بنام خداوند جان و خرد کزین برتر اندیشه بر نگذرد

PATHOPHYSIOLOGY OF THE PLEURAL DISEASE

Pleural anatomy

Blood supply Lymphatic Nerve supply

Pleural Liquid and Pleural Pressure

Pleural Effusion

Increase in fluid entrance Decrease in fluid removal (like tuberculosis, malignant effusion, yellow-nail syndrome) Obstruction of the parietal pleural stomas Inhibition of lymphatic contractility Infiltration of draining parasternal lymph nodes Elevation of the systemic venous pressure

Common Symptoms Of Patients With Pleural Effusion Pleuritic chest pain (inflammation of the parietal pleura) Cough ( due to distortion of the lung) Dyspnea (Outward displacement of the chest wall and downward displacement of the diaphragm)

CHEST X RAY (PA)

CXR (lateral decubitus)

CXR (loculated effusion)

ASBESTOSIS

Transudative & Exudative pleural effusion Light's Criteria for Exudative pleural effusion Pleural protein/ Serum protein> 0.5 or Pleural LDH/ Serum LDH> 0.6 or Pleural LDH> 2/3 of upper normal serum LDH

Transudative & Exudative pleural effusion

TRANSUDATIVE PLEURAL EFFUSIONS Congestive heart failure Pericardial disease Cirrhosis Nephrotic syndrome Peritoneal dialysis Myxedema Fontan procedure Pulmonary emboli Sarcoidosis DIFFERENTIAL DIAGNOSES OF PLEURAL EFFUSIONS

CONGESTIVE HEART FAILURE

DIFFERENTIAL DIAGNOSES OF PLEURAL EFFUSIONS EXUDATIVE PLEURAL EFFUSIONS Neoplastic diseases Metastatic disease Mesothelioma Infectious diseases Pyogenic bacterial infections Tuberculosis Actinomycosis and nocardiosis Fungal infections Viral infections Parasitic infections Pulmonary embolism Gastrointestinal disease Esophageal perforation Pancreatic disease Intra-abdominal abscesses Diaphragmatic hernia Postabdominal surgery Postendoscopic variceal sclerotherapy

Collagen vascular diseases Systemic lupus erythematosus Drug-induced lupus Immunoblastic lymphadenopathy Sjögren's syndrome Churg-Strauss syndrome Wegener's granulomatosis Postpericardiectomy or postmyocardial infarctionsyndrome Coronary artery bypass surgery Asbestos exposure Sarcoidosis Uremia Meigs' syndrome Yellow nail syndrome Rheumatoid pleuritis Drug-induced pleural disease Dantrolene Methysergide Bromocriptine Procarbazine Amiodarone Trapped lung Radiation therapy Electric burns Urinary tract obstruction Iatrogenic injury Hemothorax Chylothorax DIFFERENTIAL DIAGNOSES OF PLEURAL EFFUSIONS (continue)

TEN MECHANISMS BY WHICH MALIGNANT DISEASE MAY LEAD TO PLEURAL EFFUSION 1. Pleural metastases with increased permeability 2. Pleural metastases with obstruction of pleural lymphatic vessels 3. Mediastinal lymph node involvement with decreased pleural lymphatic drainage 4. Bronchial obstruction (decreased pleural pressures) 5. Post obstructive pneumonitis 6. Thoracic duct interruption (chylothorax) 7. Pericardial involvement 8. Hypoproteinemia 9. Pulmonary embolism 10. Post radiation therapy

APPROXIMATE ANNUAL INCIDENCE OF VARIOUS TYPES OF PLEURAL EFFUSIONS 500,000 Congestive heart failure 300,000 Pneumonia (bacterial) 200,000 Malignant disease 60,000Lung 50,000Breast 40,000Lymphoma 50,000Other 150,000 Pulmonary embolization 100,000 Pneumonia (viral) 50,000 Cirrhosis with ascites 25,000 Gastrointestinal disease 6000 Collagen vascular disease 2500Tuberculosis 2000 Asbestos exposure 1500Mesothelioma

Disorders of the Pleura General Principles and Diagnostic Approach Differentiating Exudative Pleural Effusions Pleural Fluid appearance Pleural Fluid Protein Pleural Fluid Lactate Dehydrogenase Pleural Fluid Glucose (Para pneumonic effusion, malignant effusion, tuberculous effusion, rheumatoid effusion, hemothorax, paragonimiasis, or Churg-Strauss syndrome ) Pleural Fluid Amylase (esophageal perforation, pancreatic disease, or malignant disease) Pleural Fluid White Cell Count and Differential (PMN, lymphocyte, eosinophils, mesothelial) Pleural Fluid Cytology Pleural Fluid culture and Bacteriologic Stains

Other Diagnostic Tests for Pleural Fluid Pleural Fluid pH (1) complicated Para pneumonic effusion, (2) esophageal rupture, (3) RA, (4) TB pleuritis, (5) malignant pleural disease, (6) hemothorax, (7) systemic acidosis, (8) paragonimiasis, (9) lupus pleuritis, and (10) urinothorax Tests for Collagen Vascular Diseases Adenosine Deaminase (occasionally in empyema, lymphoma, or leukemia) Interferon Gamma PCR for Mycobacterium tuberculosis

Diagnostic Tests for Pleural Fluid

PARAPNEUMONIC EFFUSION

FACTORS SUGGESTING THAT A MORE INVASIVE APPROACH WILL BE NECESSARY FOR THE RESOLUTION OF A PARAPNEUMONIC EFFUSION 1. Thick pus is present in the pleural space. 2. Pleural fluid Gram's stain is positive. 3. Pleural fluid glucose level is < 60 mg/dL. 4. Pleural fluid pH is < Pleural fluid culture is positive. 6. Pleural fluid LDH level is >3 x upper normal limit for serum. 7. Pleural fluid is loculated.

TUBERCULOUS PLEURITIS

PERFORATED ESOPHAGUS

CHRONIC PANCREATITIS

PNEUMOTHORAX Spontaneous Pneumothorax Primary Secondary Traumatic Pneumothorax Tension Pneumothorax

RIGHT SIDE PNEUMOTHORAX

PNEUMOTHORAX

HEMOPNEUMOTHORAX

PNEUMOTHORAX

CAUSES OF CHYLOTHORAX Tumor Lymphoma Other Trauma Surgical Other Idiopathic Congenital Other Miscellaneous

MEDIASTINUM

MEDIASTINAL MASS

SUPERIOR VENA CAVA SYNDROME