Other pulmonary pathology

Pleural pathology
PLEURAL DISEASES
• Serous membrane of mesodermal origin
• Visceral + parietal pleura
• Parietal pleura: lines the ribs, diaphragms and mediastinum
• Visceral pleura: covers the lung and interlobar fissures
Ethiology
• - infectious (viral/bacterial pneumonia)
• - cancer (bronhopulmonary cancer, pleural cancer, breast cancer)
• - pulmonary infarction
• - posttraumatic
• - cardiac (right cardiac insufficency )
• - oncotic pressure drop (hepatic cirosis)
Pleural effusion
• Abnormal accumulation of fluid in the pleural space (transudates/
exudates)
• Transudates: drecrease in the colloid osmotic pressure
(hypoproteinemia), increase in the microvascular hydrostatic osmotic
pressure
• Exudates: alteration in the pleural surface with either an increase in
permeability or decrease in the lymph flow
• 1. Incipient pleural effusion (50-100 ml) – not seen on PA chest Xray,
only on the profile view (in the posterior costodiafragmatic sinuss)
• 2. Small size pleural effusion (200-500 ml)– only the costo-
diafragmatic sinusses
• 3. Medium size pleural effusion (<1000 ml): sinus + 1/3 inf hemithorax
• 4. Large pleural effusion
• 5. Massive pleural effusion -
• Basal opacities which first fill the costophrenic angles
• Large (massive) effusions:
• all the cardiophrenic angles are obliterated
• the mediastinum is shifted toward the contro-lateral part (!!! Atelectasis
differential diagnostic)
• and the ipsilateral hemidiaphragm is elevated
• Loculated pleural effusions: accumulations of pleural fluid within the
fissures or between the visceral an parietal pleura when the pleural
layers are partly adgerent.
• Chest Xray PA
• Description:
• Opacity
• high intensity
• Homogeneous
• in the inferior part/third of the right lung
• My diagnostic: Pleural effusion in small quantity because:
• costophrenic angle is blunted/opac
• the superior border is concave and oblique ascendant towards the axilla
• Differential diagnosis:
• bacterial pneumonia (no aeric bronhogram)
• inferior lobe atelectasis
Massive pleural
effusion

Opacity of high
intensity,
homogeneous,
which covers
almost totally the
right lung,
DD. atelectasis
 Loculated pleural effusion
- if the visceral and parietal pleura are too adherent, pleural
effusions may be developed having the appearance of thickening
of the chest wall.
- P-A chest xray appears as fuziform or round opacity that make
obtuse angles with the chest wall
- --> !!!!! (as opposed to peripheral pulmonary tumors that are well
defined and make sharp angles with the chest wall.
- - there may be exceptions to this rule when the lesions are very
high.
Loculated pleural
effusion
Biconvex shaped
opacities located on
the minor and
major fissure
High intensity,
homogenous
Loculated pleural
effusion can be:
-at the level of
convexity of the
chest
-the diaphragmatic
level –
at the apex level -
opacity in the
headset
-Axiallary level
- apparent diaphragmatic ascension,
with the lateral pleural dome moving.
- left diaphragmatic pleural effusion can
be radiologically detected by
measuring the distance between the
base of the lung and the air chamber of
the stomach that is > 2 cm.
- -DD: subdiaphragmatic formations,
phrenic nerve paralysis

- Diaphragmatic loculated pleural

effusion
Pneumothorax

Def: affection by which the pleural cavity, normally virtual, is transformed into a
real cavity by the presence of air between the two pleural effusions: parietal
and visceral.
It's a medical-surgical emergency!!!
Clinically:
sudden laterothoracic pain;
dry cough, exacerbated when changing position;
dyspneea of variable intensity, severe;
!! accompanied by cyanosis in the suffocating pneumothorax
Etiology:
Spontaneous pneumothorax:
- emphysema, frequently in tall and slim men, other pulmonary
diseases: histiocytosis X, cavitary tuberculosis, cystic fibrosis,
pneumoconiosis, necrotizing pneumonitis, lung infarction,
bronchial metastasis, pulmonary fibrosis etc.
Traumatic pneumothorax: costal fractures with visceral pleura;
pulmonary dilaceration
Iatrogenic pneumothorax: pleural effusion; catheter in the
subclavicular vein; transpulmonary puncture; high positive pressure
ventilation; tracheostomy.
Radiological description:
a) total pneumothorax: collapsed lung and hypertransparency/lucency with the disappearance
of the pulmonary design
b) partial pneumothorax (apical, axillary, supradiafrahmatic) - occurs when the pleural cavity has
some adhesions - hypertransparency localized with absence of pulmonary design
c) pneumothorax in the cloak: the air forms a transparent blade around the lung, which is only
slightly detached from the chest wall.
d) closed pneumothorax: the air permeation port closes and there is no communication with the
outside
e) open pneumothorax: there is a large and permanent fistula and both the air enters and leaves
the pleural cavity
f) g) pneumothorax under voltage (with valve): the air enters and does not come out and
mediastinal deflection phenomena occur as a result of the increase in the amount of air in the
pleural cavity; mediastinal movement / diaphragmatic inversion; total or subtotal pulmonary
collapse; collapse VCI \ VCS (right edge of the heart); decreases systemic venous return
Hidro-pneumo-thorax

Mixed hydroaeric image with horizontal level of liquid at the

bottom
- superior pulmonary design is not observed.
- the lung is collapsing to the hill
- The level of demarcation is and remains horizontal
irrespective of the position or inclination of the patient (but
is oscillating)
- It occurs relatively quickly after pneumothorax
- A mono or multilocular and radiological encapsulation may
appear as a layered appearance