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PLEURAL DISEASE

MUHAMMAD ILYAS

Pulmonary Division Departement Of Internal Medicine


Faculty of Medicine Hasanuddin University
PLEURA
• The pleura is formed of two serosal
membranes, one covering the lung and
one covering the inner chest wall
• The pleural space is the space delimited
by two layers
• Normal condition, it contains only a
small amount of liquid that function as
a lubricator
• Composition of the thin layer of fluid
between the parietal and visceral pleura
is that of an ultrafiltrate of plasma

• The two lining act like semipermeable


membrane
Composition of Normal Pleural fluid
• Volume : 0,1-0,2 ml/kg
• Cell per mm3 : 1000 – 5000
• Meshotelial cells 3-70%
• Monocytes 30-70 %
• Lymphocyte 2-30 %
• Granulocyte 10 %
• Protein : 1 – 2 g/dl
• Albumin : 50 – 70%
• Glucose < plasma level
• LDH < 50 % plasma level
• pH ≥ plasma
• The Blood supply of the parietal pleura comes
exclusively from the systemic artery

• In contrast, visceral pleura is vascularized by


both the systemic and pulmonary circulation

• Venous blood is drained into the pulmonary


venous system
Initial Assesment
• Initial Assesment of patient with
suspected or proven pleural disease is
critical not only because history taking
and physical exm. may provide clues to
the diagnosis but also because they
may be useful in suggesting the cause
of underlying desease
• The typical symptom associated with
pleural disease are dyspnea and
“pleuritic” chest pain radiating to the
shoulder, back or neck are carried
through the sensory part of the phrenic
nerve.
• Chest pain made worse by breathing
and coughing
Diagnostic Procedures
• History and physical examination
• Conventional radiographic
• Computed Tomography
• Ultrasound
• Nuclear medicine
• Invasive prosudure :
– Thoracentesis
– Closed pleural needle biopsy
– Thoracoscopy
– Open thoracotomy
– Bronchoscopy
PLEURAL EFFUSION
PLEURAL EFFUSION
• Defined ; Accumulation of fluid within the
visceral and parietal layers of the pleura
when there is an imbalance between
formation and absorption in various disease
states.
• Caused by either excess fluid production or
decrease absorption
• Effusion are a common manifestation of both
systemic and intrathoracic disease
• Factors that determine whether pleural fluid
accumulates include :
• - oncotic pressure in the pleural fluid,
pleural microcirculation and lymphatics
• - permeability of the pleural microcirculation
• - pressure in the systemic and pulmonary
vein
Pathophisiology
• Normally : made from parietal pleura
capillary, 5-10 ml, 0.01 ml/kg BW/hr
• Absorption 20 times more than
production
• Fluid movement influence by
hydrostatic pressure and capillary
osmotic
The mechanisms that lead to accumulation
of pleural fluid
l. Increased hydrostatic pressure in
microvascular circulation (CHF)
2. Decreased oncotic pressure in microvascular
circulation (severe hypoalbuminemia )
3. Increased permeability of the microvascular
circulation (pneumonia)
4. Impaired lymphatic drainage from the pleural
space (malignant effusion)
5. Movement of fluid from peritoneal space
( ascites )
Etiology
• Most common pathologyc of pleura
disease ; pleura, lung parenchym or
mediastinum
• Type of fluid effusion :
• - Transudate
• - Exudate
• - Emphyema
• - Haemorrhagyc/ haemothorax
• - Chylous / chyliform
Criteria for “Exudative Effusion”
• criteria value
• 1. Pleural Protein : Serum Protein > 0.5
• 2. Pleural LDH : Serum LDH > 0.6
• 3. Pleural LDH > 200

• only need 1 critical value to establish the diagnosis


of exudate
Two kinds of pleural effusions
Transudates and exudates

Transudate Exudate
Cause non-inflammatory inflammatory,tumor
Apperance light yellow yellow, purulent
Specific gravity <1.018 >1.018
Coagulability unable able
Revalta test negative positive
Protein content <30g/L >30g/L
ΘP. To serum Pre < 0.5 > 0.5
LDH < 200 I U/ L > 200 I U / L
Θ P. To s < 0.6 > 0.6
Cell count < 100×10 6/ L > 500×10 6 / L
Differential cell Lymphocyte Different
Pleural Fluid Analysis
• Thoracentesis: Transudate vs. Exudate
• 1. Gross Appearance
• 2. Cell Count & Differential
• 3. Gm Stain, C & S
• 4. Cytology
• 5. LDH
• 6. Protein
• 7. Glucose, Amylase
Clinical Manifestations
• Pain
• Cough
• Dyspnea
• Dullness to Percussion
• Diminished or Absent Vocal Resonance
• Diminished or Absent Tactile Vocal
Fremitus
• Friction Rub
Upright…Meniscus
Supine…Unilateral
increased density
Decubitus…Effusion
layered on downside
Massive Pleural Effusion
• Large Effusions that prevent contact
between the Visceral & Parietal Pleura
during respiration are seldom
associated with pleuritic chest pain.

• Large effusions interfere with expansion


of the lung and produce dyspnea,
shortness of breath, and atelectasis
Treatment
• Transudative Effusion: focus on the
systemic cause
• Exudative Effusion: dependent on the exact
sub-type
• Consider Chest Thoracostomy
• Gross Pus / Empyema
• pH < 7.2
• Hemothorax
• Complicated Parapneumonic Processes
• Malignant Effusions…but remember the role of
pleurodesis!
Pneumothorax
• Collection of air or gas in chest or
pleural space which causes collapsed
lung
• A pneumothorax is a serious condition
that can be life-threatening.

Tension Pneumothorax
• If air continues to enter the pleural
space, a tension pneumothorax occurs.
• The air may compress the heart and
cause a fall in B.P.
• This is life-threatening and requires
immediate treatment to release the
pressure.
• Treatment can life-saving.
• Symptoms of a tension pneumothorax
may include:
– Shift of the trachea
– Loss of consciousness
– Sweating
– Gasping
– Shock
– Rapid HR
Types of Pneumothorax
• Spontaneous Pneumothorax
• Primary - rupture of subpleural bleb
– “Jimmy is a tall, wiry, 21-year old male, who plays
trombone in the marching band….”
• Secondary : underlying lung/pleural disease
emphysema
• Chronic bronchitis, asthma, TB, …
• Traumatic Pneumothorax
• Open
– Chest wall is penetrated : outside air enters
pleural space
• Closed
• Chest wall is intact Ex. Fractured rib
Types of Pneumothorax 2
• Tension Pneumothorax
– “Ball-valve mechanism”
– Injury to pleura creates a tissue flap that opens
on inspiration and closes on expiration
– One of our own patients
– Variations
= Hemo-thorax
= Chylo-thorax
@ Injury to thoracic duct
– Empyema
@ Parapneumonic effusions in community-acquired
pneumonia
Symptoms
Dyspnea
Pleuritic chest pain
– Nerve endings at pleural capsule
Sense of impending doom
Sudden onset
- Tension pneumothorax
- Spontaneous pneumothorax
Physical Exam - Signs
– Unstable patients vs. Stable patients
– Vital Signs
– Asymmetric chest expansion
– Deviated trachea
– Diminished breath sounds unilaterally
– Hyper-resonance unilaterally
– Decreased tactile fremitus
Diagnosis
– Unstable patient
Thoracentesis
@ Rapid release of air
@ Vital signs stabilize rapidly
– Stable patient
• CXR
• Monitor size by measuring distance from lateral
lung margin to chest wall
• Be sure that pneumothorax is not expanding
Imaging

- Plain Radiographs
• Upright PA on inspiration
- Detect other pathologies: pneumonia, cardiac, etc.
- Partially collapsed lung
- Tension Pneumothorax
• Trachea and mediastinum deviate contralaterally
• Ipsilateral depressed hemi-diaphragm
- Chest CT
- Not routine
- Only to assess the need for surgery (thoracotomy)
Treatment
• Small pneumothorax
Resolve over days to weeks
Supplemental oxygen and observation
Tension pneumothorax
– Immediate decompression via chest tube or
needle thoracostomy
Spontaneous pneumothorax
– Asymptomatic – outpatient, f/u with serial CXR
– Symptomatic – inpatient, chest tube
– Recurrent pneumothorax – CT to evaluate need
for thoracotomy
– Needle decompression
• Simple large-bore needle
• Mid, anterior chest
• 2nd or 3rd rib space
• NOT right next to Sternum

The “ Magic triangel”


Chest Tubes

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