Pleural Disorders

PLEURAL DISORDERS

ا.د اسامه عبيد الخفاجي
MBChB
FIBM Cardiothoracic & vascular surgey
MRCS Edn.

Pleural Effusion

Pleural effusion is accumulation of fluid in the pleural space.

Pathophysiology:
Passage of protein free fluid through the pleural membrane depends on hydrostatic and colloid oncotic pressure across the pleura
Therefore protein free fluid normally flows from the systemic capillaries in the parietal pleura into the pleural space then to the pulmonary capillaries in the visceral pleura
5-10 L of fluid normally traverse the pleural space over 24 hours. And normally only 15-20 ml of pleural fluid is present in the pleural space at any given time

Mechanism of abnormal accumulation of pleural fluid:

Increased hydrostatic pressure e.g.; CHF
Decreased plasma oncotic pressure e.g.; hypoalbuminemia
Increased capillary permeability e.g.; pneumonia, inflammatory pleuritis
Increase intrapleural negative pressure e.g.; atelactasis
Impaired lymphatic drainage owing to obstruction of the lymphatics by tumor, irradiation or fungal infection.
So any disturbance between fluid formation and absorption → pleural effusion


Pleural effusion are divided into : transudate and exudate.

Transudative pleural effusion:
Protein poor ultrafiltrate of plasma occurs when there is
Increase in systemic or pulmonary capillary hydrostatic pressure
Decrease in plasma osmotic pressure

Causes of transudative pleural effusion :

1-CHF: most common, 80% of patients with transudate have CHF. CXR → cardiomegally and bilateral. 75% resolve within 48 hours with the use of diuretics
2-Hypoalbuminemia
3-Liver cirrhosis
4-Renal insufficiency and nephritic syndrome
5-Myxedema
6-Peritoneal dialysis
7-Meig's syndrome: pleural effusion plus ascitis and ovarian fibroma. It may be transudate or exudate.
8-Sarcoidosis

Exudative pleural effusion:

Protein rich pleural fluid
pleural effusion of one or more of the following is considered an exudate:
1-Pleural fluid protein / serum protein > 0.5
2-Pleural fluid LDH / serum LDH > 0.6
3-pH < 7.0


Causes:
1- Neoplastic disease:
Lung cancer,Breast cancer, Mesothelioma, Chest wall tumors
2- Infections:
Bacterial pneumonia,TB,Fungal, Paracytic

3- Pulmonary infarction

4- Collagen vascular disease: Rheumatoid arthritis,SLE
5- Trauma and hemothorax
6- Gastrointestinal disease:
Pancreatitis,Esophageal rupture,Subphrinic abscess
7- Cardiac disease:
Post CABG,Pericardial disease
8- Obstetric and gynecological disease
Meig's syndrome,Post partum pleural effusion,Endometriosis
• 9- Drug induced: Ergot alkaloids ,Amiodarone

Clinical presentation:

Symptoms:
Asymptomatic
or symptomatic with dyspnea and pleuretic chest pain
Signs:
Inspection: decreased chest wall movement on the affected side
Palpation: Tracheal and mediastinal shift to the contralateral side - Decreased chest expansion - Decreased vocal fremitus
Percussion: Decrease resonance (stony dullness)
Auscultation: Decrease or absent breath sounds


Diagnosis
1-CXR:concave meniscus sign.About 250-500 ml of fluid must be present to obliterate the costodiaphragmatic recess
2-Pleural fluid analysis
A- Volume :massive effusion seen in(Malignant , CHF&TB)
B- Color:
Straw (pale) color→ mostly transudate
Cloudy → mostly exudate due to high WBC
Yellow → chronic empyema
Milky fluid → chylothorax
Black pleural fluid → aspergillosis
Brownish → rupture of amebic liver abscess into the pleural space
bloody → Trauma. Pulmonary infarction &Malignancy

C -Glucose : in the pleural fluid is less than serum in: TB ,Empyema &Ca

D- pH: low pH < 7.2 suggest effusion contaminated with bacteria
3- Pleural biopsy
4- Ultrasound
5- CT scan: to detect small abnormalities
6-Bronchoscopy
7-VATS
8- Sputum examination


Management of pleural effusion

• 1-Treatment of the underlying cause

2-Thoracocentesis
3-Tube thoracostomy + chemical pleurodesis
4-Surgical pleurodesis and pleurectomy
5-Radiotherapy
6-Pleuro-peritoneal shunt

Hemothorax

Presence of blood in the pleural space.
Causes:
I-Traumatic
II-Spontaneous: It is due to:
A- Pulmonary: Necrotizing infection,Pulmonary embolism ,TB, Arterio-venous malformation
• B-Pleural: Torn pleural adhesions,Neoplasm,Endometriosis
C-Neoplasm: Primary neoplasms or Metastatic
D- Blood dyscrasia: Thrombocytopenia ,Hemophilia

Clinical presentation

Dyspnea ,chest pain &Syncope


Treatment:
Management of hemothorax depends on:
Rate of bleeding
Amount of bleeding
Underlying cause

Small bleeding usualy ceases spontaneously so that only observation is required
Moderate (amount of blood loss is 500 cc or more) :
thoracostomy.
Continuing active bleeding (200 ml/hr or more):
Open thoracotomy.
VATS

• Indications for thoracotomy in hemothorax:

• 1- Initial chest tube output more than 1500 ml
• 2- Continuous bleeding 200-300 ml/hr for 3 consecutive hours
• 3- Retained clot

• Chylothorax

• the presence of lymph in the pleural cavity
• Etiology
• I-Trauma
• A-Blunt trauma:Sudden hyperextension
• B-Penetrating trauma to thoracic duct
• C-Surgery: like LN excision
• D-Diagnostic procedures : Left central venous line
• E-Exaggerated physiological maneuvers:
• Vomiting episodes or violent coughing especially after the duct is distended after a fatty meal can lead to spontaneous chylothorax
• II -Neoplasm: Lymphangioma, Lymphosarcoma
• III- Infection :TB ,Filariasis
• IV- Congenital :Thoracic duct atresia, Birth trauma


• Clinical picture:
• Chest pain dyspnea and fatigue
• Prolonged leakage lead to
• Dehydration
• Malnutrition
• Decrease immunity
• Diagnosis:
• 1-Aspiration of milky white odorless fluid from the pleural space is virtually diagnostic
• Characteristics of chyle
• Milky
• Alkaline and odorless
• Triglyceride (TG) > 110 mg/dl
• Cholesterol/TG < 1
• 2- Lymphangiography

• Treatment

• 1-Tube Thoracostomy
• 2-Correction of
• A-Fluid loss
• B-Electrolyte imbalance
• C-Nutritional support: TPN and avoid long chain fatty acids
• 3- Surgical opeative : failure of previous measures after 2 weeks thoracotomy or VATS (Pleurectomy or Pleuro-peritoneal shunt)

Pneumothoraxpesence of air in the pleural space

Classification:
Spontaneous and acquired.
A-Spontaneous:
Primary spontaneous pneumothorax (PSP): with no known cause or clinical evidence of underlying lung disease
Secondary spontaneous pneumothorax (SSP): secondary to any lung disease Airway disease: Bullous disease Infection: Pneumonia: TB

Neoplasm primary and secondary

Others:Pulmonary embolism Catamenial
B-Acquired: secondary to:
Iatrogenic:
Central venous line insertion
Pacemaker insertion
Needle biopsy (transthoracic or transbronchial)
After laparoscopic surgery
Barotrauma
Traumatic:
Blunt trauma
Penetrating injury


• Clinical presentation
• Asymptomatic or Symptomatic
• Dyspnea
• Pain
• On examination :
• Small pneumothorax may have no abnormal finding
• Inspection: dyspnea ± cyanosis
• decrease or absence chest wall movement
• Palpation: Trachea shifted to the other side,Decreased chest wall expansion,Decreased or absent tactile vocal fremitus
• Percussion: hyperresonance (tympanic)
• Auscultation: decrease or absent breath sounds

• Investigation:

• 1-CXR: Standard PA view in deep inspiration
• Rhea method
• 2-CT scan
• 3-Arterial blood gas analysis
• 4-Pulmonary function test
• 5-Bronchoscopy

Pneumothorax

Size
Average intrapleural distance
Less than 20% (mild)
1-2 cm
20-40%(moderate )
2-4 cm
• More than 40% (severe )
More than 4 cm


• Management
• 1- Observation: for vey mild or trivial cases
• 2- Thoracocentesis: for minimum one
• 3- Chest tube ± suction for moderate cases
• 4- Chemical pleurodesis via chest tube for recurent pneumothorax
• 5- Thoracotomy or VATS with blebectomy and pleural ablation or pleurectomy

Indication for thoracotomy in pneumothorax

1- Massive air leak that prevent lung expansion
2- Recurrent same side pneumothorax
3- Previous contralateral pneumothorax
4- Bilateral simultaneous pneumothorax
5- Presence of large cyst on CXR or bullae
6- History of previous tension pneumothorax
7- History of Previous pneumonectomy

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