DISEASES

OF PLEURA
Eliana Muis

What should I know ?

Pleural Effusion
Pneumothorax
Pleural Tumor
Schwarte

Physical Examination

Physical Examination

Physical Examination

Physical Examination
Breath
sound ?
Additional
sound ?

Pleural effusion: Introduction

Collection of excess quantity of fluid in
pleural space
Cause:
- Inflammatory
- Non inflammatory

Normal condition:
Fluid in pleural space (0,3 ml/kgBW)
Maintain by the balance of pleural fluid
production and absorption

Dinding
toraks

Rongga
pleura

Paru

Kapiler
pulmona
l

Kapiler
sistemi
k
Tek koloid

Tek koloid
osmotik
(cm H2O)

osmotik
(cm H2O)
Tek negatif
intrapleura

Tek
hidrostati
k (cm
H2O)

Pleura
parietalis

Tek
hidrostati
k (cm
H2O)

Pleura
viseralis

Dinding
toraks

Rongga
pleura

Kapiler
sistemi
k
Tek koloid

Kapiler
pulmona
l

Efusi
Pleura

osmotik
(cm H2O)

Paru

Tek koloid
osmotik
(cm H2O)

Tek negatif
intrapleura

Tek
hidrostati
k (cm
H2O)

Pleura
parietalis

Tek
hidrostati
k (cm
H2O)

Pleura
viseralis

Pleura
parietalis

Pleura
viseralis

Kapiler
paru

Kapiler
sistemik
limfatik

Cairan
pleura

limfatik

CXR

Arah cairan dalam

kavitas pleura

Fluid direction,
posteroinferior
posteroinferior

CT-Scan

Pleural effusion: Classification

Transudates: due to diseases that
affect the filtration of pleural fluid: CHF &
hypoproteinemia

Exudates:

inflammation or injury
increases pleural membrane permeability
to proteins and various types of cells

Pleural effusion: Other

Classification
Purulent Empyema
Blood Hemothorax
Milky Chylothorax

Pleural Effusion fluid

Tests

Physical
appearance
Microscopy

Pleural fluid
protein
Pleural fluid
Protein / Serum
protein
Pleural fluid
LDH / Serum

Transuda Exudates
te
(tubercular
)
Clear
Straw
coloured
<1000
>1000
Lympho/ Lymphocyt
es
M
<3
>3 gm/dl
gm/dl
<0.5
>0.5

Exudates
(Empye
ma)
Cloudy /
Turbid
>5000
PMNs
Pus cells
>3 gm/dl

<0.6

>0.6

>0.6

>0.5

Pleural effusion: Causes

Bacterial pneumonias - Most common

TB, CCF, Hypoproteinemia
Obstruction to lymphatic drainage
Collagen vascular disease
Malignancies, Rheumatoid arthritis
Aspiration pneumonia, traumatic
Pulmonary embolism, chylothorax

Pleural effusion: 3 Types

1. Dry or plastic pleurisy
2. Serofibrinous or
serosanguineous pleurisy
3. Purulent pleurisy or empyema

1. Dry pleurisy or plastic

pleurisy
Associated with
Acute bacterial infections
Tuberculosis
Connective tissue disorders- rheumatic
fever

Dry pleurisy: Clinical

manifestations
Signs & symptoms of primary disease
Dull pleural pain, exaggerated by deep
inspiration,cough, straining, referred to
shoulder and back
Increased dullness on percussion and
decreased breath sounds
Leathery, rough inspiratory and expiratory
friction rub early in the disease
X-ray- haziness at the pleural surface or a
dense, sharply demarcated shadow

Dry pleurisy: Treatment

Treat underlying condition
If pneumonia is not present- strapping of
chest to restrict expansion and analgesics
Strapping and cough suppressants not
given if pneumonia is present

2. Serofibrinous pleurisy
Infections of lungs
Inflammatory conditions of mediastinum
Less commonly with- SLE, RF, neoplasms

Serofibrinous pleurisy: Clinical

features
Initially signs and symptoms of dry
pleurisy
Asymptomatic if effusion is small
Large effusion: cough, dyspnoea,
retractions, orthopnoea, cyanosis
Shift of mediastinum away from affected
side, fullness of intercostal space,
diminished tactile vocal fremitus
Dullness to flatness on percussion
Decreased or absent breath sounds

X-ray chest: Pleural

Effusion

Serofibrinous pleurisy:
Treatment
Treat underlying cause
Thoracocentesis, up to 1 Liter of fluid
Tube thoracostomy in older child with
parapneumonic effusion if pleural fluid
pH<7.2 or glucose <50mg/dl

3. Purulent pleurisy /
Empyema
Pus or microorganism in pleural fluid
Microorganism- by smear or culture
In the absence of these:
pH of pleural fluid < 7.2
Lactic dehydrogenase (LDH) >1000IU/L
Glucose <than 40mg/dl
Lactate > 45mg/ml

Empyema: Predisposing
factors
Pneumonia in of cases
Preceding H/O of pustules
Blunt trauma to
chest/surgery/thoracocentesis
Viral infections (chickenpox, measles)
Severe malnutrition
Neglected foreign body
Extension from subphrenic, amoebic liver
abscess
CHD
Peridontal disease, steroid,
immunodeficiency

Empyema: Etiology

Staphylococcus aureus, epidermidis

Streptococcus pneumoniae, viridans
H influenzae
Pseudomonas aeroginosa
E coli
Klebsiella aerogenes
Mycobacterium tuberculosis
Fungal/ EH (rare)

Stages of Empyema
Exudative (1 to 3 days):
parapneumonic effusion
Fibrino purulent (4 to 14 days):
polymorpho nuclear & fibrin accumulation
Organizing stage (after 14 days):
fibroblasts grow and producing an inelastic
membrane

Empyema: Exudative stage

Fluid is thin
Cellular content is low
Lungs are expandable
Pleural fluid- pH >7.3, glucose >60mg/dl,
pleural fluid /serum glucose ratio >0.5,
LDH < 1000 IU/L, Gram stain and culture
negative

Empyema: Fibrino purulent

stage
pH and glucose level fall, LDH rises
Purulent and vicious, accumulation of
neutrophils and fibrin
Tendency for loculations and limiting
membranes
purulent fluid, PH <7.10, glucose
<40mg/dl LDH >1000IU/L, Gram stain &
culture +ve

Empyema: Organizing stage

Thick pleura prevent entry of anti
microbial drugs in the pleural space- drug
resistance
Restrict lung movement

Empyema: Clinical features

Common in poor socioeconomic group
Peak incidence 0-3 years
Chills, fever, dyspnoea, chest pain,
referred pain, night sweat, malaise, cough,
sputum production
Pain abdomen & ileus
Tachypnoeic, anxious, pleural rub
(disappear after fluid accumulates)

Empyema: Clinical features...

Large fluid- fullness of intercostal spaces,
diminished chest excursions
Shift of mediastinum
Dullness to percussion, decreased air
entry, decreased tactile & vocal fremitus

Empyema: Investigation &

Diagnosis
History and examination findings
Confirm the presence of empyema,
etiological agent & complications
Polymorph predominance, rarely
leukopenia
X-ray chest- blunting of costophrenic
angle, opacification of hemithorax with
mediastinal shift to opposite side , lateral
decubitus for small volume

Empyema: Investigation...
USG- confirms, for thoracocentesis,
pleural catheter placement, transudates
anechoic, exudates echoic or anechoic,
limiting membrane suggest loculation
CT scan- confirm fluid, loculation, pleural
thickening
Pleurocentesis / thoracocentesis

Empyema: Aspirate
Investigation
Aspirate- Cell count and differential, Grams
stain, culture, pH, protein, glucose, LDH,
AFB stain & culture
Uncomplicated parapneumonic effusion:pH>7.3, glucose> 60mg/dl, LDH,1000IU/L,
Complicated parapneumonic effusion:pH<7.1, glucose<60mg, LDH>1000IU/L,
microbes on Grams stain
Tuberculous empyema:- AFB <25% cases,
Pleural biopsy & culture >90%, adenosine de
aminase (ADA) >70U/L, PCR

Empyema: Treatment
Aims
Control infection
Drainage of pus
Expansion of lungs

Empyema drainage
Inter costal drainage (ICD), under water
seal, large catheter inserted in the site of
pus accumulation
Loculated fluid/pus- drainage continued for
1 week
Chest tube kept till drainage is nil or < 30
ml/day

Empyema: Inter Costal

Drainage (ICD)

Empyema: X-Ray chest

Before & After Inter costal

drainage (ICD)

Empyema: Antimicrobial
therapy
Organi
sm
Staph

Drugs

Clox + Amino

Pneum PenicillinG
o
H influ Cefurox/ceftri
oxone
/Cefotax
Pseud Ceftazidine

Alternate
Durati
on
1-4wk

3rd gen
Cephlo +
Clox
Ceftriaxon 1-2wk
e
Chlorompe 1-2wk
nic
Impenum

Empyema: Treatment...
Based on culture and sensitivity
Monotherapy not recommended
In anerobic infection- Clindamycin: 6-12wk
MRSA- Vancomycin
Antibiotics till afebrile, WBC normal,
thoracostomy yield <50ml/day, X-ray
clearing
H influenzae & S pneumoniae: 7-14 days
S aureus: 3-4 wk, anerobic: (variable) 612wk

Empyema: Thrombolytic
therapy
Multiloculated empyema by thoracostomy
tube
Streptokinase 2,50,000 unit or urokinase
1,00.000 unit in 100ml normal saline
instilled through tube & clamped for 3 hrs

Empyema: Surgical therapy

Remains febrile and dyspnoeic after IV
antibiotics and thorcostomy drain
Pleural thickening- decortication
Non expansion of lung
Bronchopleural fistula
Video assisted thoracoscopic surgery in
multi loculated effusion
Thorocoscopic debridement and irrigation
in multiloculated effusion

Empyema: Complications
Bronchopleural fistula
Cutaneous fistula
Pyopneumothorax
Purulent pericarditis
Pulmonary abscess
Peritonitis secondary to rupture through
diaphragm
Septic complications - meningitis, arthritis,
osteomyelitis

Empyema: Prognosis
In adequately treated cases prognosis is
excellent
Follow up pulmonary functions suggest
that residual disease is uncommon

Pyopneumothorax

Pneumothorax
Presence of gas in
the Pleural space

Pneumothorax: Classification
Spontaneous pneumothorax
Primary , Secondary
Traumatic pneumothorax
Iatrogenic pneumothorax
Tension Pneumothorax

Traumatic Pneumothorax

Closed

Open

Pneumothorax: Causes
Rupture of pleural
blebs
Penetrating or non
penetrating injuries
Pneumonia
Asthma
Cystic fibrosis
COPD/ Bronchitis
Inhalation of some
toxic substances,
most notably crack
cocaine

Transthoracic
aspiration needle
Thoracentesis
Central
intravenous
catheters
Mechanical
Ventilation
Resuscitative
efforts

Clinical Signs & Symptoms

Severity depends on the extent of the
lung collapse.
Simple pneumothorax - asymptomatic
or chest pain, dyspnea.
Extensive pneumothorax often
produces pleuritic chest pain, dyspnea,
tachypnea, cyanosis, Hyperresonance to
percussion on the affected side.
Decreased breath sounds on the involved
side.
If pneumothorax due to trauma - look for
contusions or abrasions on the chest wall

Tension Pneumothorax:
Signs/Symptoms
Clinical Presentation - Chest pain (90%),
Dyspnea (80%), Anxiety, Fatigue
Physical examination - Respiratory
distress and/or arrest, Cyanosis, Tracheal
deviation, Pulsus paradoxus, Tachypnea,
Tachycardia, Hypotension, Jugular venous
distension
Hyperresonance of the chest wall on
percussion
Unilaterally decreased or absent lung sounds
Increasing resistance to providing adequate
ventilation assistance
Mental status changes, including decreased
alertness and/or consciousness

Tension Pneumothorax
Lung
parenchymal or
bronchial injury
one-way
valve
air trapping
mediastinal
structures pushed to the
contralateral
side.impinges
mediastinum
on
and compresses the
contralateral lung

Pneumothorax: Differential
Diagnosis

Bronchogenic Cyst
Congenital Lung Malformations
Cystic Adenomatoid Malformation
Pleural Effusion, Pyo pneumothorax

Investigations
Chest X-ray
Pulse oxymetry : SpO2
Arterial blood gas: arterial pO2

Pneumothorax: Treatment
Without continued air leak, asymptomatic
and mildly symptomatic small
pneumothorax
100% oxygen
Sedation

Tension Pneumothorax:
Treatment
Severe respiratory and circulatory
embarrassment
Emergency Needle aspiration
Either immediately or after needle
aspiration a chest tube (ICD) should be
inserted and attached to underwater seal
drainage

Decompression by Needle /
ICD
2nd intercostal space on the mid clavicular
line
Upper border of the lower rib
Needle / ICD have to be connected to the
underwater sealed drainage

Indications for ICD

1.
2.
3.
4.
5.
6.

Pneumothorax
Hemothorax
Hemopneumothorax
Tension pneumothorax
Empyema
Chylothorax

X-ray Pneumothorax: Before

Treatment

X-ray Pneumothorax: After

Treatment