1. PLEURAL DISEASE Sevda Özdoğan MD, Chest Diseases

2.  Pleural effusions  Emphyema  Pleural malignancy  Hemothorax  Pneumothorax

3. Pleural Anatomy and Physiology  Pleura is a serous membrane formed from mesenchyme that separates the lung paranchym, mediastinum, diaphragm and thoracic cage  It is composed of 2 layers as: Parietal pleura Parietal pleura Visceral pleura Visceral pleura

4. Pleural Cavity  It is the space between the visseral and parietal pleura  Normally contains a small amount of fluid (10-20 ml in each pleural cavity)  This pleural fluid is mainly produced by the parietal pleural surface and reabsorbed by the two layers (Mainly parietal pleura)

5.   The production and reabsorbtion of the pleural fluid is normaly in an equilibrium accounted primarily by the forces employed in Starling equation: F=k[(Pcap-Ppl)-δ(πcap- πpl)] F: The rate of fluid movement P, π: Hydrostatic and oncotic pressures k: The filtration coefficient δ: Osmotic reflection coefficient

6. Pleural Effusion  If the physiologic balance between the filtration and the drainage of the pleural fluid is disturbed, pleural effusion accumulate.  Fluid may accumulate in the pleural space in response to the disease of the pleural membranes or as a manifestation of a systemic illness

7. The Mechanisms of Pleural Effusion  Increased hydrostatic pressure (Cardiac failure, increased atrial pressure)  Decreased oncotic pressure (Protein deficiency)  Decreased pleural cavity negative pressure (Atelectasis)  Increased permeability in microvascular circulation (İnfections, inflammation)  Impaired lymphatic drainage of pleural space (Tumor, fibrosis)  Transperitoneal route (Congenital defects, ascite)

8. Symptoms  Chest pain (inspiratory) Decreases when the fluid increases Decreases when the fluid increases  Dyspnea  Cough  Symptoms of the underlying disease Fever Fever Hemoptysis Hemoptysis Weight loss Weight loss......

9. Physical Examination  No physical signs can be detected when the fluid is less than 300 ml  İnspection İncreased size of the affected hemithorax İncreased size of the affected hemithorax Trachea is deviated away from the diseased side Trachea is deviated away from the diseased side

10.  Palpation İpsilateral restriction of chest wall motion İpsilateral restriction of chest wall motion VT absent VT absent  Percussion Dullness (>300-400 ml) Dullness (>300-400 ml)  Oscultation Diminished breath sounds or inaudible Diminished breath sounds or inaudible Pleural friction rub Pleural friction rub Bronchial sound over the fluid level Bronchial sound over the fluid level

11. Radiology  The fluid initially accumulates in the more dependent recesses of the thoracic cavity forming a Damoiseau Line  200-300 ml of pleural effusion can be detected on standard chest radiograph as blunting of the costophrenic angle

14.  Massive pleural fluid often shifts the mediastinum to the opposite side  Unusual localized pleural effusions can be seen due to the localized obliteration of the pleural space often by inflammatory conditions (adherence)

15.  Smaller amounts of pleural fluid can be detected on lateral decubitus radiography as the free intrapleural fluid moves from top of the diaphragm to the dependent chest wall Pleural effusion in a lateral decubitus radiograph

16.  Ultrasound is able to demonstrate smaller amounts of fluid as 100 ml  CT has similar sensitivity to ultrasound, not routine but can be performed to evaluate concomitant paranchymal lesions  CT is sensitive in identifying pleural thickening and calcification

18. Thoracenthesis and Pleural Fluid analysis  Appereance Serous (light to dark yellow, clear) Serous (light to dark yellow, clear) Serosangineous (Blood tinged can be due to thoracentesis itself) Serosangineous (Blood tinged can be due to thoracentesis itself) Hemorrhagic (hemothorax if hct>50% of blood hct) Hemorrhagic (hemothorax if hct>50% of blood hct) Purulent (fetid odor in unaerobic infections) Purulent (fetid odor in unaerobic infections) Chylous (milky) Chylous (milky)

19.  Biochemical evaluation Exudative Exudative Transudative Transudative Some special hints Some special hints  Microbiological evaluation Cellular structure Cellular structure Special stains and culture Special stains and culture  Cytologic evaluation

20. Biochemical Evaluation  Routine pH pH Glucose Glucose Lactate dehydrogenase Lactate dehydrogenase Total protein Total protein Albumine Albumine  Optional Htc Cholesterol Trigliserid Bilirubine Adenosin deaminase Amylase RF LE cell ANA Hyaluronic ascite

21. Biochemical Evaluation  Exudate Dark yellow color Dark yellow color Total protein >3 gr/dl Total protein >3 gr/dl Density >1016 Density >1016 Light Criteria: Light Criteria: Protein pl/s>0.5Protein pl/s>0.5 LDH pl/s>0.6LDH pl/s>0.6 LDH >200 or >2/3 of normal upper value of serumLDH >200 or >2/3 of normal upper value of serum  Transudate Light yellow color Total protein <3 gr/dl Density <1016 Light Criteria: Protein pl/s<0.5 LDH pl/s<0.6 LDH <200

22.  Albumine Gradient: Serum albumine- Pleural fluid albumine Serum albumine- Pleural fluid albumine <1.2 gr/dlEksudate <1.2 gr/dlEksudate >1.2 gr/dlTransudate >1.2 gr/dlTransudate  Pleural Cholesterol >60 mg/dl: Eksudate  Pl/S bilirubine >0.6:Exudate

23.  Transudative Pl. Eff. Increased hydrostatic pressure Increased hydrostatic pressure Congestive heart failureCongestive heart failure Constrictive pericarditisConstrictive pericarditis Pericardial effusionPericardial effusion Pulmonary thromboemboliPulmonary thromboemboli Decreased oncotic pressure Decreased oncotic pressure CirrhosisCirrhosis Nephyrotic syndromeNephyrotic syndrome MalnutritionMalnutrition Increased capillary permeability Increased capillary permeability MyxedemaMyxedema Pulmonary thromboemboliPulmonary thromboemboli Transperitoneal transport Transperitoneal transport Peritoneal dialysisPeritoneal dialysis AscitesAscites  Exudative Pl. Eff. Infectious diseases Pnomonia, lung abscess Tuberculosis Fungal infections Subphrenic abscess Neoplastic diseases Metastatic Mesothelioma Lymphoma Immunologic reactions Dressler syndrome Sistemic Lupus Er. Rheumatoid artritis Churg strauss syndrome Wegener granulomatosis

24.  Exudative Pl Eff Gastrointestinal disease Pancreatitis Causes of peritoneal exuda Drug induced Nitrofurantoin Dantrolene Methysergide Bromocriptine Procarbasine Amiodorone Postsurgical Pulmonary thromboembolism

25.  Exudative Pl Eff Sarcoidosis Uremic pleuritis Asbestos exposure Chylothorax Hemothorax

26.  If the effusion is transudative the main cause should be treated  If the effusion is exudative and not emphyema further diagnostic procedures should be considered Cytologic examination Cytologic examination Closed pleural needle biopsy Closed pleural needle biopsy Thoracoscopy (VATS) Thoracoscopy (VATS) Thoracotomy Thoracotomy

27. Special characteristics: Milky appearance  Chylothorax Triglyceride >110 mg/dl Triglyceride >110 mg/dl Pl TG/sTG>1 Pl TG/sTG>1 Cholesterol crystal (-) Cholesterol crystal (-) Pl Ch/s Ch<1 Pl Ch/s Ch<1 Chylomicrons (+) Chylomicrons (+)  Pseudochylothorax Triglyseride <50 mg/dl Pl TG/sTG<1 Cholesterol>250 mg/dl Pl Ch/s Ch>1  Emphyema PH<7.20 Low Glucose

28. Microbiologic evaluation  RBC >100 000/mm 3 Trauma, Trauma, Pulmonary infarction Pulmonary infarction malignancy malignancy  WBC > 1000/mm 3 : exudate > 10 000/mm 3 : emphyema, parapnomonic effusion (PNL predominates) > 10 000/mm 3 : emphyema, parapnomonic effusion (PNL predominates) Mesothelial cells<5%: tuberculosis possible Lymphocytes >50% : tuberculosis, malignancy, lymphoma, fungus, myxedema

29.  Gram staining  Ziehl-Neelsen staining  Cultures for specific and nonspecific infections  PCR

30. Infectious pleuresy, emphyema  Bacterial pneumonia is associated with an effusion in 40% of cases  The effusion may be parapneumonic without infection (uncomplicated) or culture positive (complicated, emphyema)  Parapneumonic effusions are treated with appropiate antibiotics  Tube drainage is indicated if emphyema occurs

31. Other Pleural Diseases  Hemothorax Plevral fluid htc>50% of serum Plevral fluid htc>50% of serum Can be traumatic or nontraumatic: Can be traumatic or nontraumatic: İatrogenicİatrogenic Pulmonary infarctionPulmonary infarction TumorsTumors Rupture of aneurismRupture of aneurism Anticoagulan treatmentAnticoagulan treatment Thoracic endometriosisThoracic endometriosis Treatment: Treatment: intrapleural drainageintrapleural drainage thoracotomy thoracotomy

32.  Fibrothorax A thick fibrous tissue formed on visceral pleura A thick fibrous tissue formed on visceral pleura Cause: Cause: EmpyemaEmpyema TuberculosisTuberculosis HemothoraxHemothorax Treatment: Decortication Treatment: Decortication

33.  Pneumothorax Presence of free air between the visceral and parietal pleura Presence of free air between the visceral and parietal pleura Divided into 3 Divided into 3 SpontaneousSpontaneous Primary idiopathic Primary idiopathic Secondary Secondary TraumaticTraumatic IatrogenicIatrogenic

34. Primary Spontaneous Pneumothorax  Mostly occurs in young, male, smokers  There is no obvious underlying pulmonary disease  Subpleural blebs and bullae probably play a role in pathogenesis  Symptoms can be an acute unset of dyspnea and unilateral chest pain but can be absent also depending on the size of the pneumothorax

35.  Physical examination: Hypersonority on percusion Hypersonority on percusion Reduced breath sounds, reduced VT, enlarged hemithorax Reduced breath sounds, reduced VT, enlarged hemithorax Hypotension and cardiac tamponade may occur depending on the size of the pneumothorax Hypotension and cardiac tamponade may occur depending on the size of the pneumothorax  Radiology: Pleural line Pleural line Hyperlucency at the periphery Hyperlucency at the periphery Mediastinal shift Mediastinal shift Expiration film can be used when the lesion is not apparent Expiration film can be used when the lesion is not apparent

38.  Measurement of the average diameters of the collapsed lung and the affected hemithorax can be used  100-(8 3 /11 3 )100=% 62  Simple observation with rest and supplemental oxygen can be used for asymptomatic patients with a small (<20%) px  Intercostal drainage is indicated in large px  A recurrent spontaneous pneumothorax (30-50% risk) is an indication for surgery Quantification of the size of the pneumothorax is helpfull in the decision of treatment

39. Secondary Spontaneous Pneumothorax  Patients have an underlying pulmonary disease: COPD COPD Asthma Asthma Congenital cysts and bullae Congenital cysts and bullae Interstitial lung fibrosing diseases Interstitial lung fibrosing diseases Cystic fibrosis Cystic fibrosis Hystiocytosis X Hystiocytosis X Whooping cough Whooping cough Lymphangiomyomatosis Lymphangiomyomatosis Pleural endometriosis, catamenial pneumothorax Pleural endometriosis, catamenial pneumothorax Pleural malignancy Pleural malignancy Sarcoidosis Sarcoidosis Bacterial pneumonia and Pneumocystis Pneumonia Bacterial pneumonia and Pneumocystis Pneumonia

40. Traumatic and Iatrogenic Pneumothorax  Iatrogenic pneumothorax can be seen during: Thorasentesis Thorasentesis Pleural needle biopsy Pleural needle biopsy Transthoracic lung aspiration biopsy Transthoracic lung aspiration biopsy Mechanical ventilation Mechanical ventilation Central venous catheterization Central venous catheterization Tracheostomy Tracheostomy Cardiopulmonary resusitation Cardiopulmonary resusitation

41. Pleural Neoplasms  Benign: Pleural lipoma Pleural lipoma Local pleural fibroma (Fibrous mesothelioma) Local pleural fibroma (Fibrous mesothelioma)  Malign: Diffuse malign mesothelioma Diffuse malign mesothelioma

42. Malign Pleural effusions  Diffuse Malign Mesothelioma  Bronchial carcinoma (adenocarcinoma)  Lymphoma  Breast carcinoma  Other adenocarcinomas

43. Malignant Mesothelioma  Primary tumour of pleural, pericardial, peritonial mesothelium  Etiology: 70-90% asbest exposure: Occupational: asbest is resistant to heat and friction so used in building, water pipes, brakes, isolation systems, textile Occupational: asbest is resistant to heat and friction so used in building, water pipes, brakes, isolation systems, textile Environmental: Eskişehir, Kütahya, Bilecik, Yozgat, Sivas, Diyarbakır Environmental: Eskişehir, Kütahya, Bilecik, Yozgat, Sivas, Diyarbakır  Latent period is 30-40 years in occupational exposure  Smoking dramaticaly increase the risk of cancer in asbest exposure

44. Erionite is another fibrous zeolite found in soil, high in Nevşehir: Tuzköy, Karain, Sarıhıdır area in Turkey. It is more carcinogenic than asbest. 49% of total deaths in the villages of Ürgüp are due to DMM

45.  The most common clinical presentations are dyspnea, chest pain, unilateral decreased volume of the affected hemithorax (frozen chest) (inspite of fluid accumilation)  Nodular thickening of the pleura, irregular thickening of the interlobar fissure, absence of mediastinal shift with massive pleural effusion (frozen chest)  Diagnosis by histologic examination  Treatment oncologic and surgical if possible, prognosis is poor

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