Med - Umc Final Pleural Dses

Pleural Diseases Melvin A. Pasay, MD, FPCP, FPCCP Section of Pulmonary Medicine De La Salle University Medical Center

 

 

DEFINITION • Pleural cavity contains approximately 10 mL on each side. • Volume maintained by a balance between fluid production and removal • 99% of pleural effusions classified into two general categories: transudative - systemic perturbation exudative - underlying local disease

 

 

PREVALENCE • Estimates of the incidence of pleural effusions vary • Annual incidence of up to one million in the United States • Transudative effusions – congestive heart failure – hypoalbuminemic states (eg, cirrhosis)

• Exudative effusions – malignancy – infections (eg, pneumonia) – pulmonary embolism  

 

PATHOPHYSIOLOGY 1. INCREASED PLEURAL FLUID FORMATION Elevation of hydrostatic pressure (congestive heart failure) Decreased colloid osmotic pressure (cirrhosis, nephrotic syndrome) Increased capillary permeability (infection, neoplasm) Passage of fluid through openings in diaphragm (cirrhosis with ascites) Reduction of pleural space pressures (atelectasis)

 

 

PATHOPHYSIOLOGY 2. DECREASED PLEURAL FLUID ABSORPTION Lymphatic obstruction Elevation of systemic venous pressures [superior vena cava (SVC) syndrome]

 

 

SIGNS AND SYMPTOMS • Many patients are asymptomatic • Symptoms are usually due to the underlying disease process • Pleuritic chest pain indicates inflammation of the parietal pleura • Other symptoms include dry, nonproductive cough and dyspnea • Reduced tactile fremitus, dull or flat note on percussion, and diminished/absent breath sounds on auscultation • Presence of other clues (signs of heart failure, breast masses, etc)

 

 

DIAGNOSIS Chest Radiography • Posteroanterior and lateral chest radiographs • 50 mL of fluid - needed to be visible on the lateral radiograph • 500 mL - the meniscus usually obscures the entire hemidiaphragm • The lateral decubitus films

 

 

DIAGNOSIS Ultrasound • Useful both as a diagnostic tool and as an aid in performing thoracentesis • differentiate between solid and liquid components • Valuable in detecting subpulmonic or subphrenic pathology

 

 

DIAGNOSIS Computed Tomography • distinguish anatomic compartments more clearly (the pleural space from lung parenchyma) • useful in distinguishing empyema (split pleura sign) from lung abscess, in detecting pleural masses, and in outlining loculated fluid collections

 

 

DIAGNOSIS •

Criteria of Light – begin with a diagnostic thoracentesis – classification of the pleural fluid into either a transudate or an exudate

• Pleural fluid protein/serum protein ratio greater than 0.5 • Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6 • Pleural fluid LDH greater than two-thirds the upper limit of normal for serum LDH – diagnostic sensitivity of 99% and specificity of 98% for an exudate

 

 

Additional Markers • Cholesterol – higher in exudates than transudates – cannot be used as a substitute to measurements of protein and LDH.

 

 

Additional Markers • Serum-pleural Fluid Albumin Gradient – with a cut-off of 12 g/L (exudates if below that level, transudates if above) – specificity of 100% – use of this marker alone may result in misclassification of many exudates as well.

 

 

Additional Markers • Glucose – Very low glucose levels (less than 25 mg/100 mL) are seen in a few diseases. Rheumatoid arthritis, tuberculosis, empyema, and tumors/malignancy with extensive involvement of the pleura

 

 

Additional Markers • Amylase – Elevated pleural fluid amylase is seen with pancreatitis and esophageal rupture – approximately 10% of malignant effusions

 

 

Additional Markers • pH – Normal pleural fluid pH estimated to be around 7.64 – pH below 7.30 suggests the presence of an inflammatory or infiltrative process (parapneumonic effusions, empyema, malignancy, connective tissue diseases, tuberculosis, and esophageal rupture) – Urinothorax is the only cause of a low pH transudative effusion  

 

Additional Markers • Adenosine Deaminase – higher in tuberculous pleural effusions than in other exudates – level above 70 U/L is highly suggestive of tuberculous pleuritis – level below 40 U/L virtually rules tuberculous pleuritis – high ADA levels may be seen are rheumatoid pleuritis and empyema

 

 

Other Diagnostic Modalities • Pleural Biopsy – less frequent with the increasing availability of improved serum markers and thoracoscopy – used mainly to diagnose tuberculous pleuritis when other markers (eg, ADA) are negative.

 

 

Other Diagnostic Modalities • Thoracoscopy – more popularity with the advent of video-assisted technology – advantages of visual evaluation of the pleura, direct tissue sampling, and therapeutic intervention (eg, dissecting loculations and pleurodesis) – diagnosis of pleural effusions that have remained undiagnosed despite previous, less-invasive tests  

(eg, thoracentesis)

 

THERAPY AND OUTCOMES Therapeutic Thoracentesis: • Drainage of a pleural effusion • Complicated parapneumonic effusions or empyema • Symptomatic relief of dyspnea • Need for evaluation of underlying lung parenchyma • categorize the risk for poor outcome as well as the need for drainage of the effusion based on the pleural space anatomy, pleural fluid bacteriology (culture and Gram's stain), and pleural fluid chemistry (pH)  

 

THERAPY AND OUTCOMES Therapeutic Thoracentesis • may be repeated if indicated • more definitive therapy is usually needed to treat recurrent, symptomatic pleural effusions • no more than 1 L to 1.5 L of fluid should be removed • use of supplemental oxygen is probably of benefit

 

 

THERAPY AND OUTCOMES Pleural Sclerosis and Fibrinolytics • indicated in recurrent, symptomatic malignant effusions • talc, doxycycline, bleomycin, and quinacrine have been used • use of fibrinolytics (urokinase or streptokinase instilled via a tube thoracostomy) improved fluid drainage and chest radiograph findings significantly

 

 

THERAPY AND OUTCOMES Surgical Therapy • video-assisted thoracoscopic surgery (VATS) and thoracotomy as acceptable approaches to managing patients with complicated pleural effusions • Parietal pleurectomy and decortication of the visceral pleura are definitive procedures with excellent response rates • morbidity and mortality rates remain high, and that the patient's general medical condition, expected long-term prognosis, and baseline lung function should be considered before proceeding with surgery  

 

Pleural Effusions in Specific Diseases • Collagen-vascular Diseases – pleura is involved in a majority of patients with systemic lupus erythematosus (SLE) – pleural effusions are small and bilateral – most common symptom is chest pain – finding of LE cells and high antinuclear antibody titers in pleural fluid – SLE effusions are usually responsive to corticosteroids – Pleural effusions occur less commonly in patients with rheumatoid arthritis – occur more commonly in men – low glucose level (less than 25 mg/dL) – little evidence that corticosteroids are beneficial in treating rheumatoid pleurisy  

 

Pleural Effusions in Specific Diseases • Malignancy – more commonly involved through metastasis – Lung and breast cancer are the leading causes of metastatic disease to the pleura – less common causes are hematologic (eg, lymphoma and leukemia), ovarian, and gastrointestinal tumors – Cytologic examination of the pleural fluid is positive in more than 50% of cases with pleural involvement – Immunocytometry has been used to establish the diagnosis  

 

Pleural Effusions in Specific Diseases • Chylothorax – Leakage of chyle from a disruption of the thoracic duct – triglyceride level above 110 mg/dL confirms the diagnosis – finding of chylomicrons in the effusion (using electrophoresis) also establishes the diagnosis – Treatment of a chylous effusion is aimed at preventing the complications of malnutrition due to the continuous loss of protein, fat, and electrolytes – Definitive treatment modalities include thoracic duct ligation or pleuroperitoneal shunt implantation  

 

Pleural Effusions in Specific Diseases • Hemothorax – gross appearance of pleural fluid is bloody – hematocrit level should be determined – Hemothorax most commonly results from chest trauma – Nontraumatic hemothorax, although uncommon, must alert the clinician to the possibility of malignancy or pulmonary embolism – immediate chest tube thoracostomy

 

 

Pleural Effusions in Specific Diseases • Post-coronary Artery Bypass Graft – Approximately one-half of patients who undergo coronary artery bypass grafting develop pleural effusions – related to pleural trauma during surgery or bleeding into the pleural space – Within 30 days of surgery, the fluid is bloody, eosinophilic, and easily resolvable with drainage (thoracentesis) – After 30 days, the fluid is clear-yellow and predominantly lymphocytic, but these effusions are difficult to manage because they frequently recur – usually exudative.

 

 

Other Pleural Diseases Asbestos-related Pleural Disease AIDS-related Pleural Disease

 

 

Pneumothorax • air leaks into the area between the lungs and chest wall (pleural space) • A lung collapses in proportion to the amount of air that leaks into your chest cavity • partial collapse is much more common • tension pneumothorax, a life-threatening condition, requires immediate medical care

 

 

Symptoms •

may have few signs or symptoms

•

minimally collapsed lung is likely to cause some chest pain

•

When your lung has collapsed 25 percent or more, you're likely to experience: • Sudden, sharp chest pain on the same side as the affected lung • Shortness of breath, which may be more or less severe, depending on how much of the lung is collapsed • A feeling of tightness in your chest • A rapid heart rate

•  

heart function may be impaired  

Types Primary spontaneous pneumothorax • usually occurs in otherwise healthy people • most common in tall, thin men — many of them smokers — between 20 and 40 years of age • develop when a small air blister (bleb) on the lung ruptures • genetic factors also may play a role • usually mild because pressure from the collapsed portion of the lung in turn collapses the bleb.

 

 

Types Secondary spontaneous pneumothorax • develops in people who have existing lung disorders • Other conditions causing secondary pneumothorax include tuberculosis, pneumonia, cystic fibrosis and lung cancer • secondary pneumothorax can be more severe and even life-threatening

 

 

Types Traumatic pneumothorax • Any blunt or penetrating injury to the chest can cause lung collapse • Knife and gunshot wounds, a blow to the chest, even a deployed air bag can cause a pneumothorax • certain medical procedures such as the insertion of chest tubes, cardiopulmonary resuscitation (CPR) and lung or liver biopsies • Pneumothorax is especially common in people whose breathing is aided by a mechanical ventilator.

 

 

Types Tension pneumothorax • The most serious type of pneumothorax • pressure in the pleural space is greater than the atmospheric pressure • can cause the affected lung to collapse completely. • can also push the heart toward the uncollapsed lung • comes on suddenly, progresses rapidly and is fatal if not treated quickly.  

 

Treatment • The goal in treating a pneumothorax is to relieve the pressure on the lung • The best method for achieving this depends on the severity of the lung collapse and sometimes on your overall health: • Observation • Needle or chest tube insertion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Pleural Diseases Pneumothorax Air between the lung and chest wall (in the pleural space) is termed a "pneumothorax".Table 5 lists the classification of pneumothoraces. Common causes of pneumothoraces include trauma, iatrogenic factors (eg, thoracentesis, mechanical ventilation), chronic obstructive pulmonary disease, infection, and malignancy. The incidence of primary spontaneous pneumothorax is higher in men less than 40 years old, and the relative risk rises with heavier smoking. Secondary spontaneous pneumothorax is a more serious condition, since it further compromises an already abnormal lung function. Most secondary spontaneous pneumothoraces are related to chronic obstructive pulmonary disease or infection (eg, Pneumocystis carinii). Trauma-related pneumothorax can result either in an open (to the atmosphere) pneumothorax or a closed (tension) pneumothorax, in which intrapleural pressures frequently exceed atmospheric pressures. Table 6 summarizes the currently adopted guidelines by the ACCP for the treatment of spontaneous pneumothorax. Traumatic pneumothorax usually requires the placement of a tube thoracostomy until the air leak resolves. The ACCP consensus statement also recommends surgical intervention (thoracoscopy with bullectomy and a procedure to produce pleural symphysis) in preventing the recurrence of secondary pneumothoraces.