub Management Analgesics Pleurisy 5

6 Pleural effusion Accumulation of fluid in pleural space Pleural fluid formation > pleural fluid resorption Pleural effusion: Pathogenesis 1. Changes in Starling forces 2. Fluid from peritoneum to pleural space 3. Interference with resorption 6

7 Pleural effusion: Pathogenesis 1. Changes in Starling forces Alteration of the permeability of pleural surface More permeable to fluid and large molecules Alteration in driving pressure Change in hydrostatic or colloid osmotic pressure of pleura Pleural effusion: Pathogenesis (Changes in Starling forces) Alteration of the permeability of pleural surface Pleura more permeable to proteins Accumulated fluid high protein content Inflammatory and neoplastic diseases Involving pleura EXUDATE 7

8 Pleural effusion: Pathogenesis (Changes in Starling forces) Alteration in driving pressure Accumulated fluid low protein content Pleural barrier relatively impermeable to proteins Increased hydrostatic pressure (pleural capillaries) Congestive heart failure Decreased colloid osmotic pressure Hypoproteinemia TRANSUDATE Pleural effusion: Pathogenesis 2. Fluid from peritoneum to pleural space Ascitic fluid to pleural space via Small diaphragmatic defects Diaphragmatic lymphatics Intrapleural pressure more negative than intraperitoneal pressure 8

9 Pleural effusion: Pathogenesis 3. Interference with resorption Blockage of lymphatic drainage from pleural space Seen when Tumor cells invade lymphatic channels or draining lymph nodes Pleural effusion: Causes Transudate Increased hydrostatic pressure Congestive heart failure Decreased plasma oncotic pressure Nephrotic syndrome Cirrhosis Movement of transudative ascitic fluid through diaphragm Cirrhosis 9

10 Pleural effusion: Causes Exudate Inflammatory Infection TB/ Pneumonia Pulmonary embolus/ infarction Connective tissue disease RA/ SLE Adjacent to subdiaphragmatic disease Pancreatitis/ Subphrenic abscess Malignancies Pleural effusion: Clinical features History Pleuritic chest pain Dyspnoea Resent respiratory infection Occupation Asbestos exposure TB contact Risk factors for PE Presence of disease Heart Liver Renal 10

11 Pleural effusion: Clinical features Examination Inspection Tachypnoea Palpation Expansion Trachea and apex displaced Percussion Stony dull Auscultation Absent breath sounds Bronchial breathing above effusion Investigations 1. Radiology Pleural effusion 2. Pleural aspiration 3. Pleural biopsy 4. Video- assisted thoracoscopy 11

12 Pleural effusion: Investigations 1. Radiology CXR Erect PA Curved shadow at lung base (meniscus) Blunting of costophrenic angle Lateral decubitus Pleural effusion: Investigations 1. Radiology Ultrasound Distinguish pleural fluid from thickening Determines volume more accurate Guides safe needle aspiration Locates loculation 12

13 Pleural effusion: Investigations 1. Radiology CT scan Distinguish benign from malignant disease Pleural effusion: Investigations 2. Pleural aspiration Transudate or exudate Not necessary in LVF unless atypical features Pleural fluid features A. Appearance of fluid B. Biochemical analysis C. Gram stain D. Predominant cells in fluid E. Other 13

14 Pleural effusion: Investigations A. Appearance of fluid Serous Cardiac failure PTB Malignant Connective tissue disease Milky Chylothorax (Obstruction of thoracic duct) Puss Empyema Blood- stained Malignancy Pulmonary infarction Traumatic tap Acute pancreatitis Pleural effusion: Investigations B. Biochemical analysis Transudate vs Exudate 14

15 Pleural effusion: Investigations LIGHT S CRITERIA Pleural fluid is an exudate if one or more of criteria is met: Pleural fluid protein: Serum protein ratio > 0.5 Pleural fluid LDH: Serum LDH ratio > 0.6 Pleural fluid LDH > 2/3 upper limit of normal s- LDH Pleural effusion: Investigations C. Gram stain Organisms Parapneumonic effusion Empyema M. tuberculosis 15

16 Pleural effusion: Investigations D. Predominant cells in pleural fluid Polymorphs Lymphocytes Red blood cells Eosinophils Malignant cells (send for cytology) Pleural effusion: Investigations E. Other Low ph Infection/ Empyema RA/ SLE Malignancy TB Ruptured oesophagus Low glucose As low ph High ADA 16

17 Pleural effusion: Investigations 3. Pleural biopsy Abrams needle PTB Malignancy Pleural effusion: Investigations 4. Video- assisted thoracoscopy 17

18 Pleural effusion: Management Treat underlying cause Diagnostic tap Therapeutic tap Severe dyspnoea Not more than 1.5 litres Re- expansion pulmonary oedema Pleural effusion: Management 18

19 Empyema Puss in pleural space Whole pleural space or loculated Almost always unilateral Empyema: Etiology Secondary to infection in a neighbouring structure, usually lung Most common causes Bacterial pneumonias CAP parapneumonic effusion secondary infected empyema TB Infection of a haemothorax Rupture of subphrenic abscess through diaphragm 19

20 Empyema: Clinical features High index of suspicion Pulmonary infection treated with AB, but persistence or recurrence of pyrexia Systemic features Local features Empyema: Clinical features Systemic features Pyrexia High Remittent Rigors Sweating Malaise Weight loss Polymorphonuclear leucocytosis High CRP Local features Pleural pain Dyspnoea Productive cough Underlying lung disease Copious purulent sputum Bronchopleural fistula: empyema ruptures into bronchus) Clinical signs of fluid in pleural space 20

21 Empyema: Investigations Radiology CXR Looks like pleural effusion Pyopneumothorax (if air and puss) Horizontal fluid level Empyema: Investigations Radiology Ultrasound Position of fluid Extent of pleural thickening Single collection or mutiloculated 21

22 Empyema: Investigations Radiology CT scan Underlying lung parenchyma Patency of major bronchi Empyema: Investigations Aspiration of puss Confirmation of empyema 1. Appearance of fluid: puss 2. Neutrophils 3. Positive gram stain 4. Low ph < Low glucose <

23 ICD Empyema: Management Empyema: Management Non- tuberculous ICD Connect to water- seal drain system Suction (5-10cm H2O) Flush with 20ml Saline regularly Intrapleural fibrinolytic therapy Conflicting benefit Antibiotics 2-4 weeks Surgery Thick or loculated puss Cavity cleared of puss and adhesions, ICD Decortication of lung Thickening of visceral pleura prevents re- expansion of lung 23

24 Empyema: Management Tuberculous ICD TB treatment Surgery Sometimes needed Ablate a residual empyema space Air in pleural space Pneumothorax 24

25 Pneumothorax: Classification Spontaneous Primary No lung disease Rupture of subpleural bulla or pleural bleb Tall, young smoking men Traumatic Iatrogenic After thoracic surgery or biopsy Non- iatrogenic Secondary Underlying lung disease COPD, TB, PCP, asthma, lung abscess, pulmonary infarcts, bronchogenic CA, fibrotic and cystic lung disease Pneumothorax: Clinical features Symptoms Sudden- onset unilateral pleuritic chest pain Dyspnoea 25

26 Pneumothorax: Clinical features Examination Normal if small (<15%) Inspection Tachypnoea Percussion Hyper- resonant Auscultation No breath sounds Palpation Expansion Pneumothorax: Investigations Chest x- ray Sharply defined edge of deflated lung No lung markings Mediastinal displacement Underlying lung disease Differentiate from emphysematous bulla 26

27 Pneumothorax: Investigations CT chest Distinguish from bulla Pneumothorax: Management Spontaneous primary pneumothorax < 2cm and no dyspnoea Resolves spontaneously O2 per mask (air reabsorbed by pleura) Underlying lung disease Small may cause respiratory failure ICD Large ICD 27

28 Tension pneumothorax Small communication between airway and pleura One- way valve Air into pleural space with inspiration Cannot escape with expiration Trapped air Increased intrapleural pressure With tension pneumothorax air CANNOT escape Above: trauma, air does escape Tension pneumothorax Mediastinal displacement Compression opposite lung Impairment systemic venous return Cardiovascular compromise 28

29 Tension pneumothorax: Clinical features Rapidly progressive dyspnoea Tachycardia Hypotension Cyanosis Trachea displaced MEDICAL EMERGENCY Tension pneumothorax: Management Large- bore needle inserted into pleural space 2 nd anterior intercostal space Gas escapes: diagnosis confirmed ICD 29

30 Asbestos- related pleural disease Three types of asbestos used Crocidolite (blue) Amosite (brown) Chrysotile (white) Asbestos- related pleural disease 1. Benign pleural plaques 2. Benign pleural effusion 3. Diffuse pleural fibrosis 4. Mesothelioma 30

31 Benign pleural plaques Areas of pleural thickening No symptoms Routine chest x- ray Often calcified Common on diaphragm and anterolateral pleural surfaces Benign pleural effusion Pleuritic chest pain, fever, leucocytosis Pleural fluid Can be blood- stained Self- limiting If causes diffuse pleural fibrosis Dyspnoea Difficult to distinguish from malignant effusion due to mesothelioma 31

32 Diffuse pleural fibrosis Restricts chest expansion Dyspnoea Progression Malignant tumour Pleura Peritoneum (less) Fiber types All Crocidolite more Asbestos exposure Mesothelioma 20 years after exposure 32

33 Mesothelioma: Clinical features Pleuritic chest pain Dyspnoea Pleural effusion Mesothelioma: Investigations Pleural fluid Blood- stained Pleural biopsy Histological diagnosis 33

34 Mesothelioma: Management Surgical resection Rarely successful Chemotherapy Mostly resistant Radiotherapy Prevents tumour growth through previous chest drain or biopsy sites NO CURATIVE TREATMENT Analgesics Difficult to control chest wall pain 34