PLEURAL DISEASEPLEURAL DISEASE

Pleural DiseasesPleural Diseases

Pleural effusionsPleural effusions Pleural malignancyPleural malignancy HemothoraxHemothorax PneumothoraxPneumothorax

The Mechanisms of Pleural The Mechanisms of Pleural EffusionEffusion

Increased hydrostatic pressure (Cardiac failure)Increased hydrostatic pressure (Cardiac failure) Decreased oncotic pressure (Protein deficiency)Decreased oncotic pressure (Protein deficiency) Decreased pleural cavity negative pressure Decreased pleural cavity negative pressure

(Atelectasis)(Atelectasis) Increased permeability in microvascular Increased permeability in microvascular

circulation (İnfections, inflammation)circulation (İnfections, inflammation) Impaired lymphatic drainage of pleural space Impaired lymphatic drainage of pleural space

(Tumor, fibrosis)(Tumor, fibrosis) Transperitoneal route (Congenital defects, Transperitoneal route (Congenital defects,

ascite)ascite)

SymptomsSymptoms

Chest pain (inspiratory)Chest pain (inspiratory) Decreases when the fluid Decreases when the fluid

increasesincreases DyspneaDyspnea CoughCough Symptoms of the Symptoms of the

underlying diseaseunderlying disease FeverFever HemoptysisHemoptysis Weight lossWeight loss ......

Physical signsPhysical signs

No physical signs can be No physical signs can be detected when the fluid is detected when the fluid is less than 300 mlless than 300 ml

İncreased size of the İncreased size of the affected hemithoraxaffected hemithorax

İpsilateral restriction of İpsilateral restriction of chest wall motion chest wall motion

VT absentVT absent Dullness (>300-400 ml)Dullness (>300-400 ml) Diminished breath Diminished breath

sounds or inaudiblesounds or inaudible Pleural friction rubPleural friction rub

RadiologyRadiology The fluid initially accumulates in the more The fluid initially accumulates in the more

dependent recesses of the thoracic cavity dependent recesses of the thoracic cavity forming a forming a Damoiseau LineDamoiseau Line

200-300 ml of pleural effusion can be detected 200-300 ml of pleural effusion can be detected on standard chest radiograph as blunting of the on standard chest radiograph as blunting of the costophrenic anglecostophrenic angle

Massive pleural fluid often shifts the mediastinum to the opposite side

Accumulation of the fluid between the diaphragm and the interior surface of the lung (Subpulmonic fluid):

The hemidiaphragm appears to be elevated (Widening the distance between the top of the gastric bubble and the top of the left hemidiaphragm (>2 cm) and flatened

Blunting of the posterior costophrenic angle on the lateral chest radiograph

Smaller amounts of pleural fluid can be Smaller amounts of pleural fluid can be detected on lateral decubitus radiography detected on lateral decubitus radiography as the free intrapleural fluid moves from as the free intrapleural fluid moves from top of the diaphragm to the dependent top of the diaphragm to the dependent chest wallchest wall

Pleural effusion in a lateral decubitus radiograph

Unusual localized Unusual localized pleural effusions can pleural effusions can be seen due to the be seen due to the localized obliteration localized obliteration of the pleural space of the pleural space often by inflammatory often by inflammatory conditionsconditions

Ultrasound is able to demonstrate smaller Ultrasound is able to demonstrate smaller amounts of fluid as 100 mlamounts of fluid as 100 ml

CT has similar sensitivity to ultrasound, CT has similar sensitivity to ultrasound, not routine but can be performed to not routine but can be performed to evaluate concomitant paranchymal lesionsevaluate concomitant paranchymal lesions

CT is sensitive in identifying pleural CT is sensitive in identifying pleural thickening and calcificationthickening and calcification

ThoracentesisThoracentesis

Thoracentesis is indicated in all cases of Thoracentesis is indicated in all cases of pleural efusion of unknown originpleural efusion of unknown origin

The site should be selected according to The site should be selected according to clinical examinationclinical examination

If the effusion is small thoracentesis can If the effusion is small thoracentesis can be performed under ultrasound guidancebe performed under ultrasound guidance

Thoracentesis is usually performed for diagnosisThoracentesis is usually performed for diagnosis Apperiance of the fluid (Serous, bloody, purulent)Apperiance of the fluid (Serous, bloody, purulent) Biochemical, microbiological, cytological examination Biochemical, microbiological, cytological examination

of the fluidof the fluid

It can also be performed for the drainage of It can also be performed for the drainage of excess fluid (Therapotic) to relieve dyspnea excess fluid (Therapotic) to relieve dyspnea The amount of fluid should not exceed 1000-1500 cc The amount of fluid should not exceed 1000-1500 cc

at a time to avoid hemodynamic complications and at a time to avoid hemodynamic complications and reexpansion pulmonary edemareexpansion pulmonary edema

Pleural Fluid analysisPleural Fluid analysis

AppereanceAppereance Serous (light to dark, clear)Serous (light to dark, clear) Serosangineous (Blood tinged can be due to Serosangineous (Blood tinged can be due to

thoracentesis itself)thoracentesis itself) Hemorrhagic (hemothorax if hct>50% of blood Hemorrhagic (hemothorax if hct>50% of blood

hct)hct) Purulent (fetid odor in aerobic infections)Purulent (fetid odor in aerobic infections) Chylous (milky)Chylous (milky)

Biochemical evaluationBiochemical evaluation ExudativeExudative TransudativeTransudative Some special hintsSome special hints

Microbiological evaluationMicrobiological evaluation Cellular structureCellular structure Special stains and cultureSpecial stains and culture

Cytologic evaluationCytologic evaluation

Biochemical EvaluationBiochemical Evaluation

ExudateExudate Dark yellow colorDark yellow color Total protein >3 gr/dlTotal protein >3 gr/dl Density >1016Density >1016 Light Criteria:Light Criteria:

• Protein pl/sProtein pl/s >0.5>0.5• LDH pl/sLDH pl/s >0.6>0.6• LDH >200 or >2/3 of LDH >200 or >2/3 of

normal upper value of normal upper value of serumserum

TransudateTransudate Light yellow colorLight yellow color Total protein <3 gr/dlTotal protein <3 gr/dl Density <1016Density <1016 Light Criteria:Light Criteria:

• Protein pl/sProtein pl/s <0.5<0.5• LDH pl/sLDH pl/s <0.6<0.6• LDH <200LDH <200

Albumine Gradient:Albumine Gradient: Serum albumine- Pleural fluid albumineSerum albumine- Pleural fluid albumine <1.2 gr/dl<1.2 gr/dl EksudateEksudate >1.2 gr/dl>1.2 gr/dl TransudateTransudate

Pleural Cholesterol >60 mg/dl: EksudatePleural Cholesterol >60 mg/dl: Eksudate Pl/S bilirubine >0.6:Pl/S bilirubine >0.6: ExudateExudate

Microbiologic evaluationMicrobiologic evaluation

RBC >100 000/mmRBC >100 000/mm33 Trauma,Trauma, Pulmonary infarctionPulmonary infarction malignancymalignancy

WBC > 1000/mmWBC > 1000/mm33 : exudate : exudate > 10 000/mm> 10 000/mm33 : emphyema, : emphyema,

parapnomonic effusion (PNL predominates)parapnomonic effusion (PNL predominates)Lymphocytes >50% : tuberculosis, malignancy, Lymphocytes >50% : tuberculosis, malignancy,

lymphoma, fungus, myxedemalymphoma, fungus, myxedema

Gram stainingGram staining Ziehl-Neelsen stainingZiehl-Neelsen staining Cultures for specific and nonspecific Cultures for specific and nonspecific

infectionsinfections PCRPCR

Transudative Pl. Eff.Transudative Pl. Eff. Increased hydrostatic Increased hydrostatic

pressurepressure• Congestive heart failureCongestive heart failure• Constrictive pericarditisConstrictive pericarditis• Pericardial effusionPericardial effusion• Pulmonary thromboemboliPulmonary thromboemboli

Decreased oncotic Decreased oncotic pressurepressure

• CirrhosisCirrhosis• Nephyrotic syndromeNephyrotic syndrome• MalnutritionMalnutrition

Increased capillary Increased capillary permeabilitypermeability

• Myxedema Myxedema • Pulmonary thromboemboliPulmonary thromboemboli

Transperitoneal transportTransperitoneal transport• Peritoneal dialysisPeritoneal dialysis• AscitesAscites

Exudative Pl. Eff.Exudative Pl. Eff. Infectious diseasesInfectious diseases

• Pnomonia, lung abscessPnomonia, lung abscess• TuberculosisTuberculosis• Fungal infectionsFungal infections• Subphrenic abscessSubphrenic abscess

Neoplastic diseasesNeoplastic diseases• MetastaticMetastatic• MesotheliomaMesothelioma• LymphomaLymphoma

Immunologic reactionsImmunologic reactions• Dressler syndromeDressler syndrome• Sistemic Lupus Er.Sistemic Lupus Er.• Rheumatoid artritisRheumatoid artritis• Churg strauss syndromeChurg strauss syndrome• Wegener granulomatosisWegener granulomatosis

Exudative Pl EffExudative Pl Eff Gastrointestinal Gastrointestinal

diseasedisease• PancreatitisPancreatitis• Causes of peritoneal Causes of peritoneal

exudaexuda Drug inducedDrug induced

• NitrofurantoinNitrofurantoin• DantroleneDantrolene• MethysergideMethysergide• BromocriptineBromocriptine• ProcarbasineProcarbasine• AmiodoroneAmiodorone

PostsurgicalPostsurgical Pulmonary Pulmonary

thromboembolismthromboembolism

Exudative Pl EffExudative Pl Eff SarcoidosisSarcoidosis Uremic pleuritisUremic pleuritis Asbestos exposureAsbestos exposure ChylothoraxChylothorax HemothoraxHemothorax Yellow nail syndrome Yellow nail syndrome

Special characteristics:Special characteristics:Milky appearanceMilky appearance

ChylothoraxChylothorax Triglyceride >110 Triglyceride >110

mg/dlmg/dl Pl TG/sTG>1Pl TG/sTG>1 Cholesterol crystal (-)Cholesterol crystal (-) Chylomicrons (+)Chylomicrons (+) Sterile Sterile (bacteriostatic)(bacteriostatic)

Noniritative Noniritative (do not cause (do not cause pleural thickening)pleural thickening)

Ety: Trauma, surgery, Ety: Trauma, surgery, lymphomalymphoma

PseudochylothoraxPseudochylothorax Triglyseride <50 mg/dlTriglyseride <50 mg/dl Pl TG/sTG<1Pl TG/sTG<1 Cholesterol>250 mg/dlCholesterol>250 mg/dl Pl Ch/s Ch>1Pl Ch/s Ch>1 Ety: RA, TbcEty: RA, Tbc

EmphyemaEmphyema PH<7.20PH<7.20 Low GlucoseLow Glucose

Special characteristicsSpecial characteristics

Low Glucose values (<60 mg/dl)Low Glucose values (<60 mg/dl) Emphyema, complicated parapneumonic Emphyema, complicated parapneumonic

effusioneffusion TuberculosisTuberculosis Rheumatoid artritisRheumatoid artritis Malign effusionsMalign effusions

• Lupus pleuritisLupus pleuritis• Churg strauss syndromeChurg strauss syndrome

Less frequent

pH<7.20pH<7.20 Parapneumonic Parapneumonic

effusion, emphyemaeffusion, emphyema Esophageal Esophageal

perforationperforation Rheumatoid artritisRheumatoid artritis TuberculosisTuberculosis MalignancyMalignancy UrinothoraxUrinothorax

High amylase (over High amylase (over the upper limit of the upper limit of normal serum values)normal serum values) Esophageal Esophageal

perforationperforation Acute pancreatitisAcute pancreatitis Fistula in chronic Fistula in chronic

pancreatitispancreatitis Adenocarcinoma Adenocarcinoma

(salivary amylase)(salivary amylase)

Eosinophilia >10 % of the total cellsEosinophilia >10 % of the total cells Air or blood in the pleural spaceAir or blood in the pleural space

• Recurrent punctionsRecurrent punctions• Pulmonary embolismPulmonary embolism

Benign asbestos effusionsBenign asbestos effusions Resolving pleural infectionsResolving pleural infections Echinococus infectionEchinococus infection Loeffler syndromeLoeffler syndrome Hodgkin’s lymphomaHodgkin’s lymphoma Drug induced pleural eff.Drug induced pleural eff.

If the effusion is transudative the main If the effusion is transudative the main cause should be treatedcause should be treated

If the effusion is exudative and not If the effusion is exudative and not emphyema further diagnostic procedures emphyema further diagnostic procedures should be consideredshould be considered Cytologic examinationCytologic examination Closed pleural needle biopsyClosed pleural needle biopsy Thoracoscopy (VATS)Thoracoscopy (VATS) ThoracotomyThoracotomy

TreatmentTreatment Treatment of the specific causeTreatment of the specific cause Drainage of the excess fluidDrainage of the excess fluid Pleurodesis Pleurodesis (Performed to achieve fusion between (Performed to achieve fusion between

visceral and parietal pleural layers. Main indications are visceral and parietal pleural layers. Main indications are malignant effusions, rarely recurrent benign effusions malignant effusions, rarely recurrent benign effusions when other treatments have failed. After the removal of when other treatments have failed. After the removal of pleural fluid completely by thoracal tube, special pleural fluid completely by thoracal tube, special sclerosing agents (tetracycline, doxycycline, bleomycine, sclerosing agents (tetracycline, doxycycline, bleomycine, talc etc) are injected to the pleural cavity)talc etc) are injected to the pleural cavity)

Surgical pleurectomySurgical pleurectomy Pleuroperitoneal shuntPleuroperitoneal shunt

Cardiac effusionsCardiac effusions

Predominantly caused by left ventricular failure, Predominantly caused by left ventricular failure, elevated pulmonary capillary pressureelevated pulmonary capillary pressure

>50% are bilateral effusions or 27% right sided >50% are bilateral effusions or 27% right sided only.only.

Usually the heart is enlarged on chest x ray, Usually the heart is enlarged on chest x ray, phantom tumor (pseudotumor) can be present phantom tumor (pseudotumor) can be present on the right sideon the right side

Resolves with diuretics and treatment for left Resolves with diuretics and treatment for left ventricular failureventricular failure

Infectious pleuresy, emphyemaInfectious pleuresy, emphyema

Bacterial pneumonia is associated with an Bacterial pneumonia is associated with an effusion in 40% of caseseffusion in 40% of cases

The effusion may be parapneumonic The effusion may be parapneumonic without infection (uncomplicated) or without infection (uncomplicated) or culture positive (complicated, emphyema)culture positive (complicated, emphyema)

Parapneumonic effusions are treated with Parapneumonic effusions are treated with appropiate antibioticsappropiate antibiotics

Antibiotic treatment + Tube drainage is Antibiotic treatment + Tube drainage is indicated if emphyema occursindicated if emphyema occurs

Tube drainage indications in Tube drainage indications in complicated parapneumonic effusioncomplicated parapneumonic effusion

Purulent appearancePurulent appearance Gram staining (+) for bacteriaGram staining (+) for bacteria Plevral fluid glucose<40 mg/dlPlevral fluid glucose<40 mg/dl Pleural fluid pH<7.10-7.20Pleural fluid pH<7.10-7.20 Pleural fluid LDH>1000 IU/LPleural fluid LDH>1000 IU/L

Tuberculosis pleurisyTuberculosis pleurisy Usually occurs soon after the primary infection Usually occurs soon after the primary infection

and mainly affects children or teenager groupand mainly affects children or teenager group Pathogenetic mechanisms include direct Pathogenetic mechanisms include direct

invasion of AFB to pleura or delayed type invasion of AFB to pleura or delayed type hypersensitivity reactionhypersensitivity reaction

The onset of symptoms may be acute or The onset of symptoms may be acute or subacutesubacute

Typical symptoms of pleural effusion and Typical symptoms of pleural effusion and general symptoms of tb may be presentgeneral symptoms of tb may be present

Exudative effusion, lymphocyte Exudative effusion, lymphocyte predominance, low glucose, low predominance, low glucose, low mesothelial cells (<5%), high ADA mesothelial cells (<5%), high ADA Tuberculin skin test can be (-) in 30%Tuberculin skin test can be (-) in 30%

Treatment: Pulmonary tb treatment Treatment: Pulmonary tb treatment ++ steroidsteroid

Other Pleural DiseasesOther Pleural Diseases HemothoraxHemothorax

Plevral fluid htc>50% of serumPlevral 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• thoracotomythoracotomy

ChylothoraxChylothorax Direct passage of chyle Direct passage of chyle

from the thoracic duct into from the thoracic duct into the pleural cavitythe pleural cavity

TG>110 mg/dlTG>110 mg/dl Cause:Cause:

• Tumors (Lymphoma)Tumors (Lymphoma)

• Trauma (surgery)Trauma (surgery)

• Congenital defectsCongenital defects

• LymhangioleiomyomatosisLymhangioleiomyomatosis

• TuberosclerosisTuberosclerosis

Treatment.Treatment.• Pleural drainagePleural drainage

• Parenteral nutritionParenteral nutrition

• Bed rest (to decrease Bed rest (to decrease lymphatic drainage)lymphatic drainage)

• Surgical ligation of Surgical ligation of thoracic ductthoracic duct

• Chemotherapy or RTChemotherapy or RT

FibrothoraxFibrothorax A thick fibrous tissue formed on visceral A thick fibrous tissue formed on visceral

pleurapleura Cause:Cause:

• EmpyemaEmpyema• TuberculosisTuberculosis• HemothoraxHemothorax

Treatment: DecorticationTreatment: Decortication

Pneumothorax (Px)Pneumothorax (Px)

Presence of free air between the visceral and parietal Presence of free air between the visceral and parietal pleurapleura

Divided into 3Divided into 3• Open Px ( Penetrating trauma)Open Px ( Penetrating trauma)• Closed PxClosed Px

Spontaneous (Primary, Secondary)Spontaneous (Primary, Secondary) Closed traumaClosed trauma iatrogeniciatrogenic

• Tension Px (Penetrating trauma)Tension Px (Penetrating trauma)

Physical examination:Physical examination: Hypersonority on percusionHypersonority on percusion Reduced breath soundsReduced breath sounds Hypotension and cardiac tamponade may occur Hypotension and cardiac tamponade may occur

depending on the size of the pneumothoraxdepending on the size of the pneumothorax

Radiology:Radiology: Pleural line Pleural line Hyperlucency at the peripheryHyperlucency at the periphery Mediastinal shiftMediastinal shift Expiration film, lateral decubitus film can be used Expiration film, lateral decubitus film can be used

when the lesion is not apparentwhen the lesion is not apparent

Measurement of the average Measurement of the average diameters of the collapsed diameters of the collapsed lung and the affected lung and the affected hemithorax can be usedhemithorax can be used

100-(8100-(833/11/1133)100=% 62)100=% 62

>2 cm pleural line from >2 cm pleural line from thoracic line in hiler region is thoracic line in hiler region is large pxlarge px

Simple observation with rest Simple observation with rest and supplemental oxygen can and supplemental oxygen can be used for asymptomatic be used for asymptomatic patients with a small (<20%) patients with a small (<20%) pxpx

Quantification of the size of the pneumothorax is Quantification of the size of the pneumothorax is helpfull in the decision of treatment helpfull in the decision of treatment

Intercostal drainage is indicated in large or Intercostal drainage is indicated in large or bilateral or tension pxbilateral or tension px

A recurrent spontaneous pneumothorax A recurrent spontaneous pneumothorax (30-50% risk) is an indication for surgery(30-50% risk) is an indication for surgery

Smoking should be quited after first attackSmoking should be quited after first attack

A patient with px cannot travel by air until A patient with px cannot travel by air until totaly expanded in chest x raytotaly expanded in chest x ray

Pleural NeoplasmsPleural Neoplasms Benign:Benign:

Pleural lipomaPleural lipoma Local pleural fibroma (Fibrous mesothelioma)Local pleural fibroma (Fibrous mesothelioma)

Malign: Malign: Diffuse malign mesotheliomaDiffuse malign mesothelioma

Metastatic:Metastatic: Bronchial carcinoma (adenocarcinoma) Bronchial carcinoma (adenocarcinoma) LymphomaLymphoma Breast carcinomaBreast carcinoma Other adenocarcinomasOther adenocarcinomas

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