1. Pleural disease. Dr Leon Lewis
Introduce me – details on screen. Previously Clinical Lecturer and SpR here – 3yrs RHH 1yr NGH.
So seen and managed an awful lot of the pleural disease that has passed though this hospital in the last 6 years, albeit much less in these lat 2 years. And I have been dissatisfied with the way we manage it, and hopefully I’m now in a position to be able to do something about it, hence the title – time for a change.
And this talk is going to be about pleural effusion, since pneumothorax is a topic in itself.
Dr Leon Lewis
Consultant Respiratory Physician & Clinical Lead for Pleural Disease, STHFT

2. Aims
Introduction to pleural diseases and their management

3. Objectives Understand the anatomy of the pleura
Know the commonest pleural disease
Give an outline of the approach to diagnosis
Know management options available

4. What is the Pleura?
Visceral
Parietal
Grays 20th Ed

5. What is the Pleura?

7. Pleural topography Project 3cm above the clavicle.
Remember the even numbered-ribs 2,4,6,8,10,12.
Horizontal to the lower border of 12 ribs
Lungs are 2 ribs higher than pleural reflection
Grays 20th Ed

9. ribs
intercostal
vessels
space
diaphragm
collapsed lung

10. What does it do? 1) Allows movement of the lung against the chest wall
2) Coupling system between lungs and chest wall
3) Clearing fluid from the (pulmonary) interstitium

11. Pleural Fluid
The pleural space contains a tiny amount of fluid (about 0.3ml/kg)
Pleural fluid contains:
Protein mainly albumin, globulin and fibrinogen
Few cells mainly mesothelial cells, monocytes and lymphocytes

12. Pleural Fluid Turnover
Pleural fluid is produced and reabsorbed by the parietal pleura (via lymphatic stoma)
Reabsorption occurs mainly at the dependant areas of parietal pleura i.e. posterior and inferiorly
In these areas more lymphatic stoma are found
Wang NS. Am Rev Respir Disease 1975;111:12-20

13. Pleural Fluid Turnover
Pleural fluid production and absorption by parietal pleura are both
~0.01 ml/kg/hr or ~15mls per day in health
Drainage is achieved by “lymphatic pump”
contractions of smooth muscles of lymphatic walls
Maximum fluid drainage is mls/kg/hr or 3-500mls per day

14. Pleural Diseases Pleural Effusion (Pleural thickening/nodules)
Pleural Plaques (benign and asbestos related)
Pneumothorax

15. Pleural malignancy Primary – mesothelioma Secondary
Surgery, chemotherapy, radiotherapy
Secondary
Lung Cancer
Breast Cancer

16. Of the rising incidence of mesothelioma
Of the rising incidence of mesothelioma. This figure is from the original study describing the epidemic of asbestos deaths, and shows that this isn’t a problem that will go away in our working lives, and in fact will get considerably worse before it gets better.
Peto et al. Lancet 1995

17. Pleural Biopsy Abraham’s needle US/CT guided ‘Trucut’ VATS
pickup for malignancy low (7-27% if cytol -ve)
Better for TB (72-90%)
US/CT guided ‘Trucut’
Only for visible masses
VATS
Gold standard
Medical Thoracoscopy

18. Pleural Effusion Fluid within pleural space Wide variety of causes
History/examination
Chest radiograph/CT
Diagnostic thoracentesis
Image guided v direct visualisation biopsy

20. Pleural Effusion: Causes
Transudate:
Heart failure/renal failure/nephrotic syndrome/Liver Cirrhosis
hypoalbuminaemia
Exudate:
Malignancy (lung, breast, mesothelioma)
Infection (lung, pleural, abdominal)
Inflammatory (RA, SLE) PE
Benign asbestos related
Traumatic (haemothorax/chylothorax)
Rarer: Meig’s syndrome, drug reaction

21. Pleural Effusion: Diagnosis
History/examination
Transudates
Imaging
Is there a mass/mets
Is there consolidation
Is there a big knife
Thoracentesis (or “pleural tap”)

22. Pleural Effusion: Thoracentesis
Biochemistry (Protein, LDH, glucose, pH), MC&S, cytology
Appearance (is it pus or blood!)
Transudate v Exudate (Light’s Criteria)
Pleural protein: serum protein > 0.5
Pleural LDH: Serum LDH >0.6 (or >2/3 ULN)
MC&S (&pH): is it infected (parapneumonic)?
Cytology: is it malignant? (rel low sensitivity)

23. Pleural Effusion: Diagnosis
Frequently thoracentesis just tells you it’s an exudate…
Pleural biopsy (USS/CT guided)
Thoracoscopy
VATS

24. Pleural Effusion: Case 1
Mrs P
72 year old
Previous MI, Type 2 DM, CKD
SOB progressively over 2 weeks
Bilateral reduced air entry
Bilateral pedal oedema

25. Pleural Effusion: Case 1
ECG
LBBB
CXR
Bilateral pleural effusion

26. Pleural Effusion: Case 1
Heart Failure (maybe renal disease!)
No need to perform thoracentesis
Treat – diuretics etc
Echocardiograph
If things do not progress as you’d expect then you may need to think again…

27. Pleural Effusion: Case 2
Mr T
74 year old retired joiner
2/12 of “nagging back pain”, breathlessness, fatigue and weight loss

29. Pleural Effusion: Case 2CT
Thoracentesis
pH 7.2
Protein 48 (serum 70)
LDH 500 (serum 750)
“Suspicious cells”

30. Pleural Effusion: Case 2

31. Pleural Effusion: Case 2
Need histology
Image guided v direct vision (thoracoscopy or VATS)

32. Image (CT) guided cutting needle pleural biopsy
diagnostic sensitivity 87 % for malignancy
“No” complications
(Maskell, Lancet 2003;361: )
So how can we improve?
Image guided Bx – RCT evidence of improved diagnostic yields in malignancy
Still need to admit patient for average 10 days admission and drainage to pleurodese

33. Thoracoscopy
Diagnostic
Therapeutic

34. Thoracoscopy 95% sensitivity for malignant disease
(100% sensitivity for TB)
Complications:
infection
trapped lung
Blanc et al Chest 2002;121:

35. Thoracoscopy

36. Slides courtesy of Julius jansen

42. Pleural Effusion: Case 3
Miss L
27 year old teacher
2/52 ago – SOB, productive cough.
Abx – only took 2 days worth
Seemed to get better, but developed pleuritic chest pain, breathlessness and feels “not quite right”

43. Pleural Effusion: Case 3
Feverish and sweaty
Dull at the right lung base
CRP – 300
WCC – 22
CXR – RLL consolidation and an associated pleural effusion

44. Pleural Effusion: Case 3
Pneumonia with pleural effusion
“Parapneumonic Effusion”
Simple (non-infected/sympathetic)
No specific treatment required
Complicated (infected)
Requires drainage
Empyema

45. Parapneumonic Effusions: Diagnosis
Complicated if:
Looks like pus (empyema)
Microorganisms in fluid (empyema)
pH <7.2
Glucose <2.2mmol/L
LDH >1000

46. Parapneumonic Effusions: Management
Simple parapneumonic effusions
Observation and follow-up
Complicated/Empyema
Drainage
Intra-pleural fibrinolytics
Surgery (decortication)

47. Pneumothorax
Air in the pleural space

49. Pneumothorax: Causes Traumatic (penetrating or rib fractures)
Spontaneous
Primary (inc Marfans) - PSP
Secondary (COPD, pulmonary fibrosis) -SSP
(infections – PCP, TB)
(Catamenial)
Iatrogenic (pacemakers, central lines)

50. Pneumothorax: Diagnosis
History
Examination
Chest radiograph
Tension Pneumothorax = clinical diagnosis
Deviated trachea
Haemodynamic instability
Requires immediate needle decompression

51. Pneumothorax: Management
Traumatic  drain
Patient requiring ventilation  drain
Haemothorax  drain
Tension = medical emergency
Needle aspiration, then…drain!

52. Pneumothorax: Management
Primary v secondary
Symptoms
Size (at level of hilum on CXR)
Risk of recurrence

53. Pneumothorax: Management
Observation
Small, asymptomatic PSP - OPD
More rarely in SSP – in-patient
Aspiration
Larger/symptomatic PSP
Small secondary PSP
Drainage
Larger SSP
Failed aspiration of PSP

54. Chest Drainage Pneumothorax – as above Pleural effusions
Malignant & symptomatic
Empyema/complicated parapneumonic
Traumatic haemothorax
Post-op (usually as part of op)
Ventilated patients

55. Chest Drainage: site
NB: Assumes normal anatomy.

56. Pleurodesis Reduces recurrence of malignant pleural effusions
So, improves quality of life
Underused/done badly
Chest tube – Talc 4g Steritalc graded talc
Risk of SIRS/pain
Probably negligible risk of ARDS
50-75% effective
Can be done at THORACOSCOPY
Dig out of the ground,
Shaw, Agarwal Cochrane Database Syst Rev. 2004;(1):CD

57. Thoracoscopic talc poudrage (aka pleurodesis)
success rate 93% (v. 60% chest drain talc slurry)
RR non-recurrence 1.68
De Campos et al Chest 2001;119:801-6
Cochrane database 2004;CD002916

58. Summary
Pleural disease is common, and can represent a range of pathologies
A systematic approach will help you define the cause of pleural effusion
Prompt diagnosis and relief of symptoms are the priority
Amongst most complex patients you will be expected to manage day-to-day