pleurisy

PLEURISY

الدكتور خلدون ذنون- كلية طب نينوى- المرحلة الرابعة
Objectives
The student needs to know the following:
1. Main causes of pleurisy
2. Description of pleural pain
3. Chest X-ray may be needed to look for effusion and underlying lung
lesion.
4. Pain relief is mandatory.
5. Differences between exudate and transudate and their causes.
6. Symptoms and signs of effusion
7. Chest X-ray and fluid aspiration for analysis are essential for diagnosis.
8. Features, diagnosis and treatment of TB effusion.
9. Indications of pleural aspiration and pleurodesis.

Definition of pleurisy: Inflammation of pleural surfaces.

Causes:
Bacterial pneumonias
Malignancy
Tuberculosis
Viral
Pulmonary infarction
Connective tissue diseases e.g SLE
Asbestos
Radiation


Clinical features
Sharp chest pain aggravated by deep breathing and coughing.
Rib movement restriction
pleural rub & Pleuropericardial rub
Features of underlying disease
Loss of rub & diminished pain indicate resolution or formation
of pleural effusion .

Investigations

Chest X-ray: may be normal, show increased density, or lung lesion.
Investigate Causes of pleurisy.

Management

Treatment of underlying cause.
Pain relief : mild-moderate :aspirin, codeine, paracetamol, NSAIDs
Severe: pethidine 50-100 mg or10-15 mg morphine
i.m or i.v, caution in poor respiratory function.

PLEURAL EFFUSION

Definition
Serous fluid accumulation in the pleural space, which may be:
Transudative : increased hydrostatic pressure or decreased osmotic
pressure E.g cardiac, liver, renal failure. or
Exudative: increased microvascular permeability due to inflammatory disease of pleura or adjacent lung.


Causes
Parapneumonic
Tuberculosis
Pulmonary infarction
Malignancy
Heart failure, renal failure, hepatic failure
Pancreatitis
Hypoproteinaemia e.g nephrotic synd., liver failure
Connective tissue disease E.g SLE, RA.
Acute rheumatic fever
Post myocardial infarction
Meigs synd.(ovarian tumour)
Myxedema
Asbestosis
subdiaphragmatic abscess

Clinical features

Unilateral: parapneumonic, TB, SLE, malignancy.
Bilateral: Heart failure, renal failure, nephrotic syndrome.
Acute: parapneumonic, pulmonary infarction.
Insidious: TB, malignancy.
Sign & symptom of pleurisy (chest pain) may antedate the effusion e.g pneumonia, pulmonary infarction, SLE.
Breathlessness is the only symptom related to effusion.
Severity of dyspnea: depend on size & rate of fluid accumulation. Small effusion may give no symptoms.
Signs of pleural effusion.
Tachypnea
Diminished chest exapansion on the side of effusion.
Shift of trachea and apex beat to opposite side in severe effusion.
Stony dullness over effusion.
Diminished or absent breath sounds and vocal resonance over effusion.


Investigations

Chest X-ray

Around 200 ml of fluid must accumulate to be seen by PA view. Ultrasonund and CT are more sensitive.
Dense uniform opacity in lower and lateral parts, manifests (meniscus sign).
Subpulmonary effusion
Loculated effusion in interlobar fissure.

Ultrasonography

More accurate than chest X-ray for fluid volume estimation.
Differentiate between loculated PE &pleural tumor.
Examination of diaphragm &subdiaphragmatic space.
Localize effusion prior to aspiration.

Pleural aspiration & pleural biopsy

Done under guidance of U/S or CT.
Needle inserted at maximum dullness & maximum opacity by PA & lateral CXR if U/S &CT are not available.
Aspirate 50 ml for biochemical, cytological examination &culture. In TB send large volume to laboratory.
Fluid: straw-coloured, blood-stained, purulent, chylous.
Measure protein ,LDH, glucose & PH.
Cell type: neutrophil, eosinophil, lymphocyte, RBC, malignant cells.


CT scan
Shows pleural and lung abnormalities and may distinguish benign from malignant effusion.

Video-assisted thoracoscopy Visualize pleura and biopsy taken directly.

Investigate the cause of pleural effusion

Lights criteria of exudative pleural effusion
Pleural fluid / serum protein > 0.5.
pleural fluid / serum LDH (lactate dehydrogenase) > 0.6.
Pleural fluid LDH is > 2/3 of upper limit of normal serum LDH

Features of Pleural effusions

Parapneumonic pleural effusion
Exudates
High protein low sugar
Contains polymorphonuclear WBC
Low PH if it changes to empyema.
Culture may show type of bacteria.


Tuberculous pleural effusion
Exudates
Serous, amber colour
High lymphocyte
Low glucose
Bacilli 20% +ve in fluid, 80% +ve in pleural biopsy.
Tuberculin skin test is positive.

Malignant PE

Serous , blood-stained exudates.
Serosal cells, lymphocytes, clumps of malignant cells.
Positive pleural biopsy in 40%.
Rapidly accumulating after aspiration.
Evidence of malignancy elsewhere.

Cardiac PE

Serous transudate
Straw coloured
Few serosal cells
Low protein, normal glucose
Evidence of left ventricular disease
Response to diuretics


Pulmonary infarction
Serous, blood-stained, exudates
increased RBC & esinophil
Evidence of pulmonary infarction and embolic source.

Rheumatoid arthritis

Serous, exudates
Lymphocyte increased
Very low glucose
High cholesterol in chronic effusion
Low complement
Rheumatoid factor and anti-CCP antibodies in serum.

SLE
Serous, exudates
Increased lymphocyte & serosal cells
Low complement in fluid
ANF& anti-DNA in serum

Acute pancreatitis

Serous , bloody, exudates
No cells
Fluid amylase > serum amylase


Thoracic duct obstruction
Milky, chylous
No cells
Increased chylomicrons.

Management

Aspirate to releive breathlessness, not more than 1.5 L to avoid re-expansion pulmonary oedema.
CXR after aspiration looking for pneumothorax.
Treatment of underlying disease.
Parapneumonic PE: complete & repeated aspiration to avoid empyema & pleural thickening. Give proper antibiotics.
TB: Anti TB always, aspirate to relieve breathlessness, 20 mg
prednisolone /day for 4-6 weeks in large effusion which promote
rapid fluid absorption, decrease re-accumulation & prevent fibrosis.
Malignant PE: re-accumulate rapidly, drain all fluid by intercostal tube & obliterate pleural space (pleurodesis) by injecting talc & tetracycline causing inflammation & pleural adhesion.
Heart failure: give diuretics.









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