Diseases of pleuraBeatrix Bálint MD.

Pleural cavity

Pleura

1. Apex2. Lat. mellkasfal3. Mediastinum4. diafragma

Diseases of pleura

• Inflammation = pleurisy

• Pneumothorax

• Tumor

Inflammation of pleura

• 1. Pleuritis sicca– Cause: viral infection

• Bornholm’s disease• Coxsackie B

– Symptomes:• Pleuritic chest pain• Pleural friction rub

– Therapy:• symptomatical

• 2. Pleural effusion:aetiology:multifactorial– Symptomes

• Chest pain• Dyspnoe

– Physical examination• Percussion note: dull• Auscultation: diminished/absent breath sounds

– X-ray• Small fluid: blunting of costo-phrenic angleű• Larger volume (>300 ml):homogenous shadow

– Therapy• Thoracocentesis• To treat the cause of the pelural effusion

Pleurisy

Pleural effusion

Definition: An accumulation of fluid between the layers of the membrane lining the lung and the chest cavity.

Alternative names: Fluid in the chest; Transudative pleural effusion; Exudative pleural effusion

Causes: Pleural fluid is normally formed in small amounts to lubricate the surfaces of the "pleura," the thin membrane that lines the chest cavity and surrounds the lungs. A "pleural effusion" is an abnormal collection of this fluid.

Pleural effusion

Pleural effusion

Pleural effusion

Pulmonary embolism

Pathophysiology of pleural effusion of pulm. capill. wedge pressure: cong. heart failure onc. pressure in microvas. circulation: low Se albumin in pressure in the pelural space: lung collapse due to ptx permeability of microvasc. circ.:due to inflam.

mediators• Impaired lymphatic drainage from pl. space: due to tu /

fibrosis• Occlusion of pariet. pleura stomata with fibrin, debris and

mesoth. swellings: due to pneumonia• Movement of fluid from peritoneal space through diaphr.

lymph. / diaphr. defect

ThoracocentesisDefinition: A procedure to remove fluid from the space between the lungs and the wall of the chest. How to prepare for the test: No special preparation is needed before the procedure. A chest X-ray is may be performed before and after the test. Do not cough, breathe deeply, or move during the test to avoid injury to the lung.

Risks: pneumothorax (collapse of the lung), fluid re-accumulation, pulmonary edema, bleeding,infection, and respiratory distress.

Pleural effusion: analysis

• Quantity• Quality: color, density, opacity• Lab. analysis

– Chemical– Cytological– Bacteriological: culture

• Spec• Aspec.

Lab. analysis of pleural effussion

3 % protein 3 % + Rivalta -

0.5 Protein in pl. eff./ Se protein

0.5

0.6 LDH in pl.eff/Se LDH

0.6

1014 Specific gravity 1014

inflammation Cause syst./pulm. venous pressure

Exsudate Transudate

Common Causes of Exudative Effusion

Tuberculosis Unilateral

Lung cc Bloody, large, parenchymal lesion on the X-ray, rapid. Reprod.

Pneumonia X-ray:infiltr.

Pulm. Infarction Bloody, pleural pain

Lymphoma E.g.:Hodgkin disease, +mediast. Lg.

Metastatic tumor Large, rapid. Reprod.

Mesothelioma Bloody, Large, rapid. Reprod.

Trauma Bloody

Common Causes of Transudative Effusion

Congestive heart failure Bilateral

Cirrhosis Ascites, Se protein low, usually on the right side

Nephrotic syndrome Hypoproteinaemia,

Generalized oedema, ascites

• 3.Empyema = pus in the pleural space

– Cause:bacteria: Staphylococcus aureus, Klebsiella pn, E. Coli, Mycobact. Tb, anaerobic bact.

– Appear: as the complication of bacterial pneumonia, subdiaphragmatic abscess, oesophageal perforation, following thoracic surgery

– Symptomes:• Chest pain• Dyspnoe• Fever• Night sweats• Weight loss

Empyema 2.

– Physical examination: Signs of pleural fluid• Percussion note: dull • Auscultation: diminished/absent breath sounds

– X-ray: Signs of pleural fluid– Therapy

• Drainage of pleural space• Antibiotics• In the case of uneffective th: thoracotomy,

pleural peel

II. Pneumothorax= air in the pleural space complete or partial collapse of the lung

• Symptomes:• Chest pain• Dyspnoe

• Physical sign – Percussion note:Hyperresonance – Breath sounds: diminished/absent

• X-ray: visible pleural edge with no lung markings between this edge and the chest wall

• Therapy: depends on the size of the ptxsmall: O2 th, close observation, suction of the air by needlelarge:consant tube drainagepleurodesissurgery

Potential causes of pneumothorax

• Air: from the airways– Idiopathic– Rupture of

oesophagus– COPD– Pos.pressure

ventillation– Infection, tumor,

foreign body

• Air: outside the chest wall– Trauma– Thoracocentesis,

pleural biopsy, TTB– Insertion of venous

catheter

Pneumothorax

Pneumothorax

Pneumothorax

Tension PTXA tension PTX is a life-threatening condition that requires immediate intervention. Causes: penetrating chest injuries, fractures of the trachea or bronchi, a ruptured

esophagus, the presence of an occlusive dressing over an open PTX, and PPV. Progressive build-up of pressure in the pleural space pushes the mediastinum to the

opposite hemithorax, and obstructs venous return to the heart. This leads to circulatory instability and may result in traumatic arrest.

 Symptomes: patient is tachycardic and tachypnoeic, and may be hypoxic. These signs are followed by circulatory collapse with hypotension and subsequent traumatic arrest with pulseless electrical activity (PEA). Breath sounds and percussion note may be very difficult to appreciate and misleading in the trauma room.

Mrtg: Deviation of the trachea away from the side of the tension.• Shift of the mediastinum.• Depression of the hemi-diaphragm.Th:emergent chest decompression with needle thoracostomy. A 14-16G intravenous cannula is inserted

into the second rib space in the mid-clavicular line. The needle is advanced until air can be aspirated into a syringe connected to the needle.

Constant tube drainage

Tension PTX

III. Pleural tumors

• 1. Primery tumor = mesothelioma– Localised form: solitary growth on pleural surface

• Th: surgical resection

– Diffuse mesorhelioma:highly malignant tu.• Symptomes: chest pain, cough, dyspnoe

• X-ray: rapidly reproducated peural effusion

• Dg: cytological examination of the effusion

• Th: symptomatical

• 2. Metastatic tumor: malignant pleural effusion caused by primery tumor of the body: breast cc., lung cc.

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