316.

Disorders of Pleura
PLEURA

Parietal
Visceral
Pleural fluid
Diseases of Pleura

Inflamation
Effusion
Dry

Tumor
Trauma
 Pleural Effusion
Formation>Absorption
Lymphatics have the capacity to absorb 20
times more fluid than is formed normally
Transudate/Exudate

Exudate/Transudate
1. Pleural fluid protein/serum protein >0.5
2. Pleural fluid LDH/serum LDH >0.
3. Pleural fluid LDH more than two-thirds the normal upper limit for serum
If one or more of the exudative criteria are met and the patient is clinically thought to have a condition
producing a transudative effusion the difference between the protein levels in the serum and the pleural
f1uid should be measured. If this gradient is >3 1 g/L (3.1 g/dL)
TESTS: description of the appearance of
the fluid, glucose level, differential cell
count, microbiologic studies,and cytology.
DIAGNOSTIC ALGORITHM
OF PLEURAL EFFUSION
 Effusion due to Heart Failure Hepatic Hydrothorax
the increased amounts of fluid in the
lung interstitial spaces 5% of p-ts with cirrhosis
Thoracocentesis if febrile; effusion is direct movement of
not symmetric; pleuritic chest pain;
peritoneal fluid through
A pleural fluid N-terminal pro-brain
natriuretic peptide (NT-proBNP)
small openings in the
>1500 pg/mL is virtually diagnostic diaphragm
that the effusion is secondary to
congestive heart failure usually right-sided
large enough to produe
severe dyspnea
 Pleurisy is inflammation of the pleura.
Classification:
Dry pleurisy (pleuritis sicca)
Pleurisy with effusion (pleuritis exudativa)

The character of the inflammatory effusion may be different: serous,

serofibrinous, purulent, and haemorrhagic.
 Etiology and pathogenesis

Serous and serofibrinous pleurisy (tuberculosis in 70-90 per cent of cases,

pneumonia, certain infections, and also rheumatism in 10-30 per cent of cases)
Purulent process (pneumococci, streptococci, staphylococci, and other
microbes)
Haemorrhagic pleurisy (tuberculosis of the pleura, bronchogenic cancer of the
lung with involvement of the pleura, and also in injuries to the chest)
Dry Pleurisy
 DRY PLEURISY
Clinical picture
pain in the chest (a characteristic symptom )which becomes stronger
during breathing and coughing.
cough (is usually dry)
general indisposition;
subfebrile temperature
Respiration is superficial (deep breathing intensifies friction of the
pleural membranes to cause pain). Lying on the affected side lessens
the pain. Inspection of the patient can reveal unilateral thoracic lagging
during respiration. Percussion fails to detect any changes except
decreased mobility of the lung border on the affected side. Auscultation
determines pleural friction sound over the inflamed site.
 Normal pleural fluid has the following characteristics:
clear ultrafiltrate of plasma, pH 7.60-7.64, protein
content less than 2% (1-2 g/dL), fewer than 1000
WBCs per cubic millimeter, glucose content similar to
that of plasma, lactate dehydrogenase (LDH) level
less than 50% of plasma and sodium, and potassium
and calcium concentration similar to that of the
interstitial fluid.
Transudative pleural effusion

Congestive heart failure (most common transudative

effusion)
Hepatic cirrhosis with and without ascites
Nephrotic syndrome
Peritoneal dialysis/continuous ambulatory peritoneal
dialysis
Hypoproteinemia (eg, severe starvation)
Glomerulonephritis
Superior vena cava obstruction
Urinothorax
 Exudative pleural effusion
Malignant disorders - Metastatic disease to the pleura or lungs, primary lung cancer,
mesothelioma, Kaposi sarcoma, lymphoma, leukemia
Infectious diseases - Bacterial, fungal, parasitic, and viral infections; infection with
atypical organisms such as Mycoplasma, Rickettsiae, Chlamydia, Legionella
GI diseases and conditions - Pancreatic disease (acute or chronic disease,
pseudocyst, pancreatic abscess), Whipple disease, intraabdominal abscess (eg,
subphrenic, intrasplenic, intrahepatic), esophageal perforation
(spontaneous/iatrogenic), abdominal surgery, diaphragmatic hernia, endoscopic
variceal sclerotherapy
Collagen vascular diseases - Rheumatoid arthritis, systemic lupus erythematosus,
drug-induced lupus syndrome (procainamide, hydralazine, quinidine, isoniazid,
phenytoin, tetracycline, penicillin, chlorpromazine), immunoblastic lymphadenopathy
(angioimmunoblastic lymphadenopathy), Sjgren syndrome, familial Mediterranean
fever, Churg-Strauss syndrome, Wegener granulomatosis
 Benign asbestos effusion
Meigs syndrome - Benign solid ovarian neoplasm associated with ascites and
pleural effusion
Drug-induced primary pleural disease - Nitrofurantoin, dantrolene,
methysergide, bromocriptine, amiodarone, procarbazine, methotrexate,
ergonovine, ergotamine, oxprenolol, maleate, practolol, minoxidil, bleomycin,
interleukin-2, propylthiouracil, isotretinoin, metronidazole, mitomycin
Injury after cardiac surgery (Dressler syndrome) - Injury reported after
cardiac surgery, pacemaker implantation, myocardial infarction, blunt chest
trauma, angioplasty
Uremic pleuritis
Yellow nail syndrome
Ruptured ectopic pregnancy
Electrical burns
 Characteristic Significance
Bloody Most likely an indication of malignancy in the absence of
trauma; can
also indicate pulmonary embolism, infection,
pancreatitis,
tuberculosis, mesothelioma, or spontaneous
pneumothorax
Turbid Possible increased cellular content or lipid content
Yellow or whitish, Presence of chyle, cholesterol or empyema
turbid
Brown (similar to chocolate sauce Rupture of amebic liver abscess into the pleural space
or anchovy paste) (amebiasis
with a hepatopleural fistula)
Black Aspergillus involvement of pleura
Yellow-green with debris Rheumatoid pleurisy
 Characteristic Significance
Highly viscous Malignant mesothelioma (due to increased levels of
hyaluronic acid)
long-standing pyothorax

Putrid odor Anaerobic infection of pleural space

Ammonia odor Urinothorax

Purulent Empyema
Yellow and thick, with metallic Effusions rich in cholesterol (longstanding chyliform
(stainlike) sheen effusion, eg,
tuberculous or rheumatoid pleuritis)
 PLEURISY WITH EFFUSION

Clinical picture
Complains: fever, pain or the feeling of heaviness in the side, dyspnea
(which develops due to respiratory insufficiency caused by compression of
the lung). Cough is usually mild (or absent in some cases).
Objective examination: The patient's general condition is grave, especially in
purulent pleurisy, which is attended by high temperature with pronounced
circadian fluctuations, chills, and signs of general toxicosis. Inspection of the
patient reveals asymmetry of the chest due to enlargement of the side
where the effusion accumulated; the affected side of the chest usually lags
behind respiratory movements. Vocal fremitus is not transmitted at the area
fluid accumulation.
Cyanosis in pleurisy with effusion due to respiratory insufficiency is
caused by lung collapse and limitation of its respiratory surface
 Percussionover the area of fluid accumulation produces
dullness. The upper limit of dullness is usually the S-
shaped curve (Damoiseau's curve) whose upper point is
in the posterior axillary line. The effusion thus occupies
the area, which is a triangle both anteriorly am
posteriorly. The Damoiseau curve is formed because
exudate pleurisy with effusion more freely accumulates
in the lateral portions of the pleural cavity, mostly in the
costal-diaphragmatic sinus.
Pleurisy with effusion:
posterior view:
1 Damoiseau's curve;
2 Garland's triangle
3 Rauchfuss-Grocco
triangle.
Treatment

Antibiotics (eg, for parapneumonic effusions) and

diuretics (eg, for effusions associated with CHF)
are commonly used in the initial management of
pleural effusions in the ED. The selection of drugs
in each class depends on the cause of the effusion
and its clinical presentation. Particular attention
must be given to potential drug interactions,
adverse effects, and preexisting conditions.
Tuberculous pleural effusion

TB remains the most common cause of

pleural effusion in young people
Etiology: tubercle bacillus
Pathogenesis: host hypersensitivity to
tubercular protein in pleural tubercles
Delayed hypersensitivity
Clinical Manifestations

Generalized symptoms of toxicity of TB:

fever, sweats, fatigue, weight loss ss, etc.
Pleuritic pain, dyspnea, coughlea, etc.
Pleural fluid is exudative and usually
reveals lymphocytosis
Rarely pleural fluid is blood stained
Tubercular tests usually positive
 Empyema

Thick purulent fluid with more than 100,000

cells per cubic millimeter or fluid with PH
values less than or equal to 7. 20 should
be treated as a presumptive empyema
The general objectives of therapy of empyema
are the elimination of both the systemic and
local infection.
 Treatment of acute and chronic
empyema
1. Control of infection
systemic and local
2. Repeated thoracentesis or drainage of the empyema

3. Chronic empyema is primarily treated operatively

4. Operative therapy is also indicated in the empyema with

associated bronchopleural fistula or with the
ipsilateral ruined lung
 Primary
Spontaneous
Pneumothorax
Secondary
Pneumothorax
Traumatic
Pneumothorax
Tension
Pneumothorax