Outline
z Physiology of the pleura
Diseases of the Pleura
Lecturer Catalina Lionte, M.D., PhD
Some important numbers
z Size of pleural effusion to be seen on the
chest film – 200cc
z Preferred size of effusion before
thoracentesis - > 10 mm wide in the lateral
decubitus view
z Pleuraleffusions
z Neoplastic disease of the pleura
z Pneumothorax
z Chylothorax, pseudochylothorax, and
hemothorax
Development of Pleural Effusion
pulmonary capillary pressure (CHF)
capillary permeability (pneumonia, inflammation)
intrapleural pressure (atelectasis)
plasma oncotic pressure (hypoalbuminemia)
pleural membrane permeability (malignancy)
lymphatic obstruction (malignancy)
diaphragmatic defect (hepatic hydrothorax)
thoracic duct rupture (chylothorax)
movement of fluids from extrathoracic site (pancreatitis)
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 Pleural effusion - Other causes
Causes of pleural effusion
•nephrotic syndrome •pancreatitis
•TB •yellow-
yellow-nail syndrome
•collagen vascular disease •drugs
•Urinothorax
•SVC syndrome
•Meigs syndrome
•rheumatoid arthritis

Evaluation
Evaluation
History:
Physical:
z dyspnea zwt. loss
z Dullness to percussion
z pleuritic chest pain ztrauma z Decreased breath sounds
z cough z Absent tactile fremitus
zhx cancer
z Other findings:
z fever
zcardiac surgery – ascites
z hemoptysis – jvd
– peripheral edema
– friction rub
– unilateral leg swelling

Diagnostic evaluation of the Diagnostic evaluation of the pleura

pleura
z Radiography
z Ultrasound
z Computerized tomography, MRI
z Thoracentesis
z Video-assisted thoracic surgery
(thoracoscopy)
z Closed pleural biopsy
z Open pleural biopsy - Thoracotomy

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 Pleural Effusion

Upright…Meniscus Decubitus…Effusion layered on

downside

Pleural Effusion Pleural Effusion

Supine patient

Semiupright…..Lung base
opacity fades superiorly

Unilateral increased density 63-year-old man recovering from congestive

heart failure…Effusion loculated in fissure

Massive Pleural Effusion

or
Total Lung Atelectasis Pleural Effusion
z Most sensitive way to show pleural effusion
– Decubitus chest radiograph

z Least sensitive way to show pleural effusion

– Supine chest radiograph

Total Atelectasis Massive pleural effusion

Heart and mediastinum Heart and mediastinum
shifted toward whited out shifted away from whited
hemithorax out hemithorax

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 Chest CT
z Malignant pleural disease: pleural thickening (>1
cm), irregularity, nodules

z Pleural thickening: also seen in empyema

z Pleural nodules: only 17% in malignant effusions

z Otherfeatures: lung mass, chest wall involvement,

mediastinal LAP, hepatic metastases

Chest CT
Indications for thoracentesis
z Effusions larger than 1 cm height or
unknown origin
z In heart failure:
– febrile/pleuritic pain,
– unilateral,
– no cardiomegaly,
– no response to diuresis

Pleural fluid analysis Differentiation of transudates and

exudates
Appearance
Bloody Hct <1% not significant, 1-20%= Transudates Pleural Fluid Exudates
CA, PE, Trauma
< 0.5 Pleural/serum > 0.5
>50% serum Hct = hemothorax Protein
Cloudy trig level >110mg/dl = chylothorax Pleural/serum
Putrid odor stain and culture = infection? < 0.6 LDH > 0.6

< 2/3 the upper Pleural >2/3 the upper

Transudate vs Exudate?
Exudate? limit for serum LDH limit for serum

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 Light’s Criteria
Pleural fluid is exudate if one or more:

1. Pleural fluid protein/serum protein > 0.5

2. Pleural fluid LDH/serum LDH > 0.6
3. Pleural fluid LDH > 2/3 upper limit N serum
LDH

Exudative Pleural Effusions

Transudative Pleural Effusions z Parapneumonic effusions
z Tuberculous
z Congestive heart failure
z Fungal
z Pericardial disease
z Viral
z Hepatic hydrothorax zAbdominal disease
z Nephrotic syndrome z Parasitic
zCollagen vascular disease
z Urinothorax z Pulmonary embolism
z Myxedema zPost cardiac injury
z Pulmonary embolism (sometimes) zPost CABG
z Sarcoidosis zEsophageal perforation

Exudative Pleural Effusions Exudative Effusion

z Cell count - Neutrophil predom acute pleural process (pneum., PE)

- Lymphocytic predom chronic process (Cancer, TB, CABG-

Coronary artery bypass graft)

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 Exudative Effusion
Exudative
Effusion

Food-borne parasitic infection caused by Paragonimus westermani. Infection in humans mainly

occurs by ingestion of raw or undercooked freshwater crabs or crayfishes. It is particularly
common in East Asia.

Other Tests on the Pleural Fluid

z Amylase
– Esophageal Rupture
– Pancreatitis
z Triglycerides – for chylous effusions
– >110 highly likely
– <50 highly unlikely

Unknown Etiology Parapneumonic Effusions

z 15% of the time is no diagnosis made even Parapneumonic effusions
after video assisted thoracic surgery
(VATS)?
Complex Simple

Empyema

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 Characteristics of a
Complicated Parapneumonic Empyema
Effusion
z Pus in pleura space
z Glucose < 60 mg/dL z Positive gram stain
z pH < 7.2
z Positive culture
z Pleural LDH > 3x the upper limit
for serum
z Pleural fluid is loculated

Management of Parapneumonic Management of Parapneumonic

Effusions Effusions
Antibiotic selection should be based on the suspected
z Simple Antibiotics z
causative microorganisms and the overall clinical picture.
z Complicated Antibiotics plus tube z Various effective single agents and combination
antimicrobial therapies exist.
thoracostomy z Coverage should generally include anaerobic organisms.
z Empyema Tube thoracostomy z Options may include clindamycin, extended-spectrum
penicillins, and imipenem.
and possible z Depending on the patient's clinical condition, infectious
decortication disease consultation may be appropriate.

Tuberculous Pleuritis
z Acute illness 2/3 of cases
Tuberculous pleurisy
z Chronic illness in 1/3
z Subpleural focus ruptures into the pleural
z Unilateral effusion
space
z 1/3 will have parenchymal disease
z Usually younger adults, 3 to 7 months after
z Exudative, lymphocyte predominant effusion primary tuberculous infection
z Abrupt or insidious onset. DDx: pneumonia,
pulmonary infarct, tumor, others
z Natural history untreated: 65% of 141 patients
developed active tbc.

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 Diagnosis of Tuberculous Pleuritis
Diagnosis of Tuberculous
Pleuritis
z PPD may be z Pleural fluid for
negative in up – Adenosine deaminase > 40
to 30% – Interferon-gamma
– Polymerase chain reaction (PCR) for
z Culture
tuberculous DNA
z Biopsy

Treatment for Possible

Tuberculous Pleuritis
z Treat for tuberculosis
– If lymphocyte-predominant exudate and:
z The adensoine deaminase, polymerase chain

reaction, or interferon gamma is positive in the

absence of rheumatoid arthritis or empyema 1
z PPD is positive 2

1.Light, RW, Broaddus, VC. Pleural Effusion. In Murray & Nadel: Textbook of Respiratory Medicine, 3rd ed.
W.B. Saunders Company, 2000.
2. Ansari, T, Clin Chest Med, 1998

Treatment of Tuberculous Pleuresy

For severely ill patients with extensive or bilateral pleural effusions
effusions
and sputum positivity
z Four drug regimen for first 2 months:
zINH 300 mg
zRifampin 600 mg
zPZA 15-30 mg/kg
zEthambutol 15-25 mg/kg or streptomycin 15 mg/kg
z Two drug regimen for next 4 months:
zINH and rifampin
Those with a solitary TB pleural effusion

‰ 2 months - isoniazid, rifampin,

rifampin, and pyrazinamide

‰followed by 4 months with - isoniazid and rifampin

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 Asbestos-
Asbestos-related Pleural Disease
Asbestos-
Asbestos-related Pleural Disease

z Benign asbestos pleural effusion (10-20

year latency)
z Pleural plaques (20-30 year after latency)
z Mesothelioma (30-40 year latency)
z Diffuse pleural fibrosis
z Rounded atelectasis

Asbestos-
Asbestos-related Pleural Plaques
Collagen-
Collagen-Vascular Disease of the
Pleura
z Rheumatoid Arthritis
z Systemic Lupus Erythematosis
z Sarcoidosis
z Wegener’s Granulomatosis
z Sjogren’s syndrome

RA and SLE Neoplastic disease of the pleura

Characteristics RA SLE
z Lung 36%
Incidence 3%-7% 15%-44%
Sex 80% male Female
z Breast 25%
80% with SQ nodules z Lymphoma 10%
Effusion Exudate Exudate
Glucose < 20 mg/dl – 63% > 70 mg/dl z Ovary 5%
< 50 mg/dl – 83% z Stomach 2%
C4 Low Low
Pleural RF + LE cells z Unknown 7%
immunology or + ANA
Treatment NSAID/Steroids Steroids Sahn, SA: In Fishman, JA 9ed): Fishman’s Pulmonary Diseases
and Disorders, 3rd ed. McGraw Hill, NY, 1998
Response Variable response Excellent

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Clinical Manifestations of Pleural Mechanism of malignancy-
malignancy-
Metastasis associated plural effusion
Symptom Patients with z Direct metastasis
symptom (%) z Lymphatic obstruction
z Bronchial obstruction with atelect.
Dyspnea 57 z Post obstructive pneumonia
Cough 43 z Thoracic duct involvement
Weight loss 32 z Pericardial disease
Chest pain 26 z Hypoproteinemia
Malaise 22 z Pulmonary embolism
z Radiation therapy
Fever 8 z Chemotherapy (methotrexate, procarbazine, cyclophosphamide,
Chills 5 mitomycin, bleomycin)
Asymptomatic 23 Sahn, SA, Clin Chest Med, 1998
Light, RW, Pleural Disease, Philadelphia, Lea&Febiger, 1983
Chernow, B., Sahn, SA., Am J Med, 1977

Characteristics of Malignant Diagnosis of Malignant Pleural

Pleural Effusion Effusion
z Pleural fluid cytology
z Usually exudative (though occasionally
z Pleural biopsy
transudative)
z Thoracoscopy
z Mononuclear cell predominant
(lymphocytes, macrophages, and
mesothelial cells)
z 1/3 will have low pH (less than 7.3)

Sahn, SA, Clin Chest Med, 1998

Good, TJ, et al: American Review of Respiratory Disease, 1985

Mesothelioma
Treatment of Malignant and
Paramalignant Pleural Effusions
z Serialthoracentesis
z Chest tube with pleurodesis
z Thoracoscopy with talc poudrage
z Pleuroperitoneal shunt
z Pleurectomy

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 Mesothelioma Mesothelioma
z Asbestos exposure (even very modest exposures)
– Latency of 35-40 years
z No association with smoking
z Difficult diagnosis by cytology.
z Usually a biopsy is recommended
z VATS (Video-assisted thoracic surgery )
z Three histological subtypes
– Epithelial
– Sarcomatous
– Mixed

Video-assisted thoracic surgery

Treatment of Mesothelioma Benign Mesothelioma

z Extrapleural pneumonectomy z Localized pleural tumors of mesenchymal origin
z Clinical manifestations
– 5% surgical mortality
– Asymptomatic in 50%
– Median survival of 21 months (best with – Cough, chest pain, dyspnea in 40% of symptomatic
epithelial histology) patients
– 2 paraneoplastic syndromes
– 5 year survival 22% z Hypoglycemia – caused by secretion of insulin-like growth
factor II
z There may be a role for multimodality z Hypertrophic pulmonary osteoarthropathy
therapy using chemotherapy and radiation z Solitary mass
therapy z Usually cured by surgical removal

Pneumothorax - etiology
z Primary spontaneous pneumothorax
z Secondary spontaneous pneumothorax occur
due to an underlying lung disease such as
COPD, cancer, Pneumocystis jerovici, cystic
fibrosis, tuberculosis or other lung diseases
z Iatrogenic pneumothorax
z Traumatic
z Catamenial (pneumothorax occurring in
conjunction with menstrual periods)

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 Pneumothorax
Primary Spontaneous Displaced Visceral Pleura
Pneumothorax
z Felt to arise from sub pleural blebs
z Associated with smoking
z Patients tend to be taller and thinner
z Usually occurs when the patient is at rest
Skin Fold
z Diagnosis confirmed by chest x ray
Pneumothorax
z Recurrence rate of 39% on ipsilateral side Displaced pleura (arrows) Skin fold extends
and 15% on contralateral side outside ribs

– Second recurrence rate of 50%

Look for displaced Visceral Pleura

Tension Pneumothorax Supine Patient

Medial Pneumothorax

TENSION PNEUMOTHORAX
** Examine patient
* Look for deviated heart and mediastinum, depressed hemidiaphragm
* Compare to previous radiographs

Is there a pneumothorax or
Treatment of Primary
isn’t there? Spontaneous Pneumothorax
z Order a Lateral Decubitus chest radiograph z Observation
– With the side of the chest in question as the upside z Supplemental oxygen
z Possible left pneumothorax get right lateral decubitus chest
– Look for displaced visceral pleura along upside lateral chest wall z Simple aspiration
z Chest tube
z Order Upright Expiratory chest radiograph z Thoracoscopy, bleb resection, and
– Look for pneumothorax at lung apex pleurodesis (usually reserved for recurrent
disease)
– Recurrence rates of 3-4 % after thoracoscopy

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 Secondary Spontaneous Treatment of Secondary
Pneumothorax Pneumothorax
z Chest tube
z Etiology
z Pleurodesis with first event
zCOPD
zCystic fibrosis with or without thoracoscopy
zInterstitial lung disease such as sarcoidosis or
eosinophilic granuloma
zPneumocystis
z Recurrence rates higher that for primary
spontaneous pneumothorax

Treatment of Iatrogenic
Iatrogenic Pneumothorax
Pneumothorax
z Transthroacic needle aspiration – 20% z Minimal symptoms and less that 15%
z Mechanical ventilation pneumothorax: observe
z Thoracentesis z Symptomatic or > 15 % : aspiration or

z Central line placement

chest tube
z For patients on mechanical ventilation:
z Transbronchial lung biopsy
chest tube

Traumatic Pneumothorax
z Penetrating or non-penetrating trauma
z 40% are occult to plain chest film and are
discovered with CT
z Consider rare but catastrophic diagnoses that
require immediate thoracotomy
– Rupture of the trachea
– Rupture of the esophagus
z Treatment is usually with a chest tube. If the
pneumothorax is small and the patient is not in the
ventilator, observation may be considered

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 Chylous Pleural Effusion
Causes of Chylous Effusion
z Defined by the presence of chyle (lymph) in the pleural
space.
z Tumor 54%
z Diagnosis
– Lymphoma
– Appearance often milky. Must differentiate chylous from
chyliform effusion z Trauma 25%
– Chemical confirmation – Surgical
z Triglyceride > 110 mg/dL
z If triglyceride is between 50-110 mg/dL, send fluid for lipoprotein
– Other
electrophoresis. Chylomicrons confirms a chylothorax z Idiopathic 15%
z If triglyceride is < 50, it is not chylous
– Chyliform effusion has elevated cholesterol and occurs in long z Miscellaneous 6%
standing effusions.

Treatment of Traumatic Chylous Treatment of Non-

Non-traumatic
Effusion Chylous Effusions
‰ Pleuro-peritoneal shunts ‰ Treat underlying lymphoma or carcinoma
‰ Chest tube: Caution that the patient may ‰ If ineffective, then insert a pleuro-peritoneal
become malnourished. Therefore, chyle flow shunt
is reduced by GI rest and the use of parenteral
nutrition
‰ Chemical pleurodesis
‰ Thoracotomy or thoracoscopy and ligation of
the thoracic duct.

Chyliform Effusions
z Milky pleural fluid due to elevated
cholesterol of lecithin-globulin complexes
z Most commonly associated with
tuberculosis, rheumatoid arthritis,
therapeutic pneumothorax

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 Hemothorax
z Pleural fluid hematocrit greater that 50% that of Complications of Hemothorax
peripheral blood
z Causes z Retention of clotted blood in the thorax
– Traumatic (penetrating or non-penetrating) (causing restriction)
– Iatrogenic (thoracic surgery or line placement) z Infection
– Non traumatic (from metastatic pleural disease), z Effusion (usually self limited)
spontaneous rupture of an intrathoracic vessel, bleeding
disorders z Fibrothorax (occurs in less that 1% of
– Complication of anticoagulant therapy hemothoraces. Decortication is necessary)
z Treatment is immediate chest tube (both to
evacuate the fluid and monitor for additional
bleeding)

CONCLUSION

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