Diseases of Pleura
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Diseases of Pleura. ALOK SINHA Department of Medicine Manipal College of Medical Sciences Pokhara , Nepal. Negative intrapleural pressure: ~ 5mm. PLEURISY . Disease process involving the pleura and giving rise to pleuritic pain evidence of pleural friction Common feature of

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Diseases of Pleura

ALOK SINHA

Department of Medicine

Manipal College of Medical Sciences

Pokhara, Nepal


Negative intrapleural pressure: ~ 5mm


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.


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


  • 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


PLEURAL EFFUSION


The accumulation within the pleural space of

  • Serous fluid -

  • Frank pus -

  • Blood -

pleural effusion

empyema

haemothorax


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’


Transudate

  • Congestive heart failure

  • Cirrhosis (hepatic hydrothorax)

  • Hypoalbuminemia

  • Nephrotic syndrome

  • Myxedema

  • Constrictive pericarditis


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


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


  • 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


BREATHLESSNESS - only symptom related to effusion and its severity depends on the

size

rate

of accumulation


Clinical features


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


On palapation

  • Trachea & apex beat shifted to opposite side

  • Decreased tactile fremitus


  • Displacement toward the side of the effusion is an important clue to obstruction of a lobar bronchus


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


  • surface markings

    • left sixth rib

    • left midaxillary line

    • left costal margin

Traube's space


Upper margin of fluid

Grocco’s triangle

XII th rib


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


Ascultation

  • Decreased or absent breath sounds

  • Pleural friction rub may be present ONLY WHEN EFFUSION IS SMALL


zone of compensatory emphysema

compressed lung

Findings at the upper level of moderate effusion


Increased VF, egophony & bronchial breath sounds

Skodaic resonance – percussion

Dull on percussion

Absent Br sound

Egophony: high-pitched nasal or bleating quality sound


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 sound

    2. there may be a zone of compensatory emphysema above it

  • Skodaic resonance on percussion


INVESTIGATIONS


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


200 ml fluid required to produce this shadow

60 ml in lateral view

10 ml in decubitus Xray


X ray tube

X rays


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


Subpulmonic effusion - Rt


Phantom tumor

-Pleural effusion in

Interlobar fissure


2. Ultra sonography of thorax


2. USG of thorax:

  • Can detect even less than 10 ml

  • Can differentiate between pleural thickening & effusion

  • USG guided needle aspiration in small effusion


3. Diagnostic aspiration of pleural fluid


1.Biochemical analysis

  • Protein

  • L.D.H.

    3. Sugar – low in bacterial infections & Rh. arthritis

    4. A.D.A – high (>42) in T.B. & some fungal infections

    5. Amylase – high in pancreatitis, oesophageal rupture, malignancy

Required for calculating LIGHT’S CRITERIA


6.pH

Low pH suggests

infection

rheumatoid arthritis

ruptured oesophagus

advanced malignancy


LIGHT'S CRITERIA


2. Microscopic examination

Predominant 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


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)


4. Pleural biopsy

May be required if all fails

  • With all methods combined yield is close to 95%


  • Combining pleural aspiration with biopsy increases the diagnostic yield

  • Ultrasound or CT guided biopsy with Abrams needle is most frequently employed


Pleural aspiration and biopsy

  • Abrams needle


If all of them unhelpful:

5. Throcacoscopy

6. HRCT


THORACOSCOPY


Summary of Investigations

  • X ray

  • USG thorax

  • Pleural fluid examination

    • Biochemical

    • Microscopic

    • Gram staining

    • Culture

  • PCR or ELISA

  • Pleural biopsy

  • Thoracoscopy

  • HRCT


Rheumatoid arthritis; rheumatoid factor in serum.Cholesterol in chronic effusion; very low glucose in pleural fluid


Hemorrhagic

Chylous- thoracic duct obstruction

Transudate in CCF


  • Presence of blood is consistent with

    • Pulmonary infarction

    • Malignancy

    • Tuberculosis

    • Traumatic

    • Anticoagulation

    • Mesothelioma


Tuberculous pleural effusion

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


Effusion may accompany

1.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


  • 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


    Other investigation

    Chest radiography:

    shows a small to moderate effusion (only 4% are large)

    Parenchymal disease is seen in a third of cases


    • 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


  • 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


    ADA can be +in: Fungal infections like coccidomycosis & Histoplasmosis

    Some cases of malignancy & connective tissue disorder


    Malignant

    P l e u r a l e f f u s i o n


    CausesMost malignant effusions are metastatic


    Investigations

    • Pleural fluid cytology

    • CT chest with pleural contrast

      • Nodular, mediastinal, or circumferential pleural thickening on CT-highly specific for malignant disease


    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


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