1. Pleural Diseases Magdy Khalil MD, FCCP, EDIC
Professor of Chest Diseases& Respiratory Intensive Care Medicine

2. Pleural anatomy
Pleural physiology
Pleurisy
Pleural effusion
Pneumothorax
Asbestos-related pleural diseases
Pleural malignancies

3. Anatomy of the pleura

4. Physiology of the pleura

5. Pleural fluid turnover
Pleural fluid drainage is achieved by the “Lymphatic pump”
Production=Absorption~15 ml/day
fluid, cells, proteins

6. Inflammation of the pleura
Pleurisy
Inflammation of the pleura
Symptoms:
pleuritic chest pain (pleurodynia)
Signs:
pleural rub
Causes:
Infection
Infarction
Malignancy
Vasculitis
CXR: ? free
Management:
treatment of underlying disease
Analgesia (paracetamol, NSAIDs)

7. Pleural effusion: Clinical features
Fluid in pleural space
Symptoms:
Chest pain
Dyspnea
Cough
Symptoms related to underlying diseases
Signs
Limited movement
Dullness
Diminished intensity of breath sounds

8. Imaging of pleural effusion
X-ray CT
Ultrasound

9. Pleural effusion: Diagnosis
History
Investigations
Underlying disease
Thoracentesis
Pleurl biopsy
Closed
Thoracoscopic

10. Pleural fluid analysis
Physical
Transudate
Low protein<0.5 serum
Low LDH< 0.6 serum
-Increased hydrostatic pressure in the lung (e.g. left heart failure)
-Decreased Oncotic Pressure Gradient (e.g. hypoproteinemia in nephrotic , liver-cell failure, undernutrition)
Chemical
Exudate
High protein content>o.5 serum
High LDH > 0.6 serum
-Increased Capillary Permeability (e.g. pleura inflammation)
-Obstruction of lymphatics ( e.g. malignancy)
Bacterial
Cellular

11. ±organism(Gram stain/ culture) Tuberculosis Lymphocytes
Parapneumonic effusion
Exudate
Many polymorphs
±organism(Gram stain/ culture)
Tuberculosis
Lymphocytes
± Organism (ZN/ Mycob. culture)
Collagen vascular diseses
Exudate
Lymphocytes (?PMN)
Low glucose (rheumatoid)
Infarction
?Hemorrahgic
? Eosinophils
Malignant
Exudate
Abnormal cells
Heart failure/liver failure/ Nephrotic
Transudate
Watery or light yellow
Low cellularity

12. Pleural biopsy

13. Pleural effusion: Management
Evacuation of pleural space
Pleural aspiration
Intercostal tube drainage
Treatment of underlying disease

14. Empyema Pus in pleural space Complicated parapneumonic effusion,Or
First presentation
Fever
Cough
Complications
Toxemia
Broncho-pleural fistula (copious expectoration)
Formation of cutaneous sinus

15. Empyema imaging
Chest x ray: Free or loculated
Chest CT
Ultrasound

16. Empyema: management Evacuation of the pus
Pleural drain (wide bore)± instillation of saline or fibrinolytics
Thoracoscopy or thoracotomy
Decortication
Antibiotics
(prolonged 2-4 weeks)

17. Pneumothorax Classification Spontaneous Trauma Iatrogenic Primary
Secondary
Trauma
Iatrogenic

18. Fate of spontaneous pneumothorax
Closed
Open
Tension

19. Pneumothorax: Clinical Manifestations
Symptoms:
Unilateral chest pain
Dyspnea
cough
Signs :
Diminished movement
Diminished/Absent breath sounds,
Absent fremitus,
Resonant /hyperresonant percussion,
Liver shift, ?Tracheal shift,
Tachypnea, tachycardia

20. Pneumothorax: Radiology

21. Pneumothorax: Management
Secondary
Pleural drain
Primary
Observation for spontaneous resolution
small, <15%, no dyspnea (oxygen)
Aspiration or pleural drain
Moderate/Large, or dyspnea

22. Pneumothorax: Surgery
Thoracoscopy
Thoracotomy
Plication of fistula
Removal of bulla
Resection

23. Pleurodesis: Indications
Obliteration of pleural space
Pneumothorax
Recurrent
Secondary
Specific (diving,f lights)
Pleural effusion
Rapidly re-accumulating malignant effusion

24. Asbestos- related pleural diseases
Pleural plaques
Benign pleural effusion
Diffuse pleural fibrosis
Mesothelioma
Lag period of years
Resistant to treatment
Malignat pleural tumours
Primary
Secondary