PLEURAL DISEASEPLEURAL DISEASE
Pleural DiseasesPleural Diseases
Pleural effusionsPleural effusions Pleural malignancyPleural malignancy HemothoraxHemothorax PneumothoraxPneumothorax
The Mechanisms of Pleural The Mechanisms of Pleural EffusionEffusion
Increased hydrostatic pressure (Cardiac failure)Increased hydrostatic pressure (Cardiac failure) Decreased oncotic pressure (Protein deficiency)Decreased oncotic pressure (Protein deficiency) Decreased pleural cavity negative pressure Decreased pleural cavity negative pressure
(Atelectasis)(Atelectasis) Increased permeability in microvascular Increased permeability in microvascular
circulation (İnfections, inflammation)circulation (İnfections, inflammation) Impaired lymphatic drainage of pleural space Impaired lymphatic drainage of pleural space
(Tumor, fibrosis)(Tumor, fibrosis) Transperitoneal route (Congenital defects, Transperitoneal route (Congenital defects,
ascite)ascite)
SymptomsSymptoms
Chest pain (inspiratory)Chest pain (inspiratory) Decreases when the fluid Decreases when the fluid
increasesincreases DyspneaDyspnea CoughCough Symptoms of the Symptoms of the
underlying diseaseunderlying disease FeverFever HemoptysisHemoptysis Weight lossWeight loss ......
Physical signsPhysical signs
No physical signs can be No physical signs can be detected when the fluid is detected when the fluid is less than 300 mlless than 300 ml
İncreased size of the İncreased size of the affected hemithoraxaffected hemithorax
İpsilateral restriction of İpsilateral restriction of chest wall motion chest wall motion
VT absentVT absent Dullness (>300-400 ml)Dullness (>300-400 ml) Diminished breath Diminished breath
sounds or inaudiblesounds or inaudible Pleural friction rubPleural friction rub
RadiologyRadiology The fluid initially accumulates in the more The fluid initially accumulates in the more
dependent recesses of the thoracic cavity dependent recesses of the thoracic cavity forming a forming a Damoiseau LineDamoiseau Line
200-300 ml of pleural effusion can be detected 200-300 ml of pleural effusion can be detected on standard chest radiograph as blunting of the on standard chest radiograph as blunting of the costophrenic anglecostophrenic angle
Massive pleural fluid often shifts the mediastinum to the opposite side
Accumulation of the fluid between the diaphragm and the interior surface of the lung (Subpulmonic fluid):
The hemidiaphragm appears to be elevated (Widening the distance between the top of the gastric bubble and the top of the left hemidiaphragm (>2 cm) and flatened
Blunting of the posterior costophrenic angle on the lateral chest radiograph
Smaller amounts of pleural fluid can be Smaller amounts of pleural fluid can be detected on lateral decubitus radiography detected on lateral decubitus radiography as the free intrapleural fluid moves from as the free intrapleural fluid moves from top of the diaphragm to the dependent top of the diaphragm to the dependent chest wallchest wall
Pleural effusion in a lateral decubitus radiograph
Unusual localized Unusual localized pleural effusions can pleural effusions can be seen due to the be seen due to the localized obliteration localized obliteration of the pleural space of the pleural space often by inflammatory often by inflammatory conditionsconditions
Ultrasound is able to demonstrate smaller Ultrasound is able to demonstrate smaller amounts of fluid as 100 mlamounts of fluid as 100 ml
CT has similar sensitivity to ultrasound, CT has similar sensitivity to ultrasound, not routine but can be performed to not routine but can be performed to evaluate concomitant paranchymal lesionsevaluate concomitant paranchymal lesions
CT is sensitive in identifying pleural CT is sensitive in identifying pleural thickening and calcificationthickening and calcification
ThoracentesisThoracentesis
Thoracentesis is indicated in all cases of Thoracentesis is indicated in all cases of pleural efusion of unknown originpleural efusion of unknown origin
The site should be selected according to The site should be selected according to clinical examinationclinical examination
If the effusion is small thoracentesis can If the effusion is small thoracentesis can be performed under ultrasound guidancebe performed under ultrasound guidance
Thoracentesis is usually performed for diagnosisThoracentesis is usually performed for diagnosis Apperiance of the fluid (Serous, bloody, purulent)Apperiance of the fluid (Serous, bloody, purulent) Biochemical, microbiological, cytological examination Biochemical, microbiological, cytological examination
of the fluidof the fluid
It can also be performed for the drainage of It can also be performed for the drainage of excess fluid (Therapotic) to relieve dyspnea excess fluid (Therapotic) to relieve dyspnea The amount of fluid should not exceed 1000-1500 cc The amount of fluid should not exceed 1000-1500 cc
at a time to avoid hemodynamic complications and at a time to avoid hemodynamic complications and reexpansion pulmonary edemareexpansion pulmonary edema
Pleural Fluid analysisPleural Fluid analysis
AppereanceAppereance Serous (light to dark, clear)Serous (light to dark, clear) Serosangineous (Blood tinged can be due to Serosangineous (Blood tinged can be due to
thoracentesis itself)thoracentesis itself) Hemorrhagic (hemothorax if hct>50% of blood Hemorrhagic (hemothorax if hct>50% of blood
hct)hct) Purulent (fetid odor in aerobic infections)Purulent (fetid odor in aerobic infections) Chylous (milky)Chylous (milky)
Biochemical evaluationBiochemical evaluation ExudativeExudative TransudativeTransudative Some special hintsSome special hints
Microbiological evaluationMicrobiological evaluation Cellular structureCellular structure Special stains and cultureSpecial stains and culture
Cytologic evaluationCytologic evaluation
Biochemical EvaluationBiochemical Evaluation
ExudateExudate Dark yellow colorDark yellow color Total protein >3 gr/dlTotal protein >3 gr/dl Density >1016Density >1016 Light Criteria:Light Criteria:
• Protein pl/sProtein pl/s >0.5>0.5• LDH pl/sLDH pl/s >0.6>0.6• LDH >200 or >2/3 of LDH >200 or >2/3 of
normal upper value of normal upper value of serumserum
TransudateTransudate Light yellow colorLight yellow color Total protein <3 gr/dlTotal protein <3 gr/dl Density <1016Density <1016 Light Criteria:Light Criteria:
• Protein pl/sProtein pl/s <0.5<0.5• LDH pl/sLDH pl/s <0.6<0.6• LDH <200LDH <200
Albumine Gradient:Albumine Gradient: Serum albumine- Pleural fluid albumineSerum albumine- Pleural fluid albumine <1.2 gr/dl<1.2 gr/dl EksudateEksudate >1.2 gr/dl>1.2 gr/dl TransudateTransudate
Pleural Cholesterol >60 mg/dl: EksudatePleural Cholesterol >60 mg/dl: Eksudate Pl/S bilirubine >0.6:Pl/S bilirubine >0.6: ExudateExudate
Microbiologic evaluationMicrobiologic evaluation
RBC >100 000/mmRBC >100 000/mm33 Trauma,Trauma, Pulmonary infarctionPulmonary infarction malignancymalignancy
WBC > 1000/mmWBC > 1000/mm33 : exudate : exudate > 10 000/mm> 10 000/mm33 : emphyema, : emphyema,
parapnomonic effusion (PNL predominates)parapnomonic effusion (PNL predominates)Lymphocytes >50% : tuberculosis, malignancy, Lymphocytes >50% : tuberculosis, malignancy,
lymphoma, fungus, myxedemalymphoma, fungus, myxedema
Gram stainingGram staining Ziehl-Neelsen stainingZiehl-Neelsen staining Cultures for specific and nonspecific Cultures for specific and nonspecific
infectionsinfections PCRPCR
Transudative Pl. Eff.Transudative Pl. Eff. Increased hydrostatic Increased hydrostatic
pressurepressure• Congestive heart failureCongestive heart failure• Constrictive pericarditisConstrictive pericarditis• Pericardial effusionPericardial effusion• Pulmonary thromboemboliPulmonary thromboemboli
Decreased oncotic Decreased oncotic pressurepressure
• CirrhosisCirrhosis• Nephyrotic syndromeNephyrotic syndrome• MalnutritionMalnutrition
Increased capillary Increased capillary permeabilitypermeability
• Myxedema Myxedema • Pulmonary thromboemboliPulmonary thromboemboli
Transperitoneal transportTransperitoneal transport• Peritoneal dialysisPeritoneal dialysis• AscitesAscites
Exudative Pl. Eff.Exudative Pl. Eff. Infectious diseasesInfectious diseases
• Pnomonia, lung abscessPnomonia, lung abscess• TuberculosisTuberculosis• Fungal infectionsFungal infections• Subphrenic abscessSubphrenic abscess
Neoplastic diseasesNeoplastic diseases• MetastaticMetastatic• MesotheliomaMesothelioma• LymphomaLymphoma
Immunologic reactionsImmunologic reactions• Dressler syndromeDressler syndrome• Sistemic Lupus Er.Sistemic Lupus Er.• Rheumatoid artritisRheumatoid artritis• Churg strauss syndromeChurg strauss syndrome• Wegener granulomatosisWegener granulomatosis
Exudative Pl EffExudative Pl Eff Gastrointestinal Gastrointestinal
diseasedisease• PancreatitisPancreatitis• Causes of peritoneal Causes of peritoneal
exudaexuda Drug inducedDrug induced
• NitrofurantoinNitrofurantoin• DantroleneDantrolene• MethysergideMethysergide• BromocriptineBromocriptine• ProcarbasineProcarbasine• AmiodoroneAmiodorone
PostsurgicalPostsurgical Pulmonary Pulmonary
thromboembolismthromboembolism
Exudative Pl EffExudative Pl Eff SarcoidosisSarcoidosis Uremic pleuritisUremic pleuritis Asbestos exposureAsbestos exposure ChylothoraxChylothorax HemothoraxHemothorax Yellow nail syndrome Yellow nail syndrome
Special characteristics:Special characteristics:Milky appearanceMilky appearance
ChylothoraxChylothorax Triglyceride >110 Triglyceride >110
mg/dlmg/dl Pl TG/sTG>1Pl TG/sTG>1 Cholesterol crystal (-)Cholesterol crystal (-) Chylomicrons (+)Chylomicrons (+) Sterile Sterile (bacteriostatic)(bacteriostatic)
Noniritative Noniritative (do not cause (do not cause pleural thickening)pleural thickening)
Ety: Trauma, surgery, Ety: Trauma, surgery, lymphomalymphoma
PseudochylothoraxPseudochylothorax Triglyseride <50 mg/dlTriglyseride <50 mg/dl Pl TG/sTG<1Pl TG/sTG<1 Cholesterol>250 mg/dlCholesterol>250 mg/dl Pl Ch/s Ch>1Pl Ch/s Ch>1 Ety: RA, TbcEty: RA, Tbc
EmphyemaEmphyema PH<7.20PH<7.20 Low GlucoseLow Glucose
Special characteristicsSpecial characteristics
Low Glucose values (<60 mg/dl)Low Glucose values (<60 mg/dl) Emphyema, complicated parapneumonic Emphyema, complicated parapneumonic
effusioneffusion TuberculosisTuberculosis Rheumatoid artritisRheumatoid artritis Malign effusionsMalign effusions
• Lupus pleuritisLupus pleuritis• Churg strauss syndromeChurg strauss syndrome
Less frequent
pH<7.20pH<7.20 Parapneumonic Parapneumonic
effusion, emphyemaeffusion, emphyema Esophageal Esophageal
perforationperforation Rheumatoid artritisRheumatoid artritis TuberculosisTuberculosis MalignancyMalignancy UrinothoraxUrinothorax
High amylase (over High amylase (over the upper limit of the upper limit of normal serum values)normal serum values) Esophageal Esophageal
perforationperforation Acute pancreatitisAcute pancreatitis Fistula in chronic Fistula in chronic
pancreatitispancreatitis Adenocarcinoma Adenocarcinoma
(salivary amylase)(salivary amylase)
Eosinophilia >10 % of the total cellsEosinophilia >10 % of the total cells Air or blood in the pleural spaceAir or blood in the pleural space
• Recurrent punctionsRecurrent punctions• Pulmonary embolismPulmonary embolism
Benign asbestos effusionsBenign asbestos effusions Resolving pleural infectionsResolving pleural infections Echinococus infectionEchinococus infection Loeffler syndromeLoeffler syndrome Hodgkin’s lymphomaHodgkin’s lymphoma Drug induced pleural eff.Drug induced pleural eff.
If the effusion is transudative the main If the effusion is transudative the main cause should be treatedcause should be treated
If the effusion is exudative and not If the effusion is exudative and not emphyema further diagnostic procedures emphyema further diagnostic procedures should be consideredshould be considered Cytologic examinationCytologic examination Closed pleural needle biopsyClosed pleural needle biopsy Thoracoscopy (VATS)Thoracoscopy (VATS) ThoracotomyThoracotomy
TreatmentTreatment Treatment of the specific causeTreatment of the specific cause Drainage of the excess fluidDrainage of the excess fluid Pleurodesis Pleurodesis (Performed to achieve fusion between (Performed to achieve fusion between
visceral and parietal pleural layers. Main indications are visceral and parietal pleural layers. Main indications are malignant effusions, rarely recurrent benign effusions malignant effusions, rarely recurrent benign effusions when other treatments have failed. After the removal of when other treatments have failed. After the removal of pleural fluid completely by thoracal tube, special pleural fluid completely by thoracal tube, special sclerosing agents (tetracycline, doxycycline, bleomycine, sclerosing agents (tetracycline, doxycycline, bleomycine, talc etc) are injected to the pleural cavity)talc etc) are injected to the pleural cavity)
Surgical pleurectomySurgical pleurectomy Pleuroperitoneal shuntPleuroperitoneal shunt
Cardiac effusionsCardiac effusions
Predominantly caused by left ventricular failure, Predominantly caused by left ventricular failure, elevated pulmonary capillary pressureelevated pulmonary capillary pressure
>50% are bilateral effusions or 27% right sided >50% are bilateral effusions or 27% right sided only.only.
Usually the heart is enlarged on chest x ray, Usually the heart is enlarged on chest x ray, phantom tumor (pseudotumor) can be present phantom tumor (pseudotumor) can be present on the right sideon the right side
Resolves with diuretics and treatment for left Resolves with diuretics and treatment for left ventricular failureventricular failure
Infectious pleuresy, emphyemaInfectious pleuresy, emphyema
Bacterial pneumonia is associated with an Bacterial pneumonia is associated with an effusion in 40% of caseseffusion in 40% of cases
The effusion may be parapneumonic The effusion may be parapneumonic without infection (uncomplicated) or without infection (uncomplicated) or culture positive (complicated, emphyema)culture positive (complicated, emphyema)
Parapneumonic effusions are treated with Parapneumonic effusions are treated with appropiate antibioticsappropiate antibiotics
Antibiotic treatment + Tube drainage is Antibiotic treatment + Tube drainage is indicated if emphyema occursindicated if emphyema occurs
Tube drainage indications in Tube drainage indications in complicated parapneumonic effusioncomplicated parapneumonic effusion
Purulent appearancePurulent appearance Gram staining (+) for bacteriaGram staining (+) for bacteria Plevral fluid glucose<40 mg/dlPlevral fluid glucose<40 mg/dl Pleural fluid pH<7.10-7.20Pleural fluid pH<7.10-7.20 Pleural fluid LDH>1000 IU/LPleural fluid LDH>1000 IU/L
Tuberculosis pleurisyTuberculosis pleurisy Usually occurs soon after the primary infection Usually occurs soon after the primary infection
and mainly affects children or teenager groupand mainly affects children or teenager group Pathogenetic mechanisms include direct Pathogenetic mechanisms include direct
invasion of AFB to pleura or delayed type invasion of AFB to pleura or delayed type hypersensitivity reactionhypersensitivity reaction
The onset of symptoms may be acute or The onset of symptoms may be acute or subacutesubacute
Typical symptoms of pleural effusion and Typical symptoms of pleural effusion and general symptoms of tb may be presentgeneral symptoms of tb may be present
Exudative effusion, lymphocyte Exudative effusion, lymphocyte predominance, low glucose, low predominance, low glucose, low mesothelial cells (<5%), high ADA mesothelial cells (<5%), high ADA Tuberculin skin test can be (-) in 30%Tuberculin skin test can be (-) in 30%
Treatment: Pulmonary tb treatment Treatment: Pulmonary tb treatment ++ steroidsteroid
Other Pleural DiseasesOther Pleural Diseases HemothoraxHemothorax
Plevral fluid htc>50% of serumPlevral fluid htc>50% of serum Can be traumatic or nontraumatic:Can be traumatic or nontraumatic:
• İatrogenicİatrogenic• Pulmonary infarctionPulmonary infarction• TumorsTumors• Rupture of aneurismRupture of aneurism• Anticoagulan treatmentAnticoagulan treatment• Thoracic endometriosisThoracic endometriosis
Treatment: Treatment: • intrapleural drainageintrapleural drainage• thoracotomythoracotomy
ChylothoraxChylothorax Direct passage of chyle Direct passage of chyle
from the thoracic duct into from the thoracic duct into the pleural cavitythe pleural cavity
TG>110 mg/dlTG>110 mg/dl Cause:Cause:
• Tumors (Lymphoma)Tumors (Lymphoma)
• Trauma (surgery)Trauma (surgery)
• Congenital defectsCongenital defects
• LymhangioleiomyomatosisLymhangioleiomyomatosis
• TuberosclerosisTuberosclerosis
Treatment.Treatment.• Pleural drainagePleural drainage
• Parenteral nutritionParenteral nutrition
• Bed rest (to decrease Bed rest (to decrease lymphatic drainage)lymphatic drainage)
• Surgical ligation of Surgical ligation of thoracic ductthoracic duct
• Chemotherapy or RTChemotherapy or RT
FibrothoraxFibrothorax A thick fibrous tissue formed on visceral A thick fibrous tissue formed on visceral
pleurapleura Cause:Cause:
• EmpyemaEmpyema• TuberculosisTuberculosis• HemothoraxHemothorax
Treatment: DecorticationTreatment: Decortication
Pneumothorax (Px)Pneumothorax (Px)
Presence of free air between the visceral and parietal Presence of free air between the visceral and parietal pleurapleura
Divided into 3Divided into 3• Open Px ( Penetrating trauma)Open Px ( Penetrating trauma)• Closed PxClosed Px
Spontaneous (Primary, Secondary)Spontaneous (Primary, Secondary) Closed traumaClosed trauma iatrogeniciatrogenic
• Tension Px (Penetrating trauma)Tension Px (Penetrating trauma)
Physical examination:Physical examination: Hypersonority on percusionHypersonority on percusion Reduced breath soundsReduced breath sounds Hypotension and cardiac tamponade may occur Hypotension and cardiac tamponade may occur
depending on the size of the pneumothoraxdepending on the size of the pneumothorax
Radiology:Radiology: Pleural line Pleural line Hyperlucency at the peripheryHyperlucency at the periphery Mediastinal shiftMediastinal shift Expiration film, lateral decubitus film can be used Expiration film, lateral decubitus film can be used
when the lesion is not apparentwhen the lesion is not apparent
Measurement of the average Measurement of the average diameters of the collapsed diameters of the collapsed lung and the affected lung and the affected hemithorax can be usedhemithorax can be used
100-(8100-(833/11/1133)100=% 62)100=% 62
>2 cm pleural line from >2 cm pleural line from thoracic line in hiler region is thoracic line in hiler region is large pxlarge px
Simple observation with rest Simple observation with rest and supplemental oxygen can and supplemental oxygen can be used for asymptomatic be used for asymptomatic patients with a small (<20%) patients with a small (<20%) pxpx
Quantification of the size of the pneumothorax is Quantification of the size of the pneumothorax is helpfull in the decision of treatment helpfull in the decision of treatment
Intercostal drainage is indicated in large or Intercostal drainage is indicated in large or bilateral or tension pxbilateral or tension px
A recurrent spontaneous pneumothorax A recurrent spontaneous pneumothorax (30-50% risk) is an indication for surgery(30-50% risk) is an indication for surgery
Smoking should be quited after first attackSmoking should be quited after first attack
A patient with px cannot travel by air until A patient with px cannot travel by air until totaly expanded in chest x raytotaly expanded in chest x ray
Pleural NeoplasmsPleural Neoplasms Benign:Benign:
Pleural lipomaPleural lipoma Local pleural fibroma (Fibrous mesothelioma)Local pleural fibroma (Fibrous mesothelioma)
Malign: Malign: Diffuse malign mesotheliomaDiffuse malign mesothelioma
Metastatic:Metastatic: Bronchial carcinoma (adenocarcinoma) Bronchial carcinoma (adenocarcinoma) LymphomaLymphoma Breast carcinomaBreast carcinoma Other adenocarcinomasOther adenocarcinomas
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