PLEURAL CONDITIONS

GUIDED BY : DR SWEETY SHAH

CREATED BY : KANDARP TRIVEDI

1
• Different pathological conditions :

1. Pleural Effusion
2. Pneumothorax
3. Pleurisy
4. Empyema
2
 Pleural Effusion
• Definition :

Collection of excess quantity of fluid in the pleural space.

Normally, the pleural space contains a small amount of
fluid ( about 0.26 ± 0.1mL/ kg ), ( Eg. for person having
60kg weight 9.6 - 21.6 mL is normal limit ) which allows
the lungs to inflate and deflate with minimal friction. A
mimimum of 500mL of fluid is necessary for clinical
detection of pleural effusion.
3
• Causes :
Transudative Pleural Effusion :

1. Congestive Heart Failure

2. Cirrosis
3. Nephrotic Syndrome
4. Pulmonary Embolization
5. Myxoedema
6. Superior Vena Cava Obstruction

4
Exudative Pleural Effusion :

1. Infectious Diseases : Bacterial Infections

Tuberculosis
Fungal Infections
Viral Infections
Parasitic Infections
2. Neoplastic Diseases : Metastatic disease
Mesothelioma
3. Pulmonary Embolism/ Infarction :
5
4. Collagen Vascular Diseases : Rheumatoid Arthritis
5. Gastrointestinal Disease :
Systemic Lupus Erythematosus
Drug- induced Lupus
Sjogrens syndrome
Wegners granulomatosis
Chrug - Strauss Syndrome
Sarcoidosis
Esophageal perforation
Pancreatitis
Intra-abdominal abscess
Diaphragmatic hernia
Post- abdominal surgery
Post- Liver transplant 6
6. Drugs and Toxins : Nitrofurontoin, Methylsergide,
Bromocriptine ( Drug induced )
& Asbestos ( toxin Induced )
7. Traumatic : Chest wall trauma
Iatrogenic injury
Post CABG
Hemothorax
Radiation injury
8. Chronic Uremia :
9. Cardiac Disease : Post myocardial infarction syndrome
Pericardial diseases
7
 • Types :
i. Acute pleural effusion
ii. Purulent effusion ( Empyema )
iii. Hemorrhagic effusion ( Hemothorax )
iv. Tuberculous pleural effusion
v. Iatrogenic pleural effusion
vi. Recurrent pleural effusion
vii. B/L pleural effusion
viii. Phantom ( Vanishing ) tumor
ix. Milky Effusion ( Chylous, Opalescent )
8
• Diagnosis :
SYMPTOMS :
Pleuritic pain : Pain in chest which increases on inspiration,
coughing, laughing and sneezing.
Dyspnoea : If massive collection of fluid occurs rapidly
( Acute P.E.)
Dry cough
Systemic Symptoms : Fever, anorexia, malaise, weight loss,
indicative of underlying disease.
( may or may not be present )
9
 SIGNS :
• 500 cc of fluid is required to produce signs

• Inspection : Bulging of intercostal spaces on the affected

side with fullness of hypo-chondrium if large
effusion.
: Diminished mobility of the chest wall on the
affected side.
: Shift of the mediastinum to the opposite side
10
• Palpation :
• Diminished mobility of the chest on the affected side.
• Shift of the mediastinum to the opposite side.
• Diminished or abscent TVF on the affected side below
the level of the fluid and increased TVF at the level of the fluid.
• Percussion :
• Stony dullness with increased resistance and no shifting
dullness below the level of fluid.
• Skodaic resonance ( boxy note ) just above the effusion.
• Obliteration of Traube's space if left sided effusion.
11
• Auscultation :

• Diminished or abscent breath sounds below the level of

the effusion.
• Bronchial breathing at the level of pleural effusion due to
relaxed lung.
• Egophony at the level of the pleural effusion.
• Diminished or abscent vocal fremitus below the level of
the fluid.
12
 INVESTIGATIONS :
• CBC, ESR
• Sputum Examination : Gram and Ziehl- Neelson's stain
and culture.
• X- ray chest : Homogenous opacity
Obliteration of costophrenic angle of
affected side ( 150 ml of fluid )
Concave upper border
Shift of mediastinum to the opposite side.
13
14
• Imaging : Ultrasound,
Ct Scan,
HRCT scan ( 50 ml of fluid )

• Thoracocentesis : to differentiate transudate from

exudate.

• Pleural Biopsy

• Thoracoscopy
15
16
17
 TREATMENT
• For Pleural effusion :
1) Medical Mx : General : Rest, adequate nutrition, vitamins
Management of fluid : Thoracocentesis or pleural tapping if
large effusion, cardio- respiratory
embarrassment or empyema.
For recurrent pleural effusion e.g. malignancy :
• Pleurodesis - Pleural abrasion, Talc, Doxycycline.
• Placement of small inwelling Catheter.
18
• Thoracocentesis :
Removal of fluid from pleural cavity for diagnostic or
therapeutic purposes using a needle inserted between the
ribs.

• Pleurodesis :
Artificial obliteration of pleural space
- so that fluid can no longer build up between the layers.

19
 PNEUMOTHORAX

DEFINITION : Presence of air in pleural cavity is known as

pneumothorax.
ETIOLOGY : Primary Spontaneous Pneumothorax
Secondary Spontaneous Pneumothorax
Catamenial Pneumothorax
Traumatic Pneumothorax
Iatrogenic Pneumothorax
20
• Primary Spontaneous Pneumothorax :
- Commanaly affects tall, slender males between the ages of
20 and 40 years who are smokers.
- It is believed to be due to rupture o subpleural blebs at the
lung apices.
- The gradient of negative pleural pressure increases from
the lung base to the apex so that alveoli at the lung apex in
tall individuals are subject to significantly greater distending
pressure than those at the base of the lung and this
predisposes to development of apical subpleural blebs.
21
• Secondary Spontaneous Pneumothorax :
- Rupture of emphysematous bullae
- Rupture of a subpleural tuberculous focus
- Rupture of a lung abscess, especially staphylococcal
- Bronchial Carcinoma
- Pulmonary infarction
- Bronchial Asthma
- ARDS
- Chest Trauma
- Rare causes includes Sarcoidosis, Marfan's syndrome and
cystic fibrosis.
22
• Catamenial Pneumothorax :
- Repeated attacks of spontaneous pneumothorax,
generally occurs at Rt. side, in association with
menstruation in females over 25-30 years.
• Traumatic Pneumothorax :
- Blunt and penetrating injuries to the chest wall, bronchi,
lung or oesophagus.
• Iatrogenic Pneumothorax :
- Due to diagnostic or therapeutic innervations
( e.g. biopsy, catheterisation and thoracocentesis ).
23
 Clinical Features :
• Sudden onset of chest pain and dyspnoea
• Cyanosis, rapid thready pulse, pulsus paradoxus
• Inspection and palpation of RS reveals tachypnoea,
accessory muscles of respiration in action, shift of trachea
and mediastinum to the opposite side, fullness of the
chest on the affected side, diminished chest movements
and markedly diminished vocal fremitus on the affected
side. Measurements showa reduction in total chest
expansion, increase in size of the affected hemithorax,
diminished expansion of the affected hemithorax and
increased spinoscapular distance. 24
• Percussion note is hyper- resonant over the affected
hemithorax.
• Ausculation reveals markedly diminished to abscent breath
sounds and markedly diminished Vocal Resonance. In an
open pneumothorax with a bronchopulmonary fistula,
amphoric bronchial breathing may be heard. Coin test may
be positive. Two coins when tapped on the affected side
produce a tinkling resonant sound that is audible on
auscultation.
25
 Radiological findings on Chest Radiograph
• Mediastinal shift to the opposite side
• Sharply defined edge of the deflated ling
• Complete translucency and absence of bronchovascular
markings in the area between the edge of the lung and
chest wall.
• Presence or absence of underlying lung lesion
• Presence or absence of a complicating pleural effusion.
26
27
Closed Spontaneous Pneumothorax :

• The communication obetween pleura and lung seals off

and doesn't reopen. Air can nither enter nor leave the
pleural space. The trapped air is slowly re-absorbed and
the lung re- expands completely in 2- 4 weeks.
• Clinically, closed pneumothorax manifests as trivial
breathlessness that gradually abates over a few days.
Pleral space infection is uncommon.
28
 Open Pneumothorax :
• The communication between bronchus and pleura doesn't
seal off and remains patent, resulting in a “ broncho-pleural
fistula “. Since air can freely flow through the bronchopleural
fistula, intrapleural pressure and atmospheric pressure remain
the same throughout the respiratory cycle. This prevents the
re-expansion of collapsed lung. In addition, bronchopleural
fistula facilitates spread of infection into the pleural space
resulting in empyema.
29
Tension ( Valvular ) pneumothorax :

• The communication between pleura and lung presists. It

acts as a one- way valve allowing air to enter the pleural
space during inspiration, coughing, sneezing and
straining, but allowing it to escape. Large amounts of air
gets “ trapped “ ithe pleural space and the intrapleural
pressure becomes much higher than the atmospheric
pressure.

30
31
32
 TREATMENT
• Initial management is directed at removing air from the
pleural space, with subsequent management directed at
preventing recurrane.
• Initial Mx : The choice of procedure depends on patient
characteristics and clinical circumstances :
1) If there is cardio- respiratory embrassment
2) If there is nocardio- respiratory embrassment
33
 If cardio- respiratory embrassment :
• Supplemental oxygen
• Treatment of shock
• Aspiration of pneumothorax
- Chest tube insertion ( Tube Thoracostomy )
- With the patient in sitting position, a needle s inserted
into the pleral cavirt in the second space in the mid-
clavicular line or in the fifth space in the axillary line. The
other end of the needle is connected to the underwater seal.
34
 If there is no cardio- respiratory embrassment :
• Small Pneumothorax : Supplemental oxygen and
observation
• Large Pneumothorax : Needle aspiration, Tube thoracostomy,
VATS (video-asisted thoracoscopy),
Chemical pleurodeis.
• Recurrent Pneumothorax / hydropneumothorax :
Chest tube insertion,
Thoracoscopy, Chemical
pleurodesis.
35
Further Procedure ...
• Supplemental oxygen : administered to facilitate
resorption of the pleural air.
• Aspiration
• Tube Thoracostomy
• Thoracoscopy
• Attachment of heimlich valve : Persistent air leak
• Smoking cessation
• Pleurectomy : Post-operative regime for PT Mx is same as
pleurodesis
36
 PLEURISY

• DEFINITION :

- Inflammation occurs on the visceral and parietal

pleura which come into direct contact with each

other to cause pain.

37
• CAUSES :

1. Viral infection ( Most common cause )

2. Pulmonary infarction
3. Bronchial asthma
4. Pneumonia
5. Autoimmune rheumatic diseases
( e.g. SLE, rheumatoid arthritis )

38
• CLINICAL FEATURES :
• Pleuritic pain - due to stretching of the inflamed pleura.
Sharp, severe pain occurs during deep inspiration or in
coughing.
Well localised to the area of the chest under which the
pleural irritation lies.
Irritation of the diaphragmatic pleura, however, causes
pain sensation via the phrenic nerve and this is often
referred to the tip of the shoulder.
39
• Pleural rub : Creaking or grafting sound heard through a
stethoscope on both inspiration and expiation. It
is localised to the affected area. This disappears
if an effusion develops.
• Cough : Coughing may be present if respiratory infection
is the cause.
• X- ray : The diaphragm may be raised on the affected
side.
• Other c/f : Tachycardia and pyrexia may be present,
depending on associated conditions.

40
 INVESTIGATIONS & TREATMENT
• Haematology shows a high white cell count if infection is
present.
• Analgesics are given to relieve pain, and possibly
sedative linctus to reduce coughing. Rest is important to
allow the inflammtion to subside and to minimise the pain.

41
42
 EMPYEMA
• DEFINITION : - Collection of pus in pleural cavity.
• AETIOLOGY : - The condition of empyema usually arises
secondary to pre- existing lung disease,
such as bacterial pneumonia, TB, lung
abscess or bronchiectasis.
- The most common cause is direct spread
of infection into the pleural space in a
patient with pneumonia caused by Strep.
pneumoniae.
43
 PATHOLOGICAL CHANGES :
• Infected material enters into pleural cavity

• Both layers of pleura become covered in thick inflammatory

exudate within which fibrous tissue is laid down

• As this fibrous tissue contracts, it acts as a physical barrier to

lung expansion

• Pressure of fibrous tissue on pus may rupture pleura and lung

tissue, pus may then be coughed up.
44
• Alternatively, an abscess may form. Healing occurs
when the pus has been surgically removed or the
infection has been over-come by the patient's natural
antibodies, asisted by antibiotics.

• The layers of the pleura come togather and adhesion

formation may take place, restricting lung movement.

45
 CLINICAL FEATURES :
• Pyrexia
• Lassitude and loss of weight
• Tachypnoea
• Dyspnoea
• Pleuritic pain, severe at first then decreasing in severity.
• Diminishe thoracic movements.
• There may be a h/o Pneumonia or other associated disease.

46
INVESTIGATIONS :
• On X-ray the empyema can be seen as a D- shaped
shadow, the straight line of D being on the lung surface.
Pleural aspiration or tap will confirm the diagnosis, as the
sample is often thick and purulent, and may be foul-
smelling.
• Pleural Fluid cytology will reveal an exudate with pus cells
and organisms.

47
48
 TREATMENT
• Anti- biotics are given to combat infection.
• Aspiration through a needle inserted into the cavity may
remove significant pus to relieve the condition, but continuous
underwater drainage may be necessary.
• Rib resection may be indicated if the effusion is very thick or
loculated.
• If the condition results in fibrosis of the pleura that severely
limits lung expansion, then a rib resection may be performed
and the pleura stripped of the lung ( Decortication ).
49
Physiotherapy management
for pleural conditions

50
 Aims of physiotherapy are :
- To obtain full expansion of the affected lung
- To increase ventilation of the lungs
- To minimise adhesion formation within the pleura
- To clear lung fields
- To maintain good posture and thoracic mobility
- To improve exercise tolerance
51
- Breathing exercises are important following a pleural effusion
to prevent chest deformity and loss of respiratory function due
to thickening of pleura.
- If there is large effusion, causing the patient to be dyspnoeic,
breathing exercises are not usually effective until the fluid has
been aspirated.
- In such condition, the patient should be taught localised
expansion exercises to all areas of the affected side including
the apical region where there can be some flattening.
Belt exercises are often helpful and patent should be
encouraged to practise these several times a day. 52
53
54
• If chest movement does not improve, the patient should lie on
his unaffected side with two pillows under his thorax in order to
open out the ribs on the affected side. He should be
encouraged to carry out breathing exercises while lying on his
side and it may be necessary to adopt this position for 30 min.
at least 4 times a day. Treatment should be continued until
chest expansion is equal and radiolgraphic appearances have
improved.
• Occationally, a malignant pleural effusion may be drained, and
tetracycline introduced to cause a pleurodesis.
POST OPERATIVE REGIME
55
 POST OP. REGIME :
• Care of the drainage tubes togather with costal and diaphragmatic
breathing exercises and coughing will be carried out with the patient in
side lying position and the affected lung uppermost; the foot of the bed
will be elevated.
• All exercises are increased and postural drainage continued until
intercostal tubes and/ or all excess secretions are removed.
• Walking, stair climbing and general exercises should continue
until discharge, when all movements should be unrestricted
and the posture free and upright.
56
• Full range shoulder movements are also necessary to
maintain shoulder, shoulder girdle and thoracic mobility. this
treatment is given 3-4 times daily until the drain is removed.

• Following pleurodesis, expansion breathing exercises are

essential to ensure that when the adhesions form
between the layers of the pleura - The lung is fully
expanded.
57
• For thoracic mobility also, expansion breathing exercises are
used, otherwise there may be sharp pleuritic pain occur due to
over-contracted intra-pleural adhesions

• If the patient has a chest drainage tube inserted, the

physiotherapy is similar to that following a thoracotomy. good
posture should be encouraged whenever physiotherapy is
being given.
58
• Breathing exercise to expand the lung on the affected side need to be
carried out three or four times daily.
• Postural drainage may be indicated to clear the lungs if secretions are
accumulating.
• As the patient recovers, general leg, arm and trunk exercises should
be taught. Walking should begin as soon as possible with breathing
control practised over progressively longer distances, and with going
down ( then up ) stairs incorporated.
• As the patient regains lung expansions, the treatment programme
should be expanded to increase exercise tolerance.
59
 REFERENCE :
• K George Mathew
• P J Mehta
• Pryor
• Joan E. Cash
• Tidy's Physiotherapy

60
THANK YOU

61