Diseases of the pleura

1-Spontaneous pneumothorax

Is the accumulation of air inside the pleural cavity , occurring without any known etiology .More in males ,more on the right side .It can be bilateral

Causes 1- Ruptured pulmonary bleb.2-Ruptured of a cystic defect in the pleura.3-Teared visceral pleura 4-No cause can be demonstrated in (15-20%).Complications:-1-pleural effusion2-empyema 3-tension pneumothorax which leads to mediastinal shift &circulatory collapse.

4-Respiratory failure in elderly patient with COAD.

Treatment-: 1-Bed rest ,O2 administration &observation in limited pneumothorax.

2-Aspiration3-Chest tube (thoracostomy tube or ICD intercostal drain in a safety triangle which is

bounded by pectoralis muscle anteriorly &lattismus muscle posteriorly and the superior border of the nipple.in the fifth intercostal space just anterior to the mid

axillary line to avoid the long thoracic nerve. 4-bronchoscopy is indicated if the lung fail to expand

5-Chemical pleurodesis.by injecting sclerosing agent as Tetra cycline 6-Surgery pleurectomy by thoracotomy or thoracoscopically if the lung fail to re expand

2-Spontaneous haemothorax

Is the presence of blood inside the pleural cavity Causes-:

1-pulmonary causes ----------TB , AV malformation2-pleural causes -----------torn vascular adhesion

3-pulmonary malignancy ….primary or metastatic 4-blood dyscrasia ……………..hemophilia

5-abdominal pathology ……….. haemo peritoneum6-thoracic causes ………ruptured great vessels

Clinical featuresdyspnea , chest pain ,syncopesigns of hypovolaemic shock blood inside the pleural cavity may leads to deposition of fibrin on the pleural

surface leading to fibrosis (trapped lung syndrome).

Treatment 1-Resuscitation

2-Tube thoracostomy 3-May needs thoracotomy if excessive bleeding

initial bleeding more than 1.5 literOr continuous bleeding more than 200 ml/hour for more than 4 hours •

3-Chylo –thorax

Is the presence of lymph in the pleural space CausesA-Congenital atresia of the thoracic duct , birth traumaB-Traumatic C-Neoplastic malignancy

D-Infection TBDiagnosis milky pleural effusion that does not clot and contains fat , fat

soluble vitamins & antibodies Treatment

1-Conservative consists of insertion of tube thoracostomy to drain the effusion , correction of the fluid and electrolytes with nutritional supplement.

2-Surgery consists of ligation of the thoracic duct if the effusion continues for more than two weeks .

4-Pleural effusion

Is the accumulation of fluid in the pleural space excessive transudation or exudation of the interstitial fluid from the pleural surface. It is signfrom ify pleural or systemic disease .

Its effect depends on its size (mild , moderate or massive ) & the state of the underlying lung .It is classified as transudate when the protein content is less than 3g/100ml, or exudates when protein content is more than 3 gm /100ml.Clinically patients will present with dyspnea & pleuritic chest pain

Radio logically (concave meniscus sign)Transudate as in CHFExudate as in malignancy

Treatment :-1-aspiration (thoracentesis) 2-tube thoracostomy

3-chemical pleurodesis 4-pleuectomy to remove the pleura to stop the effusion .

5-Empyaema

Is the accumulation of pus in the pleural space , it passes into three stages 1-Acute phase with the clinical manifestation of fever & toxicity .

2-Transitional phase with the increased turbidity of the fluid & decrease the size of the lung.

3-Chronic phase with the pleural thickening ,decrease amount of the fluid & the development of the trapped lung syndrome .

Tube Thoracostomy

Tube thoracostomy or Chest Tube or ICD(Intercostal drain) Is a flexible hollow plastic tube that is inserted through the chest wall into

the pleural space and connected to a bedside drainage container

Indications-:1-Pnemothorax

2-Pleural Effusion This effusion may be

A-Empyema

2-Hemothorax Traumatic or Malignant Effusion

3-Hydro thorax 4-Chylothorax 5-Thoracic Operation (Tube Thoracostomy without trocar ) .On the lung or Mediastinum Or The esophagus 6-Postoperative (Collection or Infected space ).

7-malignant Effusion drainage and giving medication through it .