Diseases of Pleura
description
Transcript of Diseases of Pleura
![Page 1: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/1.jpg)
ALOK SINHADepartment of Medicine
Manipal College of Medical SciencesPokhara, Nepal
![Page 2: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/2.jpg)
Negative intrapleural pressure: ~ 5mm
![Page 3: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/3.jpg)
PLEURISY
Disease process involving the pleura and giving rise to • pleuritic pain • evidence of pleural friction
Common feature of • Pulmonary infection • Infarction• Malignancy
Primary pleural involvement – in T.B.
![Page 4: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/4.jpg)
Clinical features
Characteristic symptom – Pleural pain On examination: Rib movement restricted – reduced chest
expansion Pleural rub may be present
• may only be heard in deep inspiration near pericardium - pleuro-pericardial rub
![Page 5: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/5.jpg)
Loss of the pleural rub and diminution in the chest pain indicate • Either recovery
or • development of a pleural effusion
Normal X-ray does not exclude pulmonary cause for pleurisy• pulmonary infection which may not have
been severe enough • may have resolved before the chest X-ray
was taken
![Page 6: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/6.jpg)
![Page 7: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/7.jpg)
The accumulation within the pleural space of
Serous fluid -
Frank pus -
Blood -
pleural effusion
empyema
haemothorax
![Page 8: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/8.jpg)
Pleural fluid accumulates
increased hydrostatic & decreased osmotic pressure – ‘Transudate’
Increased microvascular pressure due to disease of pleural surface or injury in the adjacent lung ‘Exudate’
![Page 9: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/9.jpg)
Common causes Tuberculosis Pneumonia ('para-pneumonic effusion') Cardiac failure Pulmonary infarction Malignant disease Subdiaphragmatic disorders - subphrenic abscess - pancreatitis etc Hypoproteinaemia
Nephrotic syndrome Liver failure Malnutrition
![Page 10: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/10.jpg)
Uncommon causes Connective tissue diseases systemic lupus erythematosus rheumatoid arthritis Acute rheumatic fever Post-myocardial infarction syndrome Meigs' syndrome (ovarian tumour + pleural effusion) Myxoedema Uraemia Asbestos-related benign pleural effusion
![Page 11: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/11.jpg)
Transudate Congestive heart failure Cirrhosis (hepatic hydrothorax) Hypoalbuminemia Nephrotic syndrome Myxedema Constrictive pericarditis
![Page 12: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/12.jpg)
Tuberculous Parapneumonic
causes Malignancy
(carcinoma, lymphoma,mesothelioma)
Pulmonary embolism
Pancreatitis Collagen-vascular conditions
(rheumatoid arthritis, SLE) Asbestos exposure Trauma
Postcardiac injury (Dressler’s) syndrome
Esophageal perforation Radiation pleuritis Drug use Chylothorax Meigs syndrome Sarcoidosis Yellow nail syndrome
Exudate
![Page 13: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/13.jpg)
Clinical assessment
Symptoms and signs of pleurisy often precede the development of an effusion in patients with• Tuberculosis• underlying pneumonia • pulmonary infarction • connective tissue disease
![Page 14: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/14.jpg)
Particular attention should be paid to a recent history of • contact with tuberculosis• respiratory infection• presence of heart disease• liver or renal disease • occupation (e.g. exposure to asbestos)• risk factors for thromboembolism
![Page 15: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/15.jpg)
BREATHLESSNESS - only symptom related to effusion and its severity depends on the • size • rate of accumulation
![Page 16: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/16.jpg)
Clinical features
![Page 17: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/17.jpg)
Manifest when pleural effusions >300 mL
On inspection: Fullness of chest on affected side Reduced expansion of chest Tracheal shift with Trail’s sign - observed
with effusions of > 1000 mL• Prominence of lower part of
sternocleidomastoid due to tracheal deviation
![Page 18: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/18.jpg)
On palapation
Trachea & apex beat shifted to opposite side
Decreased tactile fremitus
![Page 19: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/19.jpg)
• Displacement toward the side of the effusion is an important clue to obstruction of a lobar bronchus
![Page 20: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/20.jpg)
Percussion: Dullness on percussion- stony dull
• obliteration of tympanitic percussion note over Traube’s space in left sided effusion
Level of dullness goes up in axilla Dullness over grocco’s triangle
![Page 21: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/21.jpg)
surface markings • left sixth rib• left midaxillary line• left costal margin
Traube's space
![Page 22: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/22.jpg)
Grocco’s triangle
XII th rib
Upper margin of fluid
![Page 23: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/23.jpg)
Grocco's Paravertebral Triangle
Triangular area of dullness at the back of chest on the healthy side
Base – horizontally along the XII th rib Apex – at the level of upper margin of fluid on
diseased side Internally – vertebral line Externally – line joining the apex and lateral
base
![Page 24: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/24.jpg)
Ascultation
Decreased or absent breath sounds
Pleural friction rub may be present ONLY WHEN EFFUSION IS SMALL
![Page 25: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/25.jpg)
compressed lung
zone of compensatory emphysema
Findings at the upper level of moderate effusion
![Page 26: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/26.jpg)
Skodaic resonance – percussion
Dull on percussionAbsent Br sound
Increased VF, egophony & bronchial breath sounds
Egophony: high-pitched nasal or bleating quality sound
![Page 27: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/27.jpg)
Possible findings at the upper level of dullness in case of moderate pleural effusion:
1. lung is compressed Increased vocal fremitus & aegophony –
nasal quality of sounds transmitted Bronchial breath sound2. there may be a zone of compensatory
emphysema above it Skodaic resonance on percussion
![Page 28: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/28.jpg)
INVESTIGATIONS
![Page 29: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/29.jpg)
1.Chest X ray
P A view: minimum of 200cc of fluid required to produce blunting of costophregnic angles in
Lateral view: 60 ml lateral decubitus Xray: 10 ml
![Page 30: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/30.jpg)
200 ml fluid required to produce this shadow60 ml in lateral view10 ml in decubitus Xray
![Page 31: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/31.jpg)
![Page 32: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/32.jpg)
X ray tube
X rays
![Page 33: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/33.jpg)
Some atypical pleural effusions
Localised effusions: previous scarring or adhesions in the pleural space
Subpulmonary effusion: Pleural fluid localised below the lower lobe simulates an elevated hemidiaphragm
Fluid localised within an oblique fissure may produce a rounded opacity simulating a tumour
![Page 34: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/34.jpg)
![Page 35: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/35.jpg)
![Page 36: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/36.jpg)
![Page 37: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/37.jpg)
Subpulmonic effusion - Rt
![Page 38: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/38.jpg)
Phantom tumor-Pleural effusion inInterlobar fissure
![Page 39: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/39.jpg)
![Page 40: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/40.jpg)
2. Ultra sonography of thorax
![Page 41: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/41.jpg)
2. USG of thorax:
• Can detect even less than 10 ml• Can differentiate between pleural thickening
& effusion• USG guided needle aspiration in small effusion
![Page 42: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/42.jpg)
3. Diagnostic aspiration of pleural fluid
![Page 43: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/43.jpg)
1. Protein2. L.D.H.
3. Sugar – low in bacterial infections & Rh. arthritis4. A.D.A – high (>42) in T.B. & some fungal
infections5. Amylase – high in pancreatitis, oesophageal
rupture, malignancy
Required for calculating LIGHT’S CRITERIA
1.Biochemical analysis
![Page 44: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/44.jpg)
6.pH • Low pH suggests
infection rheumatoid arthritis ruptured oesophagus advanced malignancy
![Page 45: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/45.jpg)
(FOR DISTINGUISHING PLEURAL TRANSUDATE FROM EXUDATE)
Pleural fluid is an EXUDATE if one or more of theFollowing criteria are met:
1. Pleural fluid protein:serum protein ratio > 0.5
2. Pleural fluid LDH: serum LDH ratio > 0.6
3. Pleural fluid LDH > two-thirds of the upper limit of normal serum LDH
![Page 46: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/46.jpg)
2. Microscopic examinationPredominant cell type
• provides useful information and cytological examination is essential
Polymorphs suggest bacterial infection
Lymphocytes: tuberculous High ADA + Pl. fluid lymphocyte/neutrophil > 0.75 – Highly diagnostic of tuberculous pleural effusion
Malignant cells ma be seen in malignancy
![Page 47: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/47.jpg)
3.Gram stain • may suggest parapneumonic effusion
4.ELISA or
PCR• Helpful in diagnosing T.B. if acid-fast bacilli
are not seen
5. Cultures: positive in 30 to 70%
(Enzyme-linked immunosorbent assay)
(Polymerase chain reaction)
![Page 48: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/48.jpg)
May be required if all fails With all methods combined yield is close
to 95%
4. Pleural biopsy
![Page 49: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/49.jpg)
Combining pleural aspiration with biopsy increases the diagnostic yield
Ultrasound or CT guided biopsy with Abrams needle is most frequently employed
![Page 50: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/50.jpg)
Pleural aspiration and biopsy Abrams needle
![Page 51: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/51.jpg)
If all of them unhelpful:
5. Throcacoscopy
6. HRCT
![Page 52: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/52.jpg)
THORACOSCOPY
![Page 53: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/53.jpg)
Summary of Investigations X ray USG thorax Pleural fluid examination
• Biochemical• Microscopic• Gram staining• Culture
PCR or ELISA Pleural biopsy Thoracoscopy HRCT
![Page 54: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/54.jpg)
![Page 55: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/55.jpg)
![Page 56: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/56.jpg)
Cardiacfailure*
Serous,Strawcoloured
Transudate Few serosal cells Other evidence of leftventricular failure.Response to diuretics.
PLEURAL EFFUSION: MAIN CAUSES & FEATURES
Cause
Appearance offluid
Type offluid
Predominantcells in fluid
Other diagnostic features
Tuberculosis Serous,UsuallyAmbercoloured
Exudate Lymphocytes(occasionallypolymorphs)
+ tuberculin testIsolation of M.tuberculosis frompleural fluid (20%)Positive pleural biopsy(80%)
Malignantdisease
Serous,OftenBloodstained
Exudate Serosal cells &LymphocytesOften clumps ofmalignant cells
Positive pleural biopsy(40%)Evidence of malignantdisease elsewhere
![Page 57: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/57.jpg)
Pulmonaryinfarction
Serous or blood-stained
Exudate(rarelytransudate
Red bloodCellsEosinophils
Evidence ofPulmonaryInfarction.Source ofEmbolism.Factorspredisposingto venousthrombosi
Rheumatoid disease
SerousTurbid ifchronic
Exudate Lymphocyte(occasionalpolymorphs)
Rheumatoid arthritis; rheumatoid factor in serum.Cholesterol in chronic effusion; very low glucose in pleural fluid
![Page 58: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/58.jpg)
SystemicLupuserythematosus
(SLE)
Serous Exudate Lymphocytesand serosalcells
• OtherManifestationsof SLE• Antinuclearfactor or AntiDNA in Serum(Ds DNA)
Acutepancreatitis
Serous orBloodstained
Exudate No cellspredominate
High amylasein pleural fluid(greater thanin serum)
Obstruction ofthoracic duc
Milky Chyle(Chylous Effusion)
None Chylomicrons
![Page 59: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/59.jpg)
Hemorrhagic Chylous- thoracic duct obstruction
Transudate in CCF
![Page 60: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/60.jpg)
Presence of blood is consistent with Pulmonary infarction Malignancy Tuberculosis Traumatic Anticoagulation Mesothelioma
![Page 61: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/61.jpg)
Result from: Hypersensitivity reaction to Mycobacterium
Microbial invasion of the pleura (less common)
• acid-fast bacillus stains of pleural fluid are rarely diagnostic (<10-20 % of cases)
• pleural fluid cultures grow Mycobacterium tuberculosis in less than 65% of cases
Tuberculous pleural effusion
![Page 62: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/62.jpg)
Effusion may accompany1.Primary T. B.
• commonly unilateral, and results from a hypersensitivity phenomenon
• May recover without treatment, but in close to two thirds active tuberculosis develops within 5 years
2. Post primary T. B.: Subpleural T B focus
ruptures into the pleural space Clinically presentation as
• acute • subacute • chronic form
With fever, nonproductive cough or chest pain
![Page 63: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/63.jpg)
Diagnosed on the basis of: Microscopy + Adenosine deaminase
(ADA) activity ADA > 43 U/mL in pleural fluid supports
the diagnosis of TB pleuritis. sensitivity - 78%
ADA + Pl. fluid lymphocyte/neutrophil > 0.75 – Highly diagnostic of tuberculous pleural effusion
![Page 64: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/64.jpg)
Other investigation
Chest radiography: • shows a small to moderate effusion (only
4% are large)• Parenchymal disease is seen in a third
of cases
![Page 65: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/65.jpg)
• Enzyme-linked immunosorbent assay(ELISA) • Polymerase Chain Reaction (PCR)
may be helpful diagnostically Provide a more rapid diagnosis in the
more than 90% of cases in which acid-fast bacilli are not seen on smear
Cultures: positive in 30 to 70% - results take a long time
![Page 66: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/66.jpg)
Treatment
Fever resolves within 2 weeks of instituting category I ATT • may persist for 6 or 8 weeks
The effusion usually resolves by 6 weeks • may persist for 3 to 4 months
Very ill patients may be helped by short-term corticosteroid treatment
![Page 67: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/67.jpg)
ADA can be +in: Fungal infections like coccidomycosis & HistoplasmosisSome cases of malignancy & connective tissue disorder
![Page 68: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/68.jpg)
Malignant
P l e u r a l e f f u s i o n
![Page 69: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/69.jpg)
CausesMost malignant effusions are metastatic
![Page 70: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/70.jpg)
Investigations
Pleural fluid cytology CT chest with pleural contrast
• Nodular, mediastinal, or circumferential pleural thickening on CT-highly specific for malignant disease
![Page 71: Diseases of Pleura](https://reader038.fdocuments.us/reader038/viewer/2022102602/56816785550346895ddc99c6/html5/thumbnails/71.jpg)
Treatment options Therapeutic pleural aspiration
Intercostal chest drainage pleurodesis - seal the visceral to the
parietal pleura to prevent pleural fluid accumulating
commonly used agents are sterile talc, tetracycline, and bleomycin • Corticosteroids should be discontinued
beforehand