1. Diseases of pleura
Beatrix Bálint MD.
SZTE Szeged, 2017.

2. Pleural cavity

3. Pleural space

4. Diseases of pleura
Inflammation = pleurisy
Pneumothorax
Tumor

5. Inflammation of pleura
1. Pleuritis sicca
Cause: viral infection
Bornholm’s disease (Coxsackie B)
Symptomes:
Pleuritic chest pain
Pleural friction rub
Therapy:
symptomatical

6. 2. Pleural effusion:aetiology:multifactorial
Symptomes
Chest pain
Dyspnoe
Cough
Physical examination
Percussion note: dull
Auscultation: diminished/absent breath sounds
X-ray
Small fluid: blunting of costo-phrenic angle
Larger volume (>300 ml):homogenous shadow
Therapy
Thoracocentesis
To treat the cause of the pelural effusion

7. Pleural effusion
Definition: An accumulation of fluid between the layers of the membrane lining the lung and the chest cavity.
Alternative names: Fluid in the chest; Transudative pleural effusion; Exudative pleural effusion
Causes: Pleural fluid is normally formed in small amounts to lubricate the surfaces of the "pleura," the thin membrane that lines the chest cavity and surrounds the lungs. A "pleural effusion" is an abnormal collection of this fluid.

8. Pleural effusion

9. Pleural effusion

10. Pleural effusion

11. Pulmonary embolism

12. Pathophysiology of pleural effusion
 of pulm. capill. wedge pressure: cong. heart failure
 onc. pressure in microvas. circulation: low Se albumin
 in pressure in the pelural space: lung collapse due to ptx
 permeability of microvasc. circ.:due to inflam. mediators
Impaired lymphatic drainage from pl. space: due to tu / fibrosis
Occlusion of pariet. pleura stomata with fibrin, debris and mesoth. swellings: due to pneumonia
Movement of fluid from peritoneal space through diaphr. lymph. / diaphr. defect

13. Thoracocentesis
Definition: A procedure to remove fluid from the space between the lungs and the wall of the chest.
How to prepare for the test: No special preparation is needed before the procedure. A chest X-ray is may be performed before and after the test. Do not cough, breathe deeply, or move during the test to avoid injury to the lung.
Risks: pneumothorax (collapse of the lung), fluid re-accumulation, pulmonary edema, bleeding,infection, and respiratory distress.

14. Thoracocentesis

15. Thoracocentesis

16. Pleural effusion: analysis
Quantity
Quality: color, density, opacity
Lab. analysis
Chemical
Cytological
Bacteriological: culture
Spec
Aspec.

17. Lab. analysis of pleural effussion
Exsudate
Transudate
3 % 
protein
3 %  +
Rivalta -
0.5 
Protein in pl. eff./ Se protein
0.5 
0.6 
LDH in pl.eff/Se LDH
0.6 
1014 
Specific gravity
1014 
inflammation
Cause
 syst./pulm. venous pressure

18. Common Causes of Exudative Effusion
Tuberculosis
Unilateral
Lung cc
Bloody, large, parenchymal lesion on the X-ray, rapid. Reprod.
Pneumonia
X-ray:infiltr.
Pulm. Infarction
Bloody, pleural pain
Lymphoma
E.g.:Hodgkin disease, +mediast. Lg.
Metastatic tumor
Large, rapid. Reprod.
Mesothelioma
Bloody, Large, rapid. Reprod.
Trauma
Bloody

19. Common Causes of Transudative Effusion
Congestive heart failure
Bilateral
Cirrhosis
Ascites, Se protein low, usually on the right side
Nephrotic syndrome
Hypoproteinaemia,
Generalized oedema, ascites

20. Empyema = pus in the pleural space
Causes:bacteria: Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pn, E. Coli, Mycobact. Tb, anaerobic bact.
Risk factors: alcoholism, drug use, HIV infection, neoplasm, pre-existent pulmonary disease
Appear: as the complication of bacterial pneumonia, subdiaphragmatic abscess, oesophageal perforation, following thoracic surgery
Symptomes:
Chest pain
Dyspnoe
Cough
Fever
Night sweats
Weight loss

21. Empyema diagnosis and therapy
Physical examination: Signs of pleural fluid
Percussion note: dull
Auscultation: diminished/absent breath sounds
X-ray: Signs of pleural fluid
Ultrasonography
CT, MRI
Thoracocentesis: pus!
Therapy
prompt chest tube drainage (drainage of pleural space)
Video-assisted thoracoscopic surgery (VATS) is used as a first-line therapy in many hospitals, although open thoracic drainage remains a frequently used alternative technique.
Antibiotics iv. based on Gram stain or culture
In case of uneffective th or recurrent empyema and pleural thickening, which may lead to functional lung impairment: surgical decortication.

22. Empyema

23. Chest tube drainage

24. Pneumothorax

25. II. Pneumothorax
Air in the pleural space causing partial or complete lung collapse.
It can occur spontaneously or result from trauma or medical procedures.
Diagnosis is based on clinical criteria and chest x-ray.
Symptomes: chest pain, dyspnoe depending on the size of pneumothorax
Physical signs
Percussion note:Hyperresonance
Breath sounds: diminished/absent

26. Potential causes of pneumothorax
Air: outside the chest wall
Trauma
Thoracocentesis, pleural biopsy, TTB
Insertion of venous catheter
Air: from the airways
Idiopathic
Rupture of oesophagus
COPD
Pos.pressure ventillation
Infection, tumor, foreign body

27. Pneumothorax diagnosis and therapy
X-ray: upright inspiratory chest x-ray.
visible pleural edge with no lung markings between this edge and the chest wall
shrunken lobe or lung and the parietal pleura are diagnostic of pneumothorax.
Tracheal deviation and mediastinal shift occur with large pneumothoraces.
Therapy: depends on the size of the ptx
small: supplemental oxigen th, close observation, suction of the air by needle
large: consant tube drainage
Recurrent ptx:
Pleurodesis,
VATS (Video-assisted thoracoscopic surgery),
surgery

28. Pneumothorax

29. Pneumothorax

30. Ptx tube drainage

31. Tension PTX
A tension PTX is a life-threatening condition that requires immediate intervention.
Causes: penetrating chest injuries, fractures of the trachea or bronchi, a ruptured esophagus, the presence of an occlusive dressing over an open PTX, and PPV.
Progressive build-up of pressure in the pleural space pushes the mediastinum to the opposite hemithorax, and obstructs venous return to the heart. This leads to circulatory instability and may result in traumatic arrest.
 Symptomes: patient is tachycardic and tachypnoeic, and may be hypoxic. These signs are followed by circulatory collapse with hypotension and subsequent traumatic arrest with pulseless electrical activity (PEA). Breath sounds and percussion note may be very difficult to appreciate and misleading in the trauma room. .

32. Tension ptx X-ray
Deviation of the trachea away from the side of the tension.
Shift of the mediastinum.
Depression of the hemi-diaphragm

33. Tension PTX therapy Don’t forget: Life-threatening condition!
Emergent chest decompression with needle thoracostomy.
A 14-16G intravenous cannula is inserted into the second rib space
in the mid-clavicular line.
The needle is advanced until air can be aspirated into a syringe connected to the needle.
Later : Constant tube drainage

34. III. Pleural tumors Metastatic pleural tumor
Primary: malignant mesothelioma

35. III. Pleural tumors 1. Primary tumor = mesothelioma
Localised form: solitary growth on pleural surface
Th: surgical resection
Diffuse mesothelioma: Malignant , aggressive tumour originating in the serosal membranes that line the thoracic and abdominal cavities. More than 90% of mesothelioma cases occur in the pleura. The occurrence of it typically related to exposure to mineral fibres such as asbestos and erionite.
Symptomes: Chest pain, especially when taking a deep breath, Cough, General discomfort, uneasiness, or ill feeling (malaise), Shortness of breath, Weight loss
Diagnosis:
Chest X-ray: rapidly reproducated pleural effusion
CT scan of the chest
Thoracentesis: Pleural fluid analysis: cytology, histology, immunhistochemistry
Open pleural biopsy
Pleural needle biopsy

36. Mesothelioma therapy
Surgery: Depending on the location and stage of the cancer, and the health of the patient, tumors may be able to be removed through surgery.
Chemotherapy: pemetrexed
Radiation therapy: One of the oldest mesothelioma treatments, radiation techniques can target and shrink tumors to make other treatments more effective.
Experimental Treatment: Clinical trials that test newer therapies like immunotherapy can prove effective if other options are exhausted.
Palliative Treatment: Additional techniques and therapies can treat the symptoms of mesothelioma to help ease patient pain and suffering.: painkiller, thoracocentesis, pleurodesis, tube drainage

37. Metastatic pleural tumor
Metastatic tumor: malignant pleural effusion caused by primery tumor of the body: breast c., lung c., ovarian cancer, kidney c,
Symptomes: symptomes of pleural effusion+symptomes of primary tumor
Pleural fluid reproduction is rapid
Diagnosis: Anamnesis! X-ray, ultrasonography, CT, lab.
Thoracocentesis: cytology, histology, immunhistochemistry
Therapy: therapy of primary tumor + palliative care (thoracocentesis, pleurodesis, painkiller)