PLEURAL DISEASE

Dr.Jalal
IMS/MSU
 OBJECTIVES

At the end of this session:

• Types, causes & clinical presentation of pleural effusion

• Types, causes & clinical presentation of Pneumothorax
• Causes & clinical presentation of Empyema
• Principle of treatment of pleural disease
 DISEASE OF THE PLEURA

Pleurisy
pulmonary infection
infarction
malignancy

Pleural Effusion
Causes & Types

Clinical features
Breathlessness (only symptom related)
Severity depends on the size & rate of accumulation
S& S of underlining cause

Investigation FBC RP LFT ESR CRP LDH

CXR, fluid c&s, cytology, ZN stain

Treatment Underlining cause

 Causes of Pleural effusion

Very common Less common Rare

Transudates
(pleural fluid protein Rt ventricular failure Hypothyroidism Constrictive pericarditis
Liver cirrhosis Nephrotic syndrome (previous tuberculosis,
< 30 g/l)
Hypoalbuminaemia Mitral stenosis connective tissue diseases)
Peritoneal dialysis Pulmonary Ovarian hyperstimulation
embolism/infarction (1/3) syndrome
Meigs' syndrome - ovarian
tumour with right-sided
effusion

Exudates (pleural Malignancy (lung, breast, Pulmonary Yellow nail syndrome

fluid protein >30 g/l) mesothelioma, metastatic) embolism/infarction (2/3) Drugs: amiodarone,
Parapneumonic (consider Rheumatoid arthritis nitrofurantoin, phenytoin,
subphrenic) Autoimmune disease (SLE, methotrexate,
lymphoma polyarteritis) carbamazepine,
Benign asbestos effusion penicillamine,
Pancreatitis bromocriptine, pergolide
Post-myocardial
infarction/cardiotomy
syndrome
 PNEUMOTHORAX

Is an accumulation of gas in the pleural space

Pathophsiology
Perforation of the visceral pleura and entry of gas from the lung
Penetration of the chest wall, diaphragm, mediastinum, or esophagus
Gas generated by microorganisms in an empyema (Pyopneumothorax)

Types of Pneumothorax
Closed
Open
Tension
 PNEUMOTHORAX
Clinical manifestation

Spontaneous Pneumothorax
Healthy men between 20 and 40 years
The right lung is more frequently involved
Recurrence is frequent (30% ipsilateral, 10% contralateral
Acute chest pain, dyspnea, cough (related to the size )

Tension Pneumothorax
Mediastinal shift
Compromise circulation
SOB, Cough, Chest pain

Secondary Pneumothorax
Commonest cause is Widespread emphysema , Less common Asthma, ILD, TB, CA
Pneumothorax complicating Abscess ( Pyopnemothorax) (staph)
Pneumothrax associated Truma ( Haemopneumothrax)
 PNEUMOTHORAX
Clinically
Symptoms
Physical Signs what are they?

CXR
Classically shows the visceral pleural line
Small pneumothoraces (Expiratory or lateral decubitus film)

Rx
Small pneumothorax (<20% of the hemithorax) asymptomatic patient
Observation (reabsorbed in 7 to 14 days) Needle aspiration!!!
More than 50% of the hemithorax (Symptomatic Patient)
Chest tube insertion ( till the leak seal) ?
consider Pleurodesis

Re-expansion pulmonary edema lung trauma

subcutaneous emphysema, bleeding infection.
 EPYEMA

Empyema refers to infected pleural fluid with a turbid effusion or frank

pus

In many cases the diagnosis only becomes apparent on aspiration of the

fluid

Most commonly complicates a bacterial pneumonia particularly

pneumococcal Pneumonia

Anaerobes are responsible for many 'sterile' empyema

Empyema following thoracic surgery, and those associated with abdominal

sepsis are frequently due to Gram-negative organisms

Staphylococcal pneumonia is an important cause in children.

 EPYEMA

Causes of empyema
Pneumonias Lung abscess
Bronchiectasis Oesophageal perforation
Pulmonary infarction Thoracic surgery
Penetrating chest injuries Sub-diaphragmatic infection
Haematogenous spread of infection
Amoebic liver abscess can rarely perforate the diaphragm

clinical features
fever& chills night sweats
Pleurtic chest pain cough large volumes of purulent sputum (bronchopleural fistula)
Pleurocuttaneous fistula

Physical examination
signs of a pleural effusion
 EPYEMA

Treatment
Pleural fluid must be completely drained ASAP
AB according to C&S
The drainage of pleural fluid can be enhanced by instillation of intrapleural
streptokinase (250 000IU daily for 3 days)
surgical Drainage might require

Chronic Empyema might complicated by

Pleural calcification
Secondary Amyloidosis
Pleural thickening & reduce lung functions
 PLEURAL MESOTHELIOMA

Related to asbestos exposure, radiation

Peak risk 30 to 35 years after exposure

Men five times more frequently than in women

Presented with shortness of breath and chest wall pain or

discomfort

CXR usually showed pleural effusion (less helpful in Dx)

The diagnosis is usually made by a biopsy procedure

Empyema necessitans
 Hemothorax Chylothorax
Trauma Mediastinal malignancy (lymphoma)
Hematologic disorders Thoracic surgery
pulmonary infarction Trauma
pleural malignancies Yellow nail syndrom
Thoracic duct obstruction
 DIFFERENTIAL DIAGNOSIS

The Solitory Pulmonary Nodule

Common
Bronchial carcinoma Single metastasis
Localised pneumonia Lung abscess
Tuberculoma Pulmonary infarct

Uncommon
Benign tumours Sarcoidosis
Lymphoma Arteriovenous malformation
Hydatid cyst Bronchogenic cyst
Rheumatoid nodule Pulmonary sequestration
Pulmonary haematoma Wegener's granuloma
Aspergillom
 Case 1

23y M male
No medical illness
Presented with SOB of sudden onset, Rt pleuritic chest pain & cough
What other information you wanted to know?
………

Case 2

Haemoglobin 19g/dl
white blood count 7.3
PaO2 (air) 6.2kPa (9-12.6)
PaCO2 (air) 8.9kPa (4.7 - 6.0)
pH 7.38 and (7.35 - 7.45)
bicarbonate 32.4. (21–28 mEq/L)