5 diseases of pleura

Diseases of Pleura

Dr Yog Raj Khinchi

Pleural Effusion

Pleural effusion: Introduction

• Collection of excess quantity of fluid in pleural space

• Inflammatory or non inflammatory causes

Pleural effusion: Classification

• Transudates: due to diseases that affect the filtration of pleural fluid- CHF & hypoproteinemia

• Exudates: inflammation or injury increases pleural membrane permeability to proteins and various types of cells

Pleural Effusion fluidTests Transudate Exudates

(tubercular)Exudates

(Empyema)

Physical appearance Clear Straw coloured Cloudy /Turbid

Microscopy <1000 Lympho/M

>1000 Lympho

>5000 PMNsPus cells

Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / Serum protein

<0.5 >0.5 >0.5

Pleural fluid LDH / Serum LDH

<0.6 >0.6 >0.6

Pleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl



(Empyema)

Physical appearance Clear Straw coloured Cloudy /Turbid

Microscopy No Cells Predominantly Lymphocytes

Pus cells


<0.5 >0.5 >0.5


<0.6 >0.6 >0.6




(Empyema)

Physical appearance Clear Straw coloured Turbid yellow

Microscopy <1000Lympho/M

>1000 Lymphocytes

>5000 PMNPus cells


<0.5 >0.5 >0.5


<0.6 >0.6 >0.6




(Empyema)



Pus cells


<0.5 >0.5 >0.5


<0.6 >0.6 >0.6




(Empyema)

Physical appearance Clear Straw coloured Cloudy / Turbid


>1000 Lymphocytes

>5000 PMNsPus cells


<0.5 >0.5 >0.5


<0.6 >0.6 >0.6




(Empyema)


Microscopy <1000Lympho /M

>1000 Lymphocytes

>5000 PMNsPus cells


<0.5 >0.5 >0.5


<0.6 >0.6 >0.6




(Empyema)



>1000 Lymphocytes

>5000 PMNsPus cells


<0.5 >0.5 >0.5


<0.6 >0.6 >0.6


Pleural effusion: Causes

• Bacterial pneumonias - Most common• TB, CCF, Hypoproteinemia• Obstruction to lymphatic drainage• Collagen vascular disease• Malignancies, Rheumatoid arthritis• Aspiration pneumonia, traumatic• Pulmonary embolism, chylothorax

Pleural effusion: 3 Types

1. Dry or plastic pleurisy2. Serofibrinous or serosanguineous pleurisy3. Purulent pleurisy or empyema

1. Dry pleurisy or plastic pleurisy

Associated with • Acute bacterial infections• Tuberculosis• Connective tissue disorders- rheumatic fever

Dry pleurisy: Pathology

• Involvement of visceral pleura with small amount of yellow serous fluid

• Adhesion between pleural surfaces• Pleural thickening• Fibrothorax due to fibrin deposition and severe

adhesions

Dry pleurisy: Clinical manifestations

• Signs & symptoms of primary disease• Dull pleural pain, exaggerated by deep

inspiration,cough, straining, referred to shoulder and back

• Increased dullness on percussion and decreased breath sounds

• Leathery, rough inspiratory and expiratory friction rub early in the disease

• X-ray- haziness at the pleural surface or a dense, sharply demarcated shadow

Dry pleurisy: Treatment

• Treat underlying condition• If pneumonia is not present- strapping of chest to

restrict expansion and analgesics• Strapping and cough suppressants not given if

pneumonia is present

2. Serofibrinous pleurisy

• Infections of lungs• Inflammatory conditions of mediastinum• Less commonly with- SLE, RF, neoplasms

Serofibrinous pleurisy: Clinical features

• Initially signs and symptoms of dry pleurisy• Asymptomatic if effusion is small• Large effusion: cough, dyspnoea, retractions,

orthopnoea, cyanosis• Shift of mediastinum away from affected side,

fullness of intercostal space, diminished tactile vocal fremitus

• Dullness to flatness on percussion• Decreased or absent breath sounds

Serofibrinous pleurisy: Clinical features...

• In infants- bronchial breath sounds instead of absent breath sounds

• Friction rub in the early stages• X-ray: homogenous opacity obliterating the normal

pulmonary marking, obliteration of costophrenic angles and widening of interlobar fissure

X-ray chest: Pleural Effusion

Serofibrinous pleurisy: Treatment

• Treat underlying cause• Thoracocentesis, up to 1 Liter of fluid• Tube thoracostomy in older child with

parapneumonic effusion if pleural fluid pH<7.2 or glucose <50mg/dl

3. Purulent pleurisy / Empyema

• Pus or microorganism in pleural fluid• Microorganism- by smear or culture In the absence of these:• pH of pleural fluid < 7.2• Lactic dehydrogenase (LDH) >1000IU/L• Glucose <than 40mg/dl• Lactate > 45mg/ml

Empyema: Predisposing factors

• Pneumonia in ½ of cases• Preceding H/O of pustules• Blunt trauma to chest/surgery/thoracocentesis• Viral infections (chickenpox, measles)• Severe malnutrition• Neglected foreign body• Extension from subphrenic, amoebic liver abscess• CHD• Peridontal disease, steroid, immunodeficiency

Empyema: Etiology

• Staphylococcus aureus, epidermidis• Streptococcus pneumoniae, viridans• H influenzae• Pseudomonas aeroginosa• E coli• Klebsiella aerogenes• Mycobacterium tuberculosis• Fungal/ EH (rare)

Stages of Empyema

• Exudative (1 to 3 days): parapneumonic effusion• Fibrino purulent (4 to 14 days): polymorpho nuclear & fibrin accumulation• Organizing stage (after 14 days): fibroblasts grow and producing an inelastic membrane

Empyema: Exudative stage

• Fluid is thin• Cellular content is low• Lungs are expandable• Pleural fluid- pH >7.3, glucose >60mg/dl, pleural fluid

/serum glucose ratio >0.5, LDH < 1000 IU/L, Gram stain and culture negative

Empyema: Fibrino purulent stage

• pH and glucose level fall, LDH rises• Purulent and vicious, accumulation of neutrophils

and fibrin• Tendency for loculations and limiting membranes• purulent fluid, PH <7.10, glucose <40mg/dl LDH

>1000IU/L, Gram stain & culture +ve

Empyema: Organizing stage

• Thick pleura prevent entry of anti microbial drugs in the pleural space- drug resistance

• Restrict lung movement

Empyema: Clinical features

• Common in poor socioeconomic group• Peak incidence 0-3 years• Chills, fever, dyspnoea, chest pain, referred pain,

night sweat, malaise, cough, ↑sputum production• Pain abdomen & ileus• Tachypnoeic, anxious, pleural rub (disappear after

fluid accumulates)

Empyema: Clinical features...

• Large fluid- fullness of intercostal spaces, diminished chest excursions

• Shift of mediastinum• Dullness to percussion, decreased air entry,

decreased tactile & vocal fremitus

Empyema: Investigation & Diagnosis

• History and examination findings• Confirm the presence of empyema, etiological agent

& complications• Polymorph predominance, rarely leukopenia • X-ray chest- blunting of costophrenic angle,

opacification of hemithorax with mediastinal shift to opposite side , lateral decubitus for small volume

Empyema: Investigation...

• USG- confirms, for thoracocentesis, pleural catheter placement, transudates anechoic, exudates echoic or anechoic, limiting membrane suggest loculation

• CT scan- confirm fluid, loculation, pleural thickening • Pleurocentesis / thoracocentesis

Empyema: Aspirate Investigation

• Aspirate- Cell count and differential, Grams stain, culture, pH, protein, glucose, LDH,

AFB stain & culture • Uncomplicated parapneumonic effusion:- pH>7.3,

glucose> 60mg/dl, LDH,1000IU/L, • Complicated parapneumonic effusion:- pH<7.1,

glucose<60mg, LDH>1000IU/L, microbes on Grams stain• Tuberculous empyema:- AFB <25% cases, Pleural biopsy &

culture >90%, adenosine de aminase (ADA) >70U/L, PCR

Empyema: Treatment

Aims

• Control infection• Drainage of pus• Expansion of lungs

Empyema drainage

• Inter costal drainage (ICD), under water seal, large catheter inserted in the site of pus accumulation

• Loculated fluid/pus- drainage continued for 1 week• Chest tube kept till drainage is nil or < 30 ml/day

Empyema: Inter Costal Drainage (ICD)

Empyema: X-Ray chest

Before & After Inter costal drainage (ICD)

Empyema: Antimicrobial therapy

Organism Drugs Alternate DurationStaph Clox + Amino 3rd gen Cephlo

+ Clox1-4wk

Pneumo PenicillinG Ceftriaxone 1-2wkH influ Cefurox/ceftrioxone

/CefotaxChlorompenic 1-2wk

Pseudom CeftazidineCefoperazone

ImpenumCilastatin, Aztreonam

Empyema: Treatment...

• Based on culture and sensitivity• Monotherapy not recommended• In anerobic infection- Clindamycin: 6-12wk• MRSA- Vancomycin• Antibiotics till afebrile, WBC normal, thoracostomy

yield <50ml/day, X-ray clearing• H influenzae & S pneumoniae: 7-14 days• S aureus: 3-4 wk, anerobic: (variable) 6-12wk

Empyema: Thrombolytic therapy

• Multiloculated empyema by thoracostomy tube• Streptokinase 2,50,000 unit or urokinase 1,00.000

unit in 100ml normal saline instilled through tube & clamped for 3 hrs

Empyema: Surgical therapy

• Remains febrile and dyspnoeic after IV antibiotics and thorcostomy drain

• Pleural thickening- decortication• Non expansion of lung• Bronchopleural fistula• Video assisted thoracoscopic surgery in multi

loculated effusion• Thorocoscopic debridement and irrigation in

multiloculated effusion

Empyema: Complications

• Bronchopleural fistula• Cutaneous fistula• Pyopneumothorax• Purulent pericarditis• Pulmonary abscess• Peritonitis secondary to rupture through diaphragm • Septic complications - meningitis, arthritis,

osteomyelitis

Empyema: Prognosis

• In adequately treated cases prognosis is excellent

• Follow up pulmonary functions suggest that residual disease is uncommon

Pyopneumothorax

Pneumothorax

• Presence of gas in the Pleural space

Pneumothorax: Classification

• Spontaneous pneumothorax Primary , Secondary

• Traumatic pneumothorax • Iatrogenic pneumothorax • Tension Pneumothorax

Traumatic Pneumothorax

Closed Open

Pneumothorax: Causes

• Rupture of pleural blebs

• Penetrating or non penetrating injuries

• Pneumonia• Asthma• Cystic fibrosis• COPD/ Bronchitis• Inhalation of some

toxic substances, most notably crack cocaine

• Transthoracic aspiration needle

• Thoracentesis• Central intravenous

catheters• Mechanical

Ventilation • Resuscitative efforts

Clinical Signs & Symptoms

• Severity depends on the extent of the lung collapse. • Simple pneumothorax - asymptomatic or chest pain,

dyspnea.• Extensive pneumothorax often produces pleuritic

chest pain, dyspnea, tachypnea, cyanosis, Hyperresonance to percussion on the affected side.

• Decreased breath sounds on the involved side.• If pneumothorax due to trauma - look for contusions

or abrasions on the chest wall or a small puncture wound that does not allow free movement of air between the outside and the pleural cavity.

Tension Pneumothorax: Signs/Symptoms• Clinical Presentation - Chest pain (90%), Dyspnea

(80%), Anxiety, Fatigue• Physical examination - Respiratory distress and/or

arrest, Cyanosis, Tracheal deviation, Pulsus paradoxus, Tachypnea, Tachycardia, Hypotension, Jugular venous distension

• Hyperresonance of the chest wall on percussion• Unilaterally decreased or absent lung sounds• Increasing resistance to providing adequate ventilation

assistance• Mental status changes, including decreased alertness

and/or consciousness• Abdominal distension

Tension PneumothoraxLung parenchymal or

bronchial injury

one-way valve

air trapping

mediastinal structures - pushed to the

contralateral side.

mediastinum impinges on and compresses the

contralateral lung

Pneumothorax: Differential Diagnosis

• Bronchogenic Cyst• Congenital Lung Malformations • Cystic Adenomatoid Malformation • Pleural Effusion, Pyo pneumothorax

Investigations

• Chest X-ray• Pulse oxymetry : SpO2

• Arterial blood gas: arterial pO2

Pneumothorax: Treatment

Without continued air leak, asymptomatic and mildly symptomatic small pneumothorax

• 100% oxygen • Sedation

Tension Pneumothorax: Treatment

• Severe respiratory and circulatory embarrassment • Emergency Needle aspiration • Either immediately or after needle aspiration a chest

tube (ICD) should be inserted and attached to underwater seal drainage

Decompression by Needle / ICD

• 2nd intercostal space on the mid clavicular line• Upper border of the lower rib• Needle / ICD have to be connected to the

underwater sealed drainage

Indications for ICD

1. Pneumothorax 2. Hemothorax 3. Hemopneumothorax4. Tension pneumothorax5. Empyema 6. Chylothorax

X-ray Pneumothorax: Before Treatment

X-ray Pneumothorax: After Treatment

5 diseases of pleura

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