PLEURAL DISEASEPLEURAL DISEASE

Sevda Özdoğan MD, Sevda Özdoğan MD,

Chest DiseasesChest Diseases

Pleural effusionsPleural effusions EmphyemaEmphyema Pleural malignancyPleural malignancy HemothoraxHemothorax PneumothoraxPneumothorax

Pleural Anatomy and PhysiologyPleural Anatomy and Physiology

Pleura is a serous membrane formed from Pleura is a serous membrane formed from mesenchyme that separates the lung mesenchyme that separates the lung paranchym, mediastinum, diaphragm and paranchym, mediastinum, diaphragm and thoracic cagethoracic cage

It is composed of 2 layers as:It is composed of 2 layers as: Parietal pleuraParietal pleura Visceral pleuraVisceral pleura

Pleural CavityPleural Cavity

It is the space between the visseral and It is the space between the visseral and parietal pleuraparietal pleura

Normally contains a small amount of fluid Normally contains a small amount of fluid (10-20 ml in each pleural cavity)(10-20 ml in each pleural cavity)

This pleural fluid is mainly produced by the This pleural fluid is mainly produced by the parietal pleural surface and reabsorbed by parietal pleural surface and reabsorbed by the two layers (Mainly parietal pleura)the two layers (Mainly parietal pleura)

The production and reabsorbtion of the pleural fluid is normaly in an equilibrium accounted primarily by the forces employed in Starling equation:

F=k[(Pcap-Ppl)-δ(πcap- πpl)]

F: The rate of fluid movement

P, π: Hydrostatic and oncotic pressures

k: The filtration coefficient

δ: Osmotic reflection coefficient

Pleural EffusionPleural Effusion

If the physiologic balance between the If the physiologic balance between the filtration and the drainage of the pleural filtration and the drainage of the pleural fluid is disturbed, pleural effusion fluid is disturbed, pleural effusion accumulate.accumulate.

Fluid may accumulate in the pleural space Fluid may accumulate in the pleural space in response to the disease of the pleural in response to the disease of the pleural membranes or as a manifestation of a membranes or as a manifestation of a systemic illnesssystemic illness

The Mechanisms of Pleural The Mechanisms of Pleural EffusionEffusion

Increased hydrostatic pressure (Cardiac failure, Increased hydrostatic pressure (Cardiac failure, increased atrial pressure)increased atrial pressure)

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 increasesDecreases when the fluid increases

DyspneaDyspnea CoughCough Symptoms of the underlying diseaseSymptoms of the underlying disease

FeverFever HemoptysisHemoptysis Weight lossWeight loss ......

Physical ExaminationPhysical Examination

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

İnspectionİnspection İncreased size of the affected hemithoraxİncreased size of the affected hemithorax Trachea is deviated away from the diseased Trachea is deviated away from the diseased

sideside

PalpationPalpation İpsilateral restriction of İpsilateral restriction of

chest wall motion chest wall motion VT absentVT absent

PercussionPercussion Dullness (>300-400 ml)Dullness (>300-400 ml)

OscultationOscultation Diminished breath sounds Diminished breath sounds

or inaudibleor inaudible Pleural friction rubPleural friction rub Bronchial sound over the Bronchial sound over the

fluid levelfluid level

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 Massive pleural fluid often shifts the often shifts the mediastinum to the mediastinum to the opposite sideopposite side

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 conditions conditions (adherence)(adherence)

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

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

Thoracenthesis and Pleural Fluid analysisThoracenthesis and Pleural Fluid analysis

AppereanceAppereance Serous (light to dark yellow, clear)Serous (light to dark yellow, 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 unaerobic infections)Purulent (fetid odor in unaerobic 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

RoutineRoutine pHpH GlucoseGlucose Lactate Lactate

dehydrogenasedehydrogenase Total proteinTotal protein AlbumineAlbumine

OptionalOptional HtcHtc CholesterolCholesterol TrigliseridTrigliserid BilirubineBilirubine Adenosin deaminaseAdenosin deaminase AmylaseAmylase RFRF LE cellLE cell ANAANA Hyaluronic asciteHyaluronic ascite

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

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

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

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 (-) Pl Ch/s Ch<1Pl Ch/s Ch<1 Chylomicrons (+)Chylomicrons (+)

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

EmphyemaEmphyema PH<7.20PH<7.20 Low GlucoseLow Glucose

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, parapnomonic : emphyema, parapnomonic

effusion (PNL predominates)effusion (PNL predominates)

Mesothelial cells<5%: tuberculosis possibleMesothelial cells<5%: tuberculosis possible

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

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

Tube drainage is indicated if emphyema Tube drainage is indicated if emphyema occursoccurs

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

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

pleurapleura Cause:Cause:

• EmpyemaEmpyema• TuberculosisTuberculosis• HemothoraxHemothorax

Treatment: DecorticationTreatment: Decortication

PneumothoraxPneumothorax

Presence of free air between the visceral and Presence of free air between the visceral and parietal pleuraparietal pleura

Divided into 3Divided into 3• SpontaneousSpontaneous

Primary idiopathicPrimary idiopathic SecondarySecondary

• TraumaticTraumatic• IatrogenicIatrogenic

Primary Spontaneous Primary Spontaneous PneumothoraxPneumothorax

Mostly occurs in young, male, smokersMostly occurs in young, male, smokers There is no obvious underlying pulmonary There is no obvious underlying pulmonary

disease disease Subpleural blebs and bullae probably play Subpleural blebs and bullae probably play

a role in pathogenesisa role in pathogenesis Symptoms can be an acute unset of Symptoms can be an acute unset of

dyspnea and unilateral chest pain but can dyspnea and unilateral chest pain but can be absent also depending on the size of be absent also depending on the size of the pneumothoraxthe pneumothorax

Physical examination:Physical examination: HypersonorityHypersonority on percusion on percusion Reduced breath sounds, reduced VT, enlarged Reduced breath sounds, reduced VT, enlarged

hemithoraxhemithorax 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 can be used when the lesion is not Expiration film can be used when the lesion is not

apparentapparent

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 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

Intercostal drainage is Intercostal drainage is indicated in large pxindicated in large px

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

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

Secondary Spontaneous Secondary Spontaneous PneumothoraxPneumothorax

Patients have an underlying pulmonary disease:Patients have an underlying pulmonary disease: COPDCOPD AsthmaAsthma Congenital cysts and bullaeCongenital cysts and bullae Interstitial lung fibrosing diseasesInterstitial lung fibrosing diseases Cystic fibrosisCystic fibrosis Hystiocytosis XHystiocytosis X Whooping coughWhooping cough LymphangiomyomatosisLymphangiomyomatosis Pleural endometriosis, catamenial pneumothoraxPleural endometriosis, catamenial pneumothorax Pleural malignancyPleural malignancy SarcoidosisSarcoidosis Bacterial pneumonia and Pneumocystis PneumoniaBacterial pneumonia and Pneumocystis Pneumonia

Traumatic and Iatrogenic Traumatic and Iatrogenic PneumothoraxPneumothorax

Iatrogenic pneumothorax can be seen Iatrogenic pneumothorax can be seen during:during: ThorasentesisThorasentesis Pleural needle biopsyPleural needle biopsy Transthoracic lung aspiration biopsyTransthoracic lung aspiration biopsy Mechanical ventilationMechanical ventilation Central venous catheterizationCentral venous catheterization TracheostomyTracheostomy Cardiopulmonary resusitationCardiopulmonary resusitation

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

Malign Pleural effusionsMalign Pleural effusions

Diffuse Malign MesotheliomaDiffuse Malign Mesothelioma Bronchial carcinoma (adenocarcinoma) Bronchial carcinoma (adenocarcinoma) LymphomaLymphoma Breast carcinomaBreast carcinoma Other adenocarcinomasOther adenocarcinomas

Malignant MesotheliomaMalignant Mesothelioma

Primary tumour of pleural, pericardial, peritonial Primary tumour of pleural, pericardial, peritonial mesotheliummesothelium

Etiology: 70-90% asbest exposure:Etiology: 70-90% asbest exposure: Occupational: asbest is resistant to heat and friction Occupational: asbest is resistant to heat and friction

so used in building, water pipes, brakes, isolation so used in building, water pipes, brakes, isolation systems, textilesystems, textile

Environmental: Eskişehir, Kütahya, Bilecik, Yozgat, Environmental: Eskişehir, Kütahya, Bilecik, Yozgat, Sivas, DiyarbakırSivas, Diyarbakır

Latent period is 30-40 years in occupational Latent period is 30-40 years in occupational exposureexposure

Smoking dramaticaly increase the risk of cancer Smoking dramaticaly increase the risk of cancer in asbest exposurein asbest exposure

Erionite is another fibrous zeolite found in soil, Erionite is another fibrous zeolite found in soil, high in Nevşehir: Tuzköy, Karain, Sarıhıdır high in Nevşehir: Tuzköy, Karain, Sarıhıdır area in Turkey. It is more carcinogenic than area in Turkey. It is more carcinogenic than asbest. asbest.

49% of total deaths in the villages of Ürgüp are 49% of total deaths in the villages of Ürgüp are due to DMMdue to DMM

The most common clinical presentations are The most common clinical presentations are dyspnea, chest pain, unilateral decreased dyspnea, chest pain, unilateral decreased volume of the affected hemithorax (frozen chest) volume of the affected hemithorax (frozen chest) (inspite of fluid accumilation)(inspite of fluid accumilation)

Nodular thickening of the pleura, irregular Nodular thickening of the pleura, irregular thickening of the interlobar fissure, absence of thickening of the interlobar fissure, absence of mediastinal shift with massive pleural effusion mediastinal shift with massive pleural effusion (frozen chest)(frozen chest)

Diagnosis by histologic examinationDiagnosis by histologic examination Treatment oncologic and surgical if possible, Treatment oncologic and surgical if possible,

prognosis is poorprognosis is poor

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