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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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slide1
Diseases of Pleura

ALOK SINHA

Department of Medicine

Manipal College of Medical Sciences

Pokhara, Nepal

pleurisy
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
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
slide5
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
slide7
The accumulation within the pleural space of
  • Serous fluid -
  • Frank pus -
  • Blood -

pleural effusion

empyema

haemothorax

slide8
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
Transudate
  • Congestive heart failure
  • Cirrhosis (hepatic hydrothorax)
  • Hypoalbuminemia
  • Nephrotic syndrome
  • Myxedema
  • Constrictive pericarditis
exudate
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
slide13
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
slide14
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
slide15
BREATHLESSNESS - only symptom related to effusion and its severity depends on the

size

rate

of accumulation

slide17
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
slide18
On palapation
  • Trachea & apex beat shifted to opposite side
  • Decreased tactile fremitus
slide19
Displacement toward the side of the effusion is an important clue to obstruction of a lobar bronchus
slide20
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
slide21
surface markings
    • left sixth rib
    • left midaxillary line
    • left costal margin

Traube's space

slide22
Upper margin of fluid

Grocco’s triangle

XII th rib

grocco s paravertebral triangle
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
slide24
Ascultation
  • Decreased or absent breath sounds
  • Pleural friction rub may be present ONLY WHEN EFFUSION IS SMALL
slide25
zone of compensatory emphysema

compressed lung

Findings at the upper level of moderate effusion

slide26
Increased VF, egophony & bronchial breath sounds

Skodaic resonance – percussion

Dull on percussion

Absent Br sound

Egophony: high-pitched nasal or bleating quality sound

slide27
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
slide29
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
slide30
200 ml fluid required to produce this shadow

60 ml in lateral view

10 ml in decubitus Xray

slide33
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
slide38
Phantom tumor

-Pleural effusion in

Interlobar fissure

slide41
2. USG of thorax:
  • Can detect even less than 10 ml
  • Can differentiate between pleural thickening & effusion
  • USG guided needle aspiration in small effusion
slide43
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

slide44
6.pH

Low pH suggests

infection

rheumatoid arthritis

ruptured oesophagus

advanced malignancy

slide46
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

slide47
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)

slide48
4. Pleural biopsy

May be required if all fails

  • With all methods combined yield is close to 95%
slide49
Combining pleural aspiration with biopsy increases the diagnostic yield
  • Ultrasound or CT guided biopsy with Abrams needle is most frequently employed
slide51
If all of them unhelpful:

5. Throcacoscopy

6. HRCT

summary of investigations
Summary of Investigations
  • X ray
  • USG thorax
  • Pleural fluid examination
    • Biochemical
    • Microscopic
    • Gram staining
    • Culture
  • PCR or ELISA
  • Pleural biopsy
  • Thoracoscopy
  • HRCT
slide57
Rheumatoid arthritis; rheumatoid factor in serum.Cholesterol in chronic effusion; very low glucose in pleural fluid
slide59
Hemorrhagic

Chylous- thoracic duct obstruction

Transudate in CCF

slide60
Presence of blood is consistent with
    • Pulmonary infarction
    • Malignancy
    • Tuberculosis
    • Traumatic
    • Anticoagulation
    • Mesothelioma
slide61
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
slide62
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

slide63
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
slide64
Other investigation

Chest radiography:

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

Parenchymal disease is seen in a third of cases

slide65
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
slide66
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

slide67
ADA can be +in: Fungal infections like coccidomycosis & Histoplasmosis

Some cases of malignancy & connective tissue disorder

slide68
Malignant

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

investigations
Investigations
  • Pleural fluid cytology
  • CT chest with pleural contrast
    • Nodular, mediastinal, or circumferential pleural thickening on CT-highly specific for malignant disease
treatment options
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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