Pleural Disease

Effusions Pneumothorax Cancer Learning Objectives Effusions Pneumothorax Cancer Understand the formation of pleural fluid Be familiar with the difference between pleural fluid exudate and transudate Know the radiographic differences between atelectasis and pleural effusion Correlate physical findings with radiographic findings in pleural effusion and pneumothorax Understand the difference between a simple pneumothorax and a tension pneumothorax

Vascular supply of pleura Lymphatic drainage of pleura The Pleura Parietal pleura Visceral pleura Vascular supply of pleura Lymphatic drainage of pleura

Function of the Pleura May reduce friction of moving layers and reduce work of breathing May contain infections

Physiology Of The Pleural Space Movement of fluid through the pleural space in normal people is from parietal to visceral pleura to pulmonary lymphatics Increased fluid movement with exercise Intrapleural pressures are influenced by inspiratory movements. Gravity effects

Schematic Representation of Starling Forces

Pleural Fluid There is normally 10-15 ml of pleural fluid with about 1 gm protein, minimal cells, and a pH of about 7.6 Pleural effusion: physically or radiographically detectable fluid in the pleural space

Mechanisms of Pleural Fluid Accumulation Changes in oncotic pressure Increased venous pressures (CHF) Inflammatory processes involving the pleura Obstruction to lymphatic drainage of the pleura “Trapped” lung resulting in local changes in intrapleural pressures Peritoneal fluid with movement of fluid through transdiaphragmatic channels (e.g., cirrhosis of the liver)

Pleural Effusion Pleural effusion with shift away from opacity Atelectasis with shift towards opacity

Types of Pleural Effusions Transudative develops secondary to a disease process not directly involving the pleura (congestive heart failure, low serum protein) Exudative produced by disease processes directly involving the pleura (trauma, tumor, infection)

Special Types of Pleural Effusions 1. Hemothorax - a bloody effusion with a hematocrit greater than 50% of the blood hematocrit Usually due to trauma 2. Hemorrhagic pleural effusion – a bloody effusion with a hematocrit less than 50% of blood hematocrit most often related to tumor involving the pleura but may be seen on occasions with other diseases as tuberculosis 3. Chylous pleural effusion - an effusion that generally develops after obstruction of the lymphatics most often associated with tumors 4. Empyema - pus in the pleura Generally related to an anaerobic infection involving the pleura. 5. Parapneumonic effusions – an effusion associated with pneumonia but without direct infection in the pleura 6. Loculated pleural effusions - an effusion in localized areas of the pleura without demonstrable free fluid

Loculated Pleural Effusion: Empyema Haziness of right hemithorax Density not corresponding to lobar anatomy Diaphragmatic and cardiac silhouettes intact

Loculated Pleural Effusion: Empyema . Lateral upright film Loculated fluid overlying vertebral column

Clinical Symptoms Associated With Pleural Effusion a. Dyspnea b. Chest pain 1. Pleuritic 2. Aching discomfort c. Cough d. Sputum production d. Fever e. Weight loss

Signs Of Pleural Effusion Decreased breath sounds Dullness to percussion Decreased movement of hemithorax Egophony Tachypnea

Lateral decubitus chest x-rays Radiologic Studies PA chest x-ray Lateral decubitus chest x-rays Ultrasound of chest may be needed in selected cases CT scan of the chest

Value Of Lateral Decubitus View Subpulmonic Effusion Lateral decubitus film Reproduced with permission by AJ Chandrasekhar, LUMEN

Thoracentesis Directly introducing a needle or catheter into the pleural space and removing fluid

Diagnostic Procedures Commonly performed studies on pleural fluid 1. Protein 2. Lactic dehydrogenase (LDH) 3. Absolute cell count 4. Differential cell count 5. Glucose 6. Amylase 7. Cytology 8. Cultures Bacterial cultures -- aerobic, anaerobic Cultures – tuberculosis Fungal culture

Separating Transudates from Exudates “Light’s Criteria” 98% of exudates have at least one of the following: 1. Pleural fluid protein >0.5 gm Serum protein 2. Pleural fluid lactic dehydrogenase (LDH) >2/3 of serum LDH 3. Pleural fluid LDH >0.6 Serum LDH 20% of transudates (as determined by clinical follow up) will be misdiagnosed as exudates using these criteria often heart failure that has been treated with diuretics

Causes Of Transudative Effusions Altered mechanical pressures Congestive heart failure Superior vena cava obstruction Atelectasis Trapped lung lymphatic obstruction (more often exudative) low oncotic pressures Nephrotic syndrome Hypoalbuminemia Connection with transudative peritoneal fluid Ascites Hepatic hydrothorax (rarely ascites may be absent) Peritoneal dialysis rare causes such as myxedema and urinothorax. Some diseases as sarcoidosis and pulmonary emboli may be associated with either transudates or exudates.

Common Causes Of Exudative Effusions Neoplasm More than 50% are caused by lung and breast cancer pleural seeding (classic malignant effusion) Chylothorax due to lymphatic drainage impairment Infection Tuberculosis Parapneumonic Empyema Pancreatitis Autoimmune (lupus, rheumatoid arthritis) Hemothorax

Pleural Biopsy Histopathology Culture of tissue High yield with tuberculous pleuritis and malignancy

Pleural Biopsy Needle (Cope)

Pleural biopsy needle (Abrams) .

Pleural biopsy . Reproduced with permission by AJ Chandrasekhar, LUMEN

A Malignant Pleural Effusion . Massive Shift of mediastinum

Treatment Generally directed toward the primary disease On occasions a tube thoracostomy (chest tube) may be needed to drain the fluid from the pleural space particularly useful when the pleural effusion is associated with respiratory distress most empyemas, will require chest tube drainage

Treatment (cont’d) In recurrent effusions pleurodesis with materials such as talc may be necessary malignant effusions Open surgical drainage may rarely be necessary loculated pleural effusions. Decortication of the lung (surgical removal of the visceral pleura) rarely required fibrosing empyemas

The prognosis of most effusions is that of the primary disease

Pneumothorax – An Accumulation Of Air In The Pleural Space Simple pneumothorax Tension pneumothorax – associated with shift of the mediastinum and decreased blood pressure Recognition and treatment of a tension pneumothorax is a medical emergency

Pneumothorax History Exam Chest radiography Chest pain – pleuritic Dyspnea Cough occasionally Exam Decreased breath sounds Hyperresonant percussion note Evidence of shift of the mediastinum to the contralateral side (e.g., tracheal position, location of the cardiac maximal impulse). Chest radiography

Pneumothorax

Pneumothorax No vascular markings on right Atelectatic right lung Increased haziness on left: Diversion of entire cardiac output plus decreased volume

Pneumothorax .

Tension Pneumothorax No vascular markings on left Shift of mediastinum to right Atelectatic left lung Increased haziness on right

Therapy of Pneumothorax Oxygen Observation Chest tube Surgery Pleurodesis

Cancers Involving The Pleura Mesothelioma 50% asbestos associated Poor prognosis Other primary tumors are rare Metastatic cancer is common (breast, lung)

Mesothelioma Pleural Mass / Effusion Irregular diffuse pleural thickening / Mass on left Blunting of costophrenic angle Loss of left diaphragmatic silhouette Left hemithorax larger

Extrapleural Sign / Plasmacytoma Peripheral density Sharp inner margin Indistinct outer margin Obtuse angle with chest wall . Reproduced with permission by AJ Chandrasekhar, LUMEN

Reproduced with permission by AJ Chandrasekhar, LUMEN Resected rib with characteristic appearance. Close up below. Arrow pointing to expanding rib lesion and angles of contact with chest wall. Reproduced with permission by AJ Chandrasekhar, LUMEN

Learning Objectives Understand the formation of pleural fluid Be familiar with the difference between pleural fluid exudate and transudate Know the radiographic differences between atelectasis and pleural effusion Correlate physical findings with radiographic findings in pleural effusion and pneumothorax Understand the difference between a simple pneumothorax and a tension pneumothorax