PLEURAL DISEASE

Yani Purnamasari NP Sp.P

Definisi

The pleural cavity contains a relatively small

amount of fluid, approximately 10 mL on each
side.
Pleural fluid volume is maintained by a
balance between fluid production and removal
Light and colleagues in 1972 99% of pleural
effusions : transudative or exudative.

Pleura and Pleural Cavity

Pleural Cavity
Potential space between
visceral & parietal
pleura
Capillary layer of serous
fluid
produced by
mesothelium
Reduces friction
Surface tension provides
cohesion between lung and
thoracic wall

Pleural sac and

recesses

Pleural diseases include:

Pneumothorax
Pleural effusion:
Transudates/exudates, hematothorax,
cylothorax /pseudocylothorax,
empyema, pleural effusion in spesific
diseases (SLE, e.t.c )
Pleural tumors
Pleurisy (pleural inflammation)

Pleurisy (pleural inflammation)

Pleurisy is an inflammation of the pleura, the
lining of the lungs pain.
Inflammation :
- infection
- damaging agent irritates the pleural
surface.
Pleurisy cases : pleural effusion or as being
"dry.

Pleural tumors: abnormal growths on the

pleurae.
- benign (i.e. pleural plaques)
- malignant

Mesothelioma is a type of malignant cancer

associated with asbestos exposure.

Pleural effusion: a fluid accumulation within the

pleural space.
Abnormal collections of pleural fluid :
- excessive fluid volume (i.e. excess intravenous fluids,
renal failure),
- decreased fluid protein (e.g. cirrhosis, proteinuria),
heart failure,
- bleeding (hemothorax),
- infections (parapneumonic effusions, pleural
empyema),
- inflammation
- malignancies
- perforation of thoracic organs (i.e. chylothorax,
esophageal rupture).

Empyema
Empyema is pus in the pleural cavity; it
consists of polymorphonuclear leukocytes
and fibrin.
caused an infection
Risk factors include :
bacterial pneumonia, lung abscess,
thoracic surgery, trauma or injury to the
chest, or rarely, thoracentesis.

Prevalence

incidence of pleural effusions vary up

to 1 million in the United States.
The more common causes of :
- transudative effusions (reflect a
systemic perturbation )are congestive
heart failure & hypoalbuminemic states
(e.g., cirrhosis)
- exudative effusions (signify underlying
local
(pleuropulmonary disease) are
malignancy,
infection (e.g.,
pneumonia), and pulmonary embolism.

Pathophysiology

The accumulation of pleural fluid can usually be

explained by formation or absorption, or both.
Increased pleural fluid :
- elevation of hydrostatic pressure (e.g., congestive
heart failure),
- decreased colloid osmotic pressure (e.g., cirrhosis,
nephrotic syndrome),
- increased capillary permeability (e.g., infection,
neoplasm),
- passage of fluid through openings in the
diaphragm (e.g., cirrhosis with ascites),
- reduction of pleural space pressures (e.g.,
atelectasis).

Decreased pleural fluid absorption :

- lymphatic obstruction
- elevation of systemic venous
pressures
resulting in impaired
lymphatic
drainage (e.g., superior
vena cava
[SVC] syndrome).

Physiology of the Pleural Space

From: Cretien, J, Bignon, J., Hirsch, A, eds: The Pleura in Health and Disease.
New York: Marcel Dekker, 1985, p182.

Respiratory physiology pleural effusions

produce :
- restrictive ventilatory defect
- decrease the total lung capacity
- func-tional residual capacity
- forced vital capacity
They can cause ventilation-perfusion
mismatches and, when large enough,
compromise cardiac outpu

The differential diagnosis of

pleural effusions is
Select Causes of Transudates
Atelectasis (early)
Cirrhosis
Congestive heart failure
Hypoalbuminemia
Nephrotic syndrome
Peritoneal dialysis
Urinothorax

Select Causes of Exudates

Asbestos exposure
Atelectasis (chronic)Chylothorax
Connective tissue disease
Drugs (e.g., amiodarone)
Esophageal rupture
Hemothorax
Infection (bacteria, viruses, fungi, tuberculosis, or
parasites)
Malignancy
Pancreatitis
Postcardiotomy syndrome
Pulmonary embolism
Subdiaphragmatic abscess
Uremia

Signs and symptoms

Many patients asymptomatic (pleural effusion).

Symptoms are usually due to the underlying
disease process:
- pleuritic chest pain indicates inflammation of
the parietal pleura (because the visceral pleura
is not innervated and thus not sensitive to pain).
- dry, nonproductive cough and dyspnea.
- physical examination (effusion): reduced tactile
fremitus, dull or flat note on percussion, and
diminished or absent breath sounds on
auscultation.

Diagnosis

The posteroanterior and lateral chest

radiographs diagnosing a pleural effusion
most fluid collects around the inferior surface of
the lung
50 mL of fluid (on lateral radiograph) as a
meniscus posteriorly,
500 mL is present, the meniscus usually
obscures the entire hemidiaphragm.
The lateral decubitus films help in differentiating
free fluid from loculated fluid (that which is
confined by fibrous pleural adhesions).

Pleural Diseases & Signs 1: Pleural

Effusion

Accumulation of fluid in the pleural space

Transudative vs. exudative effusion
Empyema as potential sequelae to exudative
effusion

Ultrasound

Ultrasound a diagnostic tool and as an

aid in performing thoracentesis to
differentiate between solid and liquid
components (identifying pleural fluid
loculations).

SerumPleural Fluid Albumin Gradient

misidentify some transudates as exudative
effusions (e.g., in patients with heart failure
who undergo diuretic treatment) Roth
and colleagues used the serum-effusion
albumin gradient (serum albumin
concentration minus effusion albumin
concentration) with a cutoff of 12 g/L
(exudates if below that level, transudates if
above), and obtained a specificity of 100%
as compared with 72% with Light's criteria.

Diagnostic test: Light's criteria

for an exudate: any of:

protein effusion: protein serum ratio >

0.5
LDH > 307 IU/ml
LDH effusion: LDH serum ratio > 0.6

Glucose
Very low glucose levels ( 25 mg/100
mL), although not pathognomonic, are
seen in a few diseases.
Rheumatoid arthritis, tuberculosis,
empyema, and tumors or malignancy
very low glucose levels.

Amylase
Elevated pleural fluid amylase is seen
with pancreatitis and esophageal rupture
and in approximately 10% of malignant
effusions.

pH
Normal pleural fluid pH : 7.64.
- pH 7.30 inflammatory or infiltrative
process ( parapneumonic effusions,
empyema, malignancy, connective tissue
diseases, tuberculosis, and esophageal
rupture.
- Urinothorax is peculiar in that it is the
only cause of a low pH transudative
effusion.

Management of Patients with

Parapneumonic Effusions
Pleural Anatomy

Pleural Fluid
Bacteriology

Pleural
Fluid
Chemistry

Need
for
Drainag
e

Minimal effusion (<10 mm on

lateral decubitus view); freeflowing

Cx and GS
unknown

pH unknown

No

Small to moderate effusion (>10

mm to < one half of hemithorax
on lateral decubitus view); freeflowing

Negative Cx
and GS

pH > 7.20

No

Large effusion (> one half of

hemithorax on lateral decubitus
view) or loculated fluid or
thickened
pleura
Cx : culture,
GS : gram stain

Positive Cx or
GS

pH < 7.20

Yes

Any

Pus

pH < 7.0

Yes

Adenosine Deaminase
Adenosine deaminase levels 70 U/L is
highly suggestive of tuberculous pleuritis,
whereas a level less than 40 U/L virtually
rules out this diagnosis.
Other pleural diseases : adenosine
deaminase rheumatoid pleuritis and
empyema

Other Diagnostic Modalities

Pleural Biopsy
The use of an Abrams needle to obtain
specimens from the parietal pleura has
become less common with the increasing
availability of improved serum markers
and thoracoscopy.
Needle biopsy of the pleura to diagnose
tuberculous pleuritis when other markers
(e.g., adenosine deaminase) are
negative.

Thoracoscopy
Invasive techniques for the diagnosis of pleural effusions
video-assisted technology (VATS).
Thoracoscopy :
- visual evaluation of the pleura,
- direct tissue sampling, and
- therapeutic intervention (e.g., dissecting loculations and
pleurodesis).
Medical thoracoscopy (performed by pulmonologists under
conscious sedation) and video-assisted thoracoscopic
surgery (VATS), which is performed by surgeons under
general anesthesia, are indicated for diagnosing pleural
effusions that have remained undiagnosed despite
previous, less-invasive tests (e.g., thoracentesis).

Diagnosis of Pleural
Effusion

Treatment and outcomes

Therapeutic Thoracentesis
Drainage of a pleural effusion indicated in complicated
parapneumonic effusions or empyema for symptomatic
relief of dyspnea, and to evaluate underlying lung
parenchyma (pleural fluid bacteriology (culture and Gram
stain), and pleural fluid chemistry (pH)).
Therapeutic thoracentesis at any one time, no more
than 1 L to 1.5 L of fluid should be removed (unless
pleural space pressure is monitored) to avoid reexpansion pulmonary edema and post-thoracentesis
shock.
Supplemental oxygen because post-thoracentesis
decreases in arterial oxygenation

Pleural Sclerosis and Fibrinolytics

- The use of a sclerosing agent to produce a
chemical serositis and subsequent fibrosis of
the pleura is indicated in recurrent
symptomatic malignant effusions.
- Agents : talc, doxycycline, bleomycin, and
quinacrine .
- All fluid must be drained initially and that
full expansion of the underlying lung (usually
via a tube thoracostomy) is essential before
proceeding with sclerosis.

Surgery
complicated pleural effusions parietal
pleurectomy and decortication of the
visceral pleura.
(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

The pleural effusion in patients with
systemic lupus erythematosus (SLE)
small and bilateral, chest pain.
(lupus erythematosus cells and high
antinuclear antibody titers in pleural fluid
have a high specificity but are not
sensitive )

responsive to corticosteroids.

Pleural effusions rheumatoid arthritis

and, SLE effusions men.
- rheumatoid effusions is their low
glucose level (<25 mg/dL).
- rheumatoid factor in pleural fluid
elevated in other inflammatory states.

little evidence that corticosteroids are

beneficial in treating rheumatoid pleurisy

Malignancy
neoplastic disease metastasis than through
primary tumors.
- Lung and breast cancers metastatic disease
to
the pleura. Other less common causes are
hematologic (e.g., lymphoma, leukemia),
ovarian, and gastrointestinal tumors.
- Cytologic of the pleural fluid positive ( 50%
of cases )
- Tumor markers (e.g., carcinoembryonic antigen
[CEA] are not specific enough.
- Immunocytometry the diagnosis of lymphoma

Chylothorax
Leakage of chyle from a disruption of the
thoracic duct leads to a chylothorax.
milky fluid measuring pleural fluid
triglyceride levels
- A triglyceride 110 mg/dL confirms the
diagnosis, whereas 40 mg/dL excludes the
diagnosis.
- chylomicrons in the effusion (using
electrophoresis) establishes the diagnosis.

Pleural Diseases & Signs 3: Chylothorax

Leakage of lymph
Usually a result of surgical trauma during mediast.
proc.
Traumatic vs nontraumatic
Traumatic: 2/3, unilateral
Nontraumatic: 1/3, bilateral, assoc. with SVC
thrombosis

Common Causes of Chylothorax

Filariasis
Idiopathic
Intestinal lymphangiectasia
Lymphangiomyomatosis
Subclavian venous thrombosis
Trauma (including surgery)
Tumors

Treatment of a chylous effusion preventing

the complications of malnutrition due to the
continuous loss of protein, fat, and
electrolytes. Conservative measures include
shifting to a medium-chain triglyceride diet to
minimize the accumulation of fluid and total
parenteral nutrition.
Definitive treatment modalities thoracic duct
ligation or pleuroperitoneal shunt implantation.
Pleurodesis is not very effective due to the
anti-inflammatory characteristics of chyle.

Hemothorax
pleural fluid is bloody the pleural fluid
hematocrit 50% of the peripheral blood
hematocrit.
Hemothorax most commonly results from chest
trauma.
Nontraumatic hemothorax malignancy or
pulmonary embolism.

requires immediate chest tube thoracostomy and,

if bleeding persists (drainage >200
mL/hr)
thoracotomy.

Pleural Diseases & Signs 2:

Hemothorax
Intrathoracic bleeding (e.g.,
trauma)
Numerous sources of
potential
bleeds
Large hemothorax:
hypovolemic
shock,
restricted ipsilateral
ventilation contralateral
mediastinal
shift
Clotting may not be too
problematic (except for
catheters)

Coronary Artery Bypass Graft

one half of patients who undergo coronary artery bypass

grafting develop pleural effusions.
The pathophysiology is unclear (pleural trauma during
surgery or bleeding into the pleural space).
Light and coworkers: divided these large effusions into two
categories:
- those that occur 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 often recur. In either case, it is easy to
distinguish these effusions from those caused by congestive
heart failure, because the former are usually exudative.

Other Pleural Diseases

Pneumothorax

Air in the pleural space pneumothorax .

Causes : trauma, iatrogenic factors (e.g., thoracentesis,
mechanical ventilation), chronic obstructive pulmonary
disease, infection, and malignancy.
Primary spontaneous pneumothorax in men younger than
40 years, and the relative risk rises with heavy smoking.
Most secondary spontaneous pneumothoraces to chronic
obstructive pulmonary disease or infection (e.g.,
Pneumocystis jiroveci).
Trauma-related pneumothorax can result either in an open (to
the atmosphere) pneumothorax or a closed (tension)
pneumothorax, in which intrapleural pressures commonly
exceed atmospheric pressures.

Pleural Diseases & Signs

5: Pneumothorax
Presence of free air or gas in the

pleural

cavity

Types of pneumothorax
Open pneumothorax
Spontaneous pneumothorax
Tension pneumothorax
Collapse of ipsilateral lung due to
pressure change & disruption of
surface tension
Potential for mediastinal shifts

pneumothorax

Classification of Pneumothorax
Traumatic or iatrogenic
Spontaneous (without antecedent cause):
Primary (no underlying lung pathology)
Secondary (underlying lung pathology)

Traumatic pneumothorax usually requires

placement of a thoracostomy tube until
the air leak resolves.
The ACCP consensus statement
surgical intervention (thoracoscopy with
bullectomy and a procedure to produce
pleural symphysis) in preventing the
recurrence of secondary
pneumothoraces. 16

Management of Spontaneous
Pneumothorax
Primary Spontaneous Pneumothorax
Stable Patients with Small Pneumothoraces
Observation in the emergency department for 3 to 6 hours
Discharge home if a repeat chest radiograph excludes progression
Follow up 12-48 hours with repeat chest radiograph resolution
Stable Patients with Large Pneumothoraces
Hospitalization
Re-expansion of lung using a small-bore catheter or placing a 1622 F chest tube
Suction if lung fails to re-expand
Unstable Patients with Large Pneumothoraces
Hospitalization
Chest tube placement with 16-22 F standard chest tube
Use 24-28 F chest tube if the patient has a large air leak or
requires positive-pressure ventilation

Secondary Spontaneous Pneumothorax

Hospitalization
Observation or treatment with a chest
tube, depending on the extent of the
symptoms and the course of the
pneumothorax

Asbestos-Related Pleural Disease

asbestos exposure 20 years the classic pleural
plaques to effusions and malignancy the pleural
fluid the presence of mesothelial cells with
atypical features mesothelioma.
mesothelioma and asbestos most patients are
middle-aged and have history of asbestos exposure.
The diagnosis the history of cough and pleuritic
chest pain as well as chest CT results and findings
of elevated hyaluronic acid levels in pleural fluid.
The diagnosis tissue biopsy (thoracoscopy or
thoracotomy).
Prognosis poor (<1 year survival after diagnosis)

Pleural Diseases & Signs 4: Malignant

Mesothelioma

Neoplasm of pleural serosa

Linked to asbestos exposure
Coalescence of pleural plaques
May be restricted to parietal
pleura
but can involve
visceral
pleura
Can lead to contracture of all
structures in affected
hemithorax

AIDS-Related Pleural Disease

The immunologic impairment in AIDS infectious
complications ( bacterial parapneumonic effusions
and empyema).
In developing countries:
tuberculous,Pneumocystis jiroveci in patients with
AIDS, pleural effusions.
P. jiroveci pneumothorax
Pleural effusions can also occur with Kaposi's
sarcoma and non-Hodgkin's lymphoma, and
responses to treatment these disease poor.

Summary

Pleural effusion is usually the result of an imbalance between fluid

production and removal.
Light's criteria help differentiate transudative pleural effusions, which
usually reflect a systemic disease, from exudative effusions, which
usually signify underlying local (pleuropulmonary) disease.
The more common causes of transudative effusions are congestive heart
failure and hypoalbuminemic states (e.g., cirrhosis); common causes of
exudative effusions are malignancy, infections (e.g., pneumonia), and
pulmonary embolism.
Ideally, the workup of a new pleural effusion begins with a diagnostic
thoracentesis unless the amount of fluid is too small.
The management of pleural effusions associated with pneumonia
(parapneumonic effusions) is based on the pleural space anatomy,
pleural fluid bacteriology (culture and Gram stain), and pleural fluid
chemistry (pH).
Medical or surgical thoracoscopy offers the advantages of visual
evaluation of the pleura and direct tissue sampling, and it can be helpful
for the diagnosis of unknown pleural effusions and in the management
of complicated effusions.

Thank you