1. Pleural Disease

2. 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

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

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

8. 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

9. Schematic Representation of Starling Forces

10. Pleural Fluid
There is normally 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

11. 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)

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

13. 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)

14. 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

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

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

17. 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

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

19. 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

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

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

23. 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

24. 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

25. 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.

26. 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

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

28. Pleural Biopsy Needle (Cope)

29. Pleural biopsy needle (Abrams).

30. Pleural biopsy .
Reproduced with permission by AJ Chandrasekhar, LUMEN

31. A Malignant Pleural Effusion.
Massive
Shift of mediastinum

32. 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

33. 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

34. The prognosis of most effusions is that of the primary disease

35. 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

36. 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

37. Pneumothorax

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

39. Pneumothorax .

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

42. Therapy of Pneumothorax
Oxygen
Observation
Chest tube
Surgery
Pleurodesis

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

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

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

46. 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

47. 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