Mesothelioma

Is a malignant tumour of pleura, usually resulting from asbestos exposure. Asbestos is the major single cause and there is a history of occupational asbestos exposure in up to 90% of cases. Mean latent interval between the 1 st exposure and death is around 40 years. There is no significant association with smoking.

Clinical features -Chest pain usually dull in nature, diffuse, and occasional. -Breathlessness and it is progressive. -Clubbing may occur but it is rare. - Pleural effusion is common presentation.

Investigations -Pleural fluid aspiration, reveals exudative, straw coloured or bloody effusion. Cytological analysis rarely provide the diagnosis, ( sensitivity is around 32% ). -Imaging ( CXR, CT chest), features include; 1- moderate to large effusion 2- plural mass or thickening 3- local invasion 4- pleural plaque or pulmonary fibrosis.

Treatment -Management or pleural effusion by repeated aspiration and Talc pleurodesis. -Radiotherapy, prophylactic radiotherapy greatly reduce chest wall invasion. -Surgery, very limited use -Chemotherapy, the role is still unclear and under researches. -Median survival is varies between 8-14 months.

Pneumothorax Is air in the plural space, may occur with apparently normal lung ( primary pneumothorax), or in the presence of underline lung disease ( secondary pneumothorax). It could occur spontaneously or result from iatrogenic injury to the lungs or chest wall. The primary form principally affects male aged years, they are usually tall, thin and smokers.

Calssification l- spontaneous A- primary pneumothorax; Without evidence of lung disease, air escape from the lung in to the pleural space through rupture of a small emphysematous bulla or pleural blep. B- secondary pneumothorax; there is underline lung disease, most commonly, COPD, TB, asthma, lung abscess, ca bronchus and interstitial lung diseases.

II- Iatrogenic, or traumatic following surgery or biopsy,

Clinical features; -Sudden onset pleuretic chest pain -SOB, in those with underline lung disease, the SOB may be so severe. - Clinical signs may be absent in small pneumothorax, but in large pneumothorax when > 15% of hemi thorax involved it might result in decrease or absent breath sound on auscultation. The combination of absent breath sound and hyper resonant percussion note is diagnostic of pneumothorax.

Types of spontaneous pneumothorax 1- closed type; when there is no communication between the lung and pleural space ( communication seal off), here the pleural pressure is negative. 2- open, when the communication between the lung and pleural space fails to seal off, the pleural pressure will be atmospheric. 3- Tension type, large amount of air accumulates in the pleural cavity and mean pleural pressure will be positive.

The positive pressure causes mediastinal displacement towards the opposite side, with compression of the opposite normal lung causing cardio- respiratory compression. ( Tension Pneumothorax)

Investigations -CXR, shows the sharply defined edge of deflated lung with complete translucency ( no lung marking), between the lung edge and the chest wall. - CT chest is useful to differentiate emphysematous bullae from pneumothorax

Management l- primary pneumothorax; -When the distance between the lung edge and the chest wall is < 2cm and the patient not SOB it will normally resolve with out intervention. - When the distance is > 2cm and the patient symptomatic, percutaneous needle aspiration is well tolerated procedure of choice with % chance of avoidance the need of Intercostal chest drain.

-Failure of needle aspiration. Required intercostal chest drain insertion, and it should be inserted in 4 th – 6 th intercostal space in mid- axillary line. ll – secondary pnemothorax Even small secondary pneumothorax may cause respiratory failure, hence all patients required intercostal chest drain insertion.

Recurrent pneumothorax required surgical intervention in the form of either surgical pleurodesis or pleurectomy. Patient with tension pneumothorax required urgent intervention to relieve the pressure by insertion of a needle in to the 2 nd intercostal space, mid clavicular line of the affected site.

All patients with pneumothorax should receive high concentration oxygen therapy, as this accelerate the rate that the air will be absorbed by pleura. Smoking sessation advise should be given to every one with pneumothorax.