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www.wjpr.net Vol 7, Issue 9, 2018.
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Deshpande et al. World Journal of Pharmaceutical Research
RETROSPECTIVE STUDY OF PLEURAL DISEASES
Roma Raykar*1, Mansi Deshpande
2, Joanna Baptist
3 and Tushar J Palekar
4
1,3
Assistant Professor, Dr. D.Y. Patil College of Physiotherapy, Pune.
2Final Year BPT, Dr. D.Y. Patil College of Physiotherapy, Pune.
4Principal and Professor, Dr. D.Y. Patil College of Physiotherapy, Pune.
ABSTRACT
Background: The extent of pleural disease has substantially increased
in the past decade because of rise in incidence of pleural space
infection and pleural malignancies. The aetiology of pleural disease is
broadly multifactorial; viral and bacterial infection, pneumonia and
lung diseases. Common pleural diseases are Pleural Effusion,
Pneumothorax, Hydro pneumothorax, Pleurisy and Empyema.
Objective: The study was carried out to find out the extent of pleural
disease based on demographic data of age and gender, incidence of
cough, extent of dyspnoea, incidence of addition and to rule to
common form of pleural disease in Indian Population. The study would
help in preventing the disease and taking early intervention in patients who fall under the
population at risk. Materials and Methods: A retrospective study comprising of a sample
size of 114 patients was collected in the past three years, the data collected was analysed
using graphs and tables and presented in a tabular format. Results and Conclusion: Results
reviewed that 47% of patients were between 41-60 years of age group to have pleural disease.
61% male patients were affected with pleural disease. Presence of cough was found in 59%
of patients, while dyspnoea was found in 72% of patients. Incidence of addiction was 62%
associated with pleural disease. Pleural effusion was the commonest pleural disease. The
study would be helpful to determine aetiological hazards and identify individuals at high risk
of infection.
KEYWORDS: Pleural disease, retrospective study, infections, addictions.
INTRODUCTION
Pleural diseases affect the pleura and the pleural space of the lung.[1]
World Journal of Pharmaceutical Research SJIF Impact Factor 8.074
Volume 7, Issue 9, 1433-1446. Research Article ISSN 2277– 7105
Article Received on
19 March 2018,
Revised on 09 April 2018,
Accepted on 30 April 2018
DOI: 10.20959/wjpr20189-11988
*Corresponding Author
Mansi Deshpande
Final Year BPT, Dr. D.Y.
Patil College of
Physiotherapy, Pune.
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Pleura is a thin tissue covered by a layer of cells that surround lungs and inside of chest wall,
while pleural space is the space between lungs and the chest wall. It allows normal to and fro
motion of lungs during breathing. The outer pleura are the visceral pleura and the
corresponding inner layer is the parietal pleura.[1]
The pleural cavity contains a small amount of fluid – 10 ml on each side. Pleural fluid
volume is maintained by a balance between fluid production and removal and changes in the
rates of either can result in presence of excess fluid.[2]
Pleural diseases are high in region of high pollution and poor hygiene, as these individuals
are more prone to parenchymal diseases like pneumonia, tuberculosis, etc which later
predisposes to involve pleural region.[2]
Pleural diseases are caused due to viral, bacterial infections, pulmonary embolism, chest
trauma, pneumonia, lung diseases or any heart surgery.[3]
Common symptoms shown by patients of pleural diseases are dyspnoea, cough, sputum,
chest pain, fever, etc. Cough is caused by accumulation of fluid in the pleura. Dry cough is
common in pleural disease.[2]
Dyspnoea is a marked symptom in early stage of pleural disease. Dyspnoea which is more on
exertion initially, increases as the disease deteriorates.
Pleural diseases affect adults and older age group because of increased risk of infections and
other lung conditions3.
Males have higher predominance due to increased risk of infection,
smoking, etc. Smoking and tobacco chewing fuels mutagenesis, initiation and proliferation of
mesothelioma cells, this lead to inflammation of the pleura and surrounding leading to
pleurisy and empyema.[4]
Physical examination reveals diminished or absent breath sounds with severe chest pain and
breathlessness.[3]
Investigations that can be carried out are chest radiography, ultra sound, pleural fluid
examination, pleural biopsy and thoracoscopy.
Risk factors of pleural diseases are congestive heart failure, pneumonia, malignancy,
myocardial infarction, chronic smoking, drug induced infection.[4]
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Complications include lung scarring, lobar collapse, re-expansion pulmonary oedema,
trapped lung, etc.[4]
Surgical management includes pleurodesis, thoracentesis, tube thoracotomy, pleurectomy.[4]
Physiotherapy marks a very important role in betterment of patients with pleural diseases.
Physiotherapy management includes thoracic breathing exercises to increase lung volume and
aid normal breathing. Spirometer techniques are used to increase the lung capacity and lung
function.[3]
Chest physiotherapy includes percussion, vibration and shaking for the removal of cough
secretions, while dyspnoea relieving positions are taught to reduce shortness of breath.[3]
The common pleural diseases are:
1. Pleural effusion
2. Pneumothorax
3. Hydro pneumothorax
4. Pleurisy
5. Empyema
1. Pleural effusion
Any abnormal amount of pleural fluid in the pleural space is called pleural effusion. Pleural
fluid enters the pleural space across both the visceral and parietal pleura, when the interstitial
pressure within either the lung or chest wall is increased. Abnormalities of increased pleural
fluid production or blockade of drainage can cause pleural fluid to accumulate.[3]
Accumulation may occur by transudation from the circulation or by exudation and
inflammation. Causes of exudates include malignant disease, pneumonia, tuberculosis, SLE,
etc. Causes of transudates include CHF, nephrotic disease and cirrhosis.[4]
Clinical signs include chest pain, difficulty in breathing, dry cough. There is also diminished
movement on the affected side with dullness to percussion and reduced tactile vocal fremitus
over the fluid. Males are affected more. Complications include lung scarring, empyema, and
sepsis.[4]
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Investigations such as chest radiography show fluid as whitish areas on the lung base.
Thoracentesis is an invasive procedure to remove fluid from the pleural space for diagnostic
as well as therapeutic purposes. There is evidence of homogenous opacity with obliteration of
the costophrenic angle.[4]
Small pleural effusions require no treatment, while larger ones require drainage of pleural
fluid. Pleurodesis is a process of fusing the parietal and visceral pleura with a fibrotic reaction
that prevents further pleural fluid formation or seals the pleural space.[5]
Thoracentesis is a
procedure of inserting a needle into the pleural space and removing the fluid.
Physiotherapy treatment includes postural drainage, percussion, vibration and coughing
techniques for secretion clearance. Diaphragmatic breathing to maintain and retain
respiratory function. Localised expansion exercises to control breath volume are useful[4]
.
Fig 1: Pleural effusion.[1]
2. Pneumothorax
Pneumothorax is the presence of air in the pleural space, sometimes associated with collapse
of the lung. This may result from penetrating injuries of the chest wall but more commonly
from spontaneous rupture of the visceral pleura with leak of air from the lung.[3]
Primary pneumothorax occurs in patients with no history of lung disease. Secondary
pneumothorax affects patients with pre-existing lung disease. Where the communication
between the airway and pleural space seals of as the lung deflates and does not re-open the
pneumothorax is referred to as ‘closed pneumothorax’.[6]
A larger pneumothorax results in
absent or decreased breathe sounds. Intension pneumothorax there is progressive
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breathlessness associated with tachycardia, hypotension, cyanosis and tracheal displacement
away from the side.[6]
The sharp pleuritic pain may refer to shoulder tip. Chest movements
will be diminished and there will be resonance to percussion.[3]
Investigations such as chest radiography will show a collapsed lung with peripheral
radiolucency and the lung edge is visible.[3]
X-rays may also show the extent of any
mediastinal displacement and reveal any pleural fluid or underlying pulmonary disease.[3]
Primary pneumothorax usually resolves without interventions. In young patients with
moderate or secondary pneumothorax, percutaneous needle aspiration of air is a simple
method. With a large pneumothorax, treatment by intercostal drainage with a valve is
indicated.[5]
Physiotherapy includes manual assistance like percussion, vibration and shaking for removal
of secretions. Diaphragmatic and relaxation breathing exercises for breathing technique
retraining. Illness progression and effect of allergen factors should be advised.[3]
Fig 2: Pneumothorax.[13]
3. Hydropneumothorax
It is the accumulation of both air and fluid in the pleural cavity due to introduction of air
during pleural fluid aspiration presence of gas forming organism, thoracic trauma. There is
usually fluid at the bottom and air at the top.[4]
Clinical signs are straight line dullness, splash, sound of coin and fullness of chest.[7]
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Investigations include chest radiography which shows a sharp pleural line with increased
opacity.[8]
Chest x-ray also shows upright air fluid level in the thoracic cavity. There is
marked straight horizontal fluid demarcation.[7]
Surgical interventions include simple aspiration, chest tube placement for removal of air.
Surgery options also include thoracoscopy, open thoracotomy, resection of blebs or pleura.[4]
Physiotherapy management includes chest physiotherapy for airway clearance of excessive
secretions. Postural drainage in anti-gravity positions is also useful.[4]
Fig 3: Hydropneumothorax.[8]
4. Pleurisy
It is the inflammation of the pleura lining and the inner chest wall. It is also known as
pleuritis. It can be caused due to infections, TB, CHF, pulmonary embolism. Inflammation
can lead to sharp chest pain (pleuritic pain) that worsens during breathing. Due to
inflammation, two layers of pleural membrane rub against each other producing pain when
you inhale and exhale.[1]
Signs and symptoms include chest pain that worsens when you breathe, cough or sneeze,
shortness of breath, cough and fever only in some cases.[8]
Investigations such as chest x-ray include show inflated lungs. It also includes rubbing of two
inflamed layers of pleura with each breath, the noise generated is pleural friction rub.
Thoracentesis, thoracoscopy or pleuroscopy includes removal of fluid and tissue for testing.[7]
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Deshpande et al. World Journal of Pharmaceutical Research
Treatment includes thoracentesis in which a hollow, plastic tube is inserted to draw fluid out.
External splinting of the chest wall and pain medications reduces pain of pleurisy.[9]
Fig 4: Pleurisy.[14]
5. Empyema
Empyema is a condition in which pus gathers in the area between pleural cavities. Empyema
can develop after pneumonia, which can cause due to streptococcus pneumonia and
staphylococcus auras. It can also result from bronchiectasis, COPD, RA. It is also known as
pylothorax, purulent pleuritis or lung empyema.[10]
The infection causes the fluid to build up faster that it is absorbed. The infected fluid
thickens, it causes lining of lung and chest cavity to stick together and form pockets called
empyema.[10]
Simple empyema occurs in early stage of illness, includes dyspnoea, dry cough, fever,
stabbing chest pain, etc. complex empyema results in sever inflammation and if infection gets
worse, it can lead to formation of a thick peel, called pleural peel. Symptoms include
dyspnoea, decreased breath sounds, chest pain, and weight loss.[9]
Investigations include chest radiographs that show the fluid and pus in the pleural space.
Ultrasound shows exact amount and location of fluid. While blood tests help to identify the
causative microorganism, thoracentesis is used by inserting a needle through the back of
ribcage to take a sample of fluid.[9]
Treatment is aimed at removing the pus and treating infection. In simple empyema,
percutaneous thoracentesis is performed by inserting a needle in pleural space to drain the
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fluid. In complex stages, drainage tubes are must use under anaesthesia; thoracotomy is one
example of that.[11]
Physiotherapy includes good postural drainage to drain out the pus, followed by breathing
exercise to increase lung volume.[12]
Fig. 5 Empyema[5]
MATERIALS AND METHODOLOGY
Study commenced after necessary approvals from the college authorities. Case records of
patients of surgery ward of D.r. D.Y Patil medical college and hospital for pleural diseases
from 1st January 2015 to 31
st December 2017 are collected. In this study, inclusion criteria
were patients with pleural diseases and their corresponding symptoms. While, exclusion
criteria were patients with Obstructive pulmonary diseases.
Data was collected based on demographic data of age and gender, presence or absence of
cough, extent of dyspnoea, incidence of addiction and to find out the common pleural
disease.
The data collected was analysed using graphs and tables and presented in a tabular format.
DATA RECORDING CHART
Sr.
no Name Age Gender
Cough
(present/absent)
Dyspnoea
(present/absent)
Addiction
(present/absent) Diagnosis
RESULTS: The data obtained was analysed and presented in tables and graphs.
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Graph- I : Demographic Data.
Table I(a) Age.
AGE GROUP NO. OF PATIENTS
20-40 29
41-60 53
61-80 32
Interpretation: Graph I(a) and Table I(a) shows that 41-60 years of age group is affected the
most (47%), 61-80 (28%) and 20-40 (25%)
Graph I(b): GENDER
Table I(b).
GENDER RATIO NO. OF PATIENTS
MALES 70
FEMALES 44
TOTAL 114
Interpretation: Graph I(b) and Table I(b) shows that 61% were males and 39% were females.
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Graph II: Presence and absence of cough
Table II.
Cough No. of patients
Present 67
Absent 37
Total 114
Interpretation: Graph II shows that 59% patients show presence of cough while 41% show
absence of cough.
Graph III: Presence and absence of dyspnoea.
Table III.
Dyspnoea No. of patients
Present 82
Absent 32
Total 114
Interpretation: Graph III and Table III showed that out of 114, 82 patients showed symptoms
of dyspnoea.
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Graph IV: Incidence of addiction.
Table IV.
Addiction No. Of patients
Present 71
Absent 43
Total 114
Interpretation: Graph IV and Table IV showed that 71 out of 114 patients had history of
addiction.
Graph V : Commonest form of pleural disease.
Table V.
Diagnosis No. Of Patients
Pleural effusion 66
Pneumothorax 32
Hydropneumothorax 5
Pleurisy 4
Empyema 7
Total 114
Interpretation: Graph V and table V shows that Pleural effusion is the commonest form of
pleural disease.
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DISCUSSION
Diseases of the pleura and their extent have increased by a decade due to increasing pollution,
increased risk of infections, addiction among young adults, etc.
A retrospective study was conducted among 114 individuals aged between 20-80, those
having pleural disease.
Graph I based on the demographic data of age and gender was reviwed, and the study showed
the common age group to have pleural disease was 41-60 years. Lung capacity and muscle
function on a cellular level decreases as age increases. Clearance of particles from the lung
through the mucociliary elevator is decreased and associated with ciliary dysfunction.[15]
Many complex changes in immunity with aging contribute to increased susceptibility to
infections producing a low immune response. Considering all of these age- related changes to
lungs and pleura, pleural diseases are common in older age groups.[15]
As with gender, male population is affected more as compared to female, the ratio being 2:1.
This is because of the primary risk for mesothelioma remains occupational with certain drugs
like asbestos, which is common in male dominated population. Also the incidence and
evidence of smoking and tobacco chewing is common among males, which leads to further
inflammation of the pleura leading to evident pleural diseases.[15]
Graph II shows that pleural diseases showed a common symptom of cough among more than
half of the individuals.
The pleura creates too much fluid when its inflamed or irritated. The fluid accumulates in the
chest cavity outside the lung, resulting in disturbance in normal respiration.[16]
In pleural disease like pneumothorax, there is inflation of the lung, which leads to cough. In
empyema, there are filled pockets of exudate fluids, which lead to faulty breathing
mechanisms, which results in disturbance in normal respiration resulting in cough. Dry cough
is more common in patients of pleural disease.[16]
Graph III showed that dyspnoea is found to be another major symptom in pleural disease.
Gas exchange worsens with pleural effusions leading to faulty lung and respiratory
mechanisms. Also the sense of respiratory effort, chemoreceptor stimulation, and mechanical
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Deshpande et al. World Journal of Pharmaceutical Research
stimuli arising in lung and chest wall receptors, and neuro ventilatory dissociation may all
contribute to dyspnoea.[16]
Airway inflammation and perturbation in the ventilator response due to weakness in the
respiratory muscles causes difficulty in breathing. This leads to altered respiratory muscle
function and breathlessness.[16]
Graph IV showed that addiction was found to be a risk factor among maximum patients of
pleural diseases.
Smoking leads to infections which affect the alveoli and airways, smoke moves more deeply
into the respiratory tract, more soluble gases are absorbed and particles are deposited in the
airways and alveoli.[17]
The substantial doses of carcinogens and toxins delivered to the pleura and lungs place
smokers at risk for malignant para pneumonic effusions and other non-malignant pleural
diseases.
Chronic smoking causes sustained injurious stimulus which damages the lung tissue and
decreases the lung defence healing property. This further leads to diffuse changes in the
lining of airways of lung and epithelium, years later leading to diseases affecting the pleura.17
Graph V concluded that pleural effusion was found to be the commonest pleural disease,
because of common viral and bacterial function.
Pleural effusion affects all age groups and incidences of other diseases are secondary to
pleural effusion. Pneumothorax, hydropenumothorax, pleurisy and empyema are secondary to
pleural effusion in most of the cases.[18]
CONCLUSION
From the 114 subjects taken into consideration for the study of pleural diseases the following
are the conclusions:-
The most common affected age group is 41-60 years (47%)
Males are more affected than females (61%)
Majority of patients showed the addiction associated with pleural disease (62%)
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Dyspnoea (72%) and cough (59%) are found to be the common symptoms among patients
of pleural disease.
Pleural effusion was found to be the commonest pleural disease (58%)
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