1. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013 Diseases of The Pleura Dr.Mustafa Nema Consultant Chest Physician Baghdad College of Medicine 2014

2. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

3. Objectives At the end of this lecture, student should be able to: – Make an ideas on common pleural diseases. – Relate the mechanism of pleural fluid formation to the underlying cause. – Learn how to differentiate between major types of pleural diseases. – Describe how can pleural diseases be presented, diagnosed and treated. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

4. Lecture 1 Pleural effusion Pleurisy Pleural malignancy Lecture 2 Pneumothorax Empyema Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

5. Case scenario Case 1: A young man presented with fever and cough. After 1 week, he developed dyspnea, right side chest pain. OE; decreased chest expansion on right side, dull percussion and decreased breath sound. – What is the possible diagnosis? – How can we reach the diagnosis? Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

6. Case 2: A 17 year’s old female came to the hospital with 1 month history of fever, night sweating, left sided chest pain and increasing dyspnea. OE; you have found signs of pleural effusion on the left side of the chest. – What is the most likely diagnosis? – How can you reach the definitive diagnosis? Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

7. Case 3: A 67 year’s old women with known breast cancer presented with progressive dyspnea over the last month with no cough and no fever. Examination revealed signs of pleural effusion on right side. – What is your first impression on diagnosis? – How can you investigate for this effusion? Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

8. Introduction Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

9. The PARIETAL PLEURA covers the surface of the chest wall, diaphragm, and mediastinum. It is supplied with blood from the systemic circulation and contains sensory nerves. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

11. The VISCERAL PLEURA covers the surface of the lungs, including the interlobar fissures. Its blood supply arises from the low- pressure pulmonary circulation, and it has no sensory nerves. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

12. The two layers of the pleura are separated by a pleural space, which is lubricated by to 10-20 mL of fluid, facilitates lung expansion. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013 Pleural fluid

13. Movement of pleural fluid Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

14. Normal production estimated at 15 mL/day in a 60-kg person. Pleural fluid has a low protein concentration (<2 g/dL) with a pH and glucose value similar to that of blood. Pleural fluid is formed mainly from the parietal pleura. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

15. Pleural effusion

16. Pleural effusion result from disturbance of the physiological balance between the formation and removal of pleural fluid. Pleural effusion is defined as accumulation of fluid in the pleural space that exceeds the physiological amounts of 10–20 mL. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

17. Common causes Pneumonia (‘parapneumonic effusion’) Tuberculosis Pulmonary infarction* Malignant disease Cardiac failure* Subdiaphragmatic disorders (subphrenic abscess, pancreatitis etc.) * May be bilateral Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

18. Uncommon causes Hypoproteinaemia* (nephrotic syndrome, liver failure, malnutrition) Connective tissue diseases* (particularly systemic lupus erythematosus (SLE) and rheumatoid arthritis) Post-myocardial infarction syndrome Acute rheumatic fever Meigs’ syndrome (ovarian tumour plus pleural effusion) Myxoedema* Uraemia* Asbestos-related benign pleural effusio Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

19. Pleural effusion

20. Mechanisms that lead to accumulation of pleural fluid hydrostatic force or oncotic pressure result in low-protein “transudates”. Note that the pleura itself is not involve by a disease process. Increased outpouring by capillaries or blocking of lymphatics (or both) results in high-protein “exudates”. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

21. The fluid may be transudate or exudate. The accumulation of frank pus is termed empyema, that of blood is haemothorax, and that of chyle is a chylothorax Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

22. Pleural effusion Exudate Transudate Pus Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013 lymph Transudate Blood

23. The nature of the fluid can only be determined by visual and laboratory inspection of an aspirated specimen. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

24. Transudative pleural effusion Transudative pleural effusions occur when the “systemic factors” influencing the formation and absorption of pleural fluids are altered so that pleural fluid accumulates. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

25. Causes of transudate effusion 1.Congestive Heart failure: due to increased hydrostatic pressure (most common transudative cause). 2. Liver cirrhosis (Hepatic Hydrothorax): secondary to movement of ascitic fluid through diaphragmatic defects or lymphatic channels; the effusion is more frequent on the right. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

26. 3. Hypoalbuminemia : because of decreased oncotic pressure (e.g. nephrotic syndrome). 4. Urinothorax: retroperitoneal urinary leakage secondary to urinary obstruction or trauma. 5. Peritoneal dialysis 6. Atelectasis Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

27. 7. Myxedema (also can be exudative) 8. “Meigs' syndrome” is the triad of benign fibroma or other ovarian tumors with ascites and large pleural effusions. Usually on the right side. (also can be exudative) 9. Sarcoidosis (also can be exudative) Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

28. Unilateral effusion Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

29. Bilateral effusion Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

30. Exudative pleural effusion Exudative pleural effusions occur when the “local pleural factors” influencing the formation and absorption of pleural fluids are altered so that pleural fluid accumulates. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

31. Causes of exudate pleural effusion A) INFECTIONS Parapneumonic effusion – Associated with pneumonia or lung abscess. – Have large numbers of polymorphs. – The fluid my turned to a frank pus (empyema) – Most common exudative cause Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

32. Tuberculous effusion – Tuberculous effusion is common in our patients (endemic area). – It develops due to one of the following causes: i.Primary TB infection. ii.Subpleural focus of Mycobacterium tuberculosis ruptures into the pleural space. – Presence of an ‘adenosine deaminase’ in the fluid correlate with tuberculosis. – Pleural biopsy are positive in 50 to 80% of cases (caseating granuloma on histopathology) Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

33. Other Infective / Inflammatory Disorders – Subdiaphragmatic processes: such as an upper abdominal abscess. – Pancreatitis and pancreatic pseudocysts: (more often on the left). The amylase level is higher than that in serum. – Esophageal rupture: effusion with high concentrations of salivary amylase. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

34. B) NON INFECTIOUS CAUSES Malignancy: – suggested in any patient older than 60 year’s old – bronchogenic carcinoma, metastatic ca from breast, stomach, colon, thyroid ca..etc, lymphoma and pleural mesothelioma) Rheumatoid arthritis. Systemic lupus erythematosus. Uremia Asbestosis Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

35. Drug-induced, e.g.: – Nitrofurantoin – Methotrexate – Amiodarone – Bleomycin – INH Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

36. HEMOTHORAX Frank blood in the pleural space is usually the result of trauma, hematologic disorders, pulmonary infarction, pleural malignancies or rupture of the aorta. Pleural blood often does not clot. PCV of this pleural bloody fluid >50% of periphral blood PCV. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

37. CHYLOTHORAX Leakage of lymph (chyle) from the thoracic duct. Most commonly results from mediastinal malignancy (especially lymphoma) or thoracic surgery /trauma. Usually milky appearance. The best diagnostic criterion is the presence of a triglyceride greater than 110 mg/dL in the pleural fluid. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

38. DIAGNOSING THE CAUSE AND TYPE OF EFFUSION Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

39. This is based on the: Case history and clinical examination, e.g. history of TB, pneumonia or breast cancer. Imaging techniques: CXR, US, CT, MRI Examination of the pleural fluid, and pleural biopsy. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

40. History History of pain, dyspnea, or cough : due to pleurisy and significant amount of effusion. Symptoms (pain on inspiration and coughing) and signs of pleurisy (a pleural rub) often precede the development of an effusion. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

41. On chest examination Small effusion may be undetectable, but if 500 ml or more of fluid are present, abnormal clinical findings could be detected. What are the findings on chest exam? Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

42. Radiology Chest X-Ray Ultrasound (US) is able to demonstrate small effusions. Computed tomography (CT). Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

43. Chest X ray: The pleural fluid accumulates in the most dependent part of the thoracic cavity The normally sharp posterior costophrenic angle is obliterated. Upper surface is meniscus-shaped (meniscus sign). Around 200 mL of fluid is required in order for it to be detectable on a PA chest X-ray Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

44. The amount of pleural effusion may be small, large or massive. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

45. Thoracentesis This mean taking a sample from the pleural effusion by a syringe. Thoracentesis is indicated in all cases of pleural effusion of unknown origin and in effusions that do not resolve after appropriate treatment. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

46. Thoracentesis (pleural fluid aspiration) Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

47. INVESTIGATIVE PARAMETERS OF PLEURAL EFFUSION Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

48. The most important criteria are: Appearance. Protein content. Cellular components (cytology). Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

49. Appearances of pleural effusion. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013 Blood-stained pulmonary infarction or malignancy. High RBC count Milky ( chylous) Thoracic duct obstruction High TG Clear transudated low protein content

50. Light’s criteria for distinguishing pleural transudate from exudate Exudate is likely if one or more of the following criteria are met: Pleural fluid protein : serum protein ratio > 0.5 Pleural fluid LDH : serum LDH ratio > 0.6 Pleural fluid LDH > two-thirds of the upper limit of normal serum LDH (LDH = lactate dehydrogenase) Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

51. CORRELATION OF PLEURAL FLUID EXUDATE FINDINGS AND CAUSATIVE DISEASE Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

52. Pleural fluid cells o Cell count and Differential count e.g.: – high neutroph. occur in bacterial infection – high lymphocyte in TB and malignancy o CytologyI important for diagnosis of malignancy Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013 Malignant cells in pleural fuid aspirate ‘ Adenocarcinoma’

53. Pleural biopsy Biopsy procedures, such as closed needle biopsy or medical thoracoscopy/ pleuroscopy, may be necessary to confirm or exclude malignant or tuberculous causes. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013 Thoracoscopy Pleural mass

54. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013 Pleural biopsy shows caseating granuloma of TB

55. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

56. May I be excused.. My Brain is Full Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

57. TREATMENT OPTIONS Drug therapy (e.g. antibiotic, anti TB ) Therapeutic aspiration (using a proper gauged needle). Therapeutic drainage ( using pleural catheter or chest tube). Instillation of fibrenolytic agent (to prevent pleural adhesions in case of purulent disease) Instillation of sclerosing agent (to prevent recurrent effusion e.g. in malignant effusion ). Surgery (decortication) Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

58. Case 1: A young man presented with fever and cough with primary diagnosis of lobar pneumonia. After 1 week, he developed dyspnea, right side chest pain. OE; decreased chest expansion on right side, dull percussion and decreased breath sound. – What is the possible diagnosis? – How can we reach the diagnosis? Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

59. Pleural fluid analysis: Appearance: light yellow Protein: 3.5 gm/dL. Serum protein 6gm/dL Cell count &Cytology: high neutrophil count. No malignant cell Diagnosis: parapneumonic pleural effusion. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

60. Case 2: A 17 year’s old female came to the hospital with 1 month history of fever, night sweating, left sided chest pain and increasing dyspnea. OE; you have found signs of pleural effusion on the left side of the chest. – What is the most likely diagnosis? – How can you reach the definitive diagnosis? Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

61. Pleural fluid analysis: Appearance: amber color Protein: 3.3 gm/dL. Serum protein 6 gm/dL Cell count/cytology: high WBC mainly lymphocytes. No malignant cells. Pleural biopsy: caseating granuloma. Diagnosis: TB pleura Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

62. Case 3: A 67 year’s old women with known breast cancer presented with progressive dyspnea over the last month with no cough and no fever. Examination revealed signs of pleural effusion on right side. – What is your first impression on diagnosis? – How can you investigate for this effusion? Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

63. Pleural fluid analysis: Appearance: bloody Protein: 3.6 gm/dL. Serum protein 6.5gm/dL Cell count/cytology: malignant cells seen. Diagnosis: malignant pleural effusion due to lung cancer metastasis Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

64. Pleurisy

65. PLEURISY Pleurisy is not a diagnosis, but simply a term used to describe the result of any disease process involving the pleura and giving rise to pleuritic pain or evidence of pleural friction. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

66. Pleurisy is a common feature of pulmonary infection and infarction; it may also occur in malignancy. Pleuretic chest pain is sharp localized chest pain usually in the lower chest or axillary region that aggravated by deep breath. This pain is characteristic symptom. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

67. On examination rib movement is restricted and a pleural rub may be present. This may only be heard in deep inspiration or near the pericardium (pleuro-pericardial rub). The other clinical features depend upon the nature of the disease causing the pleurisy, e.g. bronchial breath in lobar consolidation. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

68. Loss of the pleural rub and diminution in the chest pain may indicate recovery or herald the development of a pleural effusion. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

69. The primary cause of pleurisy must be treated. Symptomatic treatment of pleural pain, e.g. NSAIDs. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

70. Plueral malignancy

71. Primary: Mesothelioma is a malignant tumour affecting the pleura (pleural mesothelioma) or, less commonly, the peritoneum (peritoneal mesothelioma) due to asbestos exposure. It has poor prognosis. Secondary : metastasis involving the pleura with malignant effusion is more common cause than primary one. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

72. Malignant mesothelioma Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

73. Summary

74. Cardiac failure is the main cause of pleural effusions. Of noncardiac causes, TB, parapneumonic effusions are commonest, followed by malignant pleural effusions. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

75. Small pleural effusions can be detected best by ultrasound (or CT). The most important laboratory parameter of pleural fluid is total protein, distinguishing trans- and exudates. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

76. Biopsy procedures may be necessary to confirm or exclude malignant or tuberculous causes. Treatment depends upon the underlying disease. Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013

77. Thank you Diseases of the Pleura Dr.Mustafa Nema. Baghdad College of Medicine 2013