1. Pathology of pleura & laboratory investigations in lung diseases
DR.USHA

3. Pleural fluid
Normally 10-15ml of pleural fluid is present in the pleural cavity.
Pleural fluid is produced by pairetal & visceral layers.
Most of the fluid is removed by the lymphatics, remaining fluid lubricates the lung & chest wall.

4. Pleural effusion
Is the accumulation of excess fluid in the pleural cavity.
Important manifestation
Normally, no more than 15ml of serous fluid present. This fluid is acellular, clear fluid that lubricates the surface.

6. Etiology of pleural effusion
Increased hydrostatic pressure, as in congestive cardiac failure.
Increased vascular permeability, as in Pneumonias.
Decreased osmotic pressure, as in Nephrotic syndrome.
Decreased lymphatic drainage, as in Mediastinal carcinomatosis.

7. Clinical features
Pleuritic chest pain- increases on inspiration, coughing, sneezing
Dyspnea

8. Clinical features
500ml of fluid should be present to produce the signs
Bulging of intercostal spaces on the affected side
Diminished mobility of chest wall
Shift of mediastinum to the opposite side
Stony dullness on percussion
Bronchial breath sounds on auscultation.

9. Types of pleural effusion
Trasudate
-Congestive cardiac failure
-Cirrhosis of liver
-Nephrotic syndrome
Exudate
-Pneumonias
-Tuberculosis
-Pulmonary embolism
-Malignancy

10. Types of pleural effusion based on etiology
Non-inflammatory effusion
Inflammatory effusion

11. Non inflammatory effusion
Hydrothorax
Haemothorax
Chylothorax

12. Hydrothorax Accumulation of serous fluid
Unilateral or bilateral depending on the cause.
Causes- Congestive cardiac failure
Nephrotic syndrome
Cirrhosis of liver
Primary & Secondary tumors

13. Nature of Hydrothorax Is a transudate Clear, straw colored
Protein content less
Very few cells.

14. Haemothorax Accumulation of blood Causes- -Trauma to the chest wall
-Ruptured aortic aneurysm

15. Chylothorax
Accumulation of milky fluid of lymphatic origin

16. Causes of chylothorax Thoracic duct trauma
Obstruction to the thoracic duct by secondary malignancy
Filariasis

17. Inflammatory effusions
Exudate type
Serofibrinous
Suppurative/Empyema thoracis
Haemorrhagic

18. Serofibrinous type Causes- -Pneumonias, Lung abscess, Bronchectasis,
-Tuberculosis
-Rare causes-Rheumatoid arthritis, SLE, Radiation injury.

19. Purulent/Empyema type
Accumulation of pus
Causes-
-direct spread of pyogenic infection from lung
-direct extension of sub diaphragmatic abscess or liver abscess
-Septicemia

21. Hemorrhagic effusion
-usually seen in primary or secondary malignancies of pleura.

23. Investigations CBC Sputum examination-gram’s, ZN, Cytology
X-Ray- Homogeneous opacity(150ml)
CT, MRI- 50ml
Pleural tap- for pleural fluid examination

25. Pleural fluid examination
Lymphocytic predominance-tuberculosis, fungal infections, carcinoma
Polymorphic predominence-acute bacterial infections
Presence of pleomorphic cells- malignancy

26. Sequelae of pleural effusion
Permanent collapse of the lung (Compression atelactesis)
Pleural thickening, Adhesions
Empyema

27. Pneumothorax
Accumulation of air in the pleural cavity.

28. Causes of pneumothorax
Spontaneous:
Emphysema,Bronchial asthma, Tuberculosis.
2. Traumatic:
Perforating injury to the chest wall
3.Therapeutic:
Was once used in treatment of tuberculosis

29. Types of pneumothorax
Closed type- the opening is very small & heals spontaneously
Open type- the opening is large & remains patent
Tension- the opening is valvular(air enters the pleural space during inspiration but cannot escape during expiration so that a positive pressure occurs in the pleural cavity.

30. Clinical features Pleuritic chest pain Dyspnea Collapse
Crack pot sound on percussion
Hyper-resonent sound on auscultation

31. X-ray
Hyper-translucent

33. Clinical significance of Pneumothorax
Compression of pleura on lung may lead to Atelactasis & leading to Respiratory distress.
Tension pneumothorax- results if the defect acts as ball valve permitting entry of air & preventing escape of air.

34. Pleural tumors Primary- Benign mesothelioma, malignant mesothelioma
secondary

35. Solitary fibrous tumor
Very rare
Benign tumor
Not related Asbestos exposure.

36. Malignant mesothelioma
Etiopathogenesis:
Strong association with asbestos exposure
Smoking
Chromosomal abnormalities

37. Gross appearance
Multiple nodules studding the pleura or diffuse thickening of the pleura.

38. Gross appearance

40. Microscopy
Two types:
Epithelioid type:consists of cuboidal or columnar cells forming papillary or tubular structures resembling adenocarcinoma.
Sarcomatoid type: consists of spindle shaped cells resembling fibrosarcoma.
Mixed type: both epithelioid & sarcomatoid components

42. Metastatic tumors Are more common then primary tumors
Most of metastasis is from lung, breast & GIT.

44. Laboratory investigations in lung diseases
Complete blood count
X-Ray, CT Scan, MRI
Sputum cytology
Bronchial washings/lavage/brushings
FNAC of lung
Lung Biopsy
Pleural tap for pleural fluid examination

46. Sputum cytology
Is the tracheobronchial secretions.

47. Collection of sputum
Early morning sample is preferred as it represents the pulmonary secretions.

48. Sputum examination Macroscopic examination Microscopic examination
Sputum culture

49. Macroscopic examination
Volume: a 24 hrs sputum is measured in chronic bronchitis, lung abscess, bronchial asthma. An increasing volume of sputum indicates bad prognosis.
Colour: normal sputum is clear & colorless.
Yellowish- infectious process like pneumonia
Greenish tint- pseudomonas
Rust colored- pneumococcal pneumonia
Bright red- pulmonary infarction, tuberculosis, malignancy.

50. 3. Odour: normal sputum is odourless.
Putrid odour- seen in lung abscess, cavitary tuberculosis.

51. Microscopic examination
Gram’s stain-detect various bacteria
Ziehl Neelson’s stain- detect AFB
Pap’s/ H&E stain- for cytological examination. Normally sputum shows few tracheobronchial cells, occasional squamous cells & inflammatory cells.

52. Uses of sputum examination
Infectious diseases- Pneumonia, Lung abscess, Tuberculosis, Fungal infections.
COPD’s
Malignancies

58. Advantages of sputum cytology
Less expensive
OPD based
No anesthesia required
Non invasive

59. Disadvantages
Detects lesions which opens into bronchi. Peripheral lung lesions may be missed.
Difficult in children, comatose patients.
Contamination with oral secretions.

60. Bronchial washings
An bronchoscope is passed via trachea into bronchioles & about 5ml of balanced salt solution is introduced.
Solution introduced is aspirated back & collected in a sterile container.
Solution is smeared, stained with PAP’s stain & examined.

61. Advantages
No dilution with oral secretions
Useful in children

62. Disadvantages
Invasive procedure
Costly
Requires anesthesia

63. FNAC Lung
Fine needle aspiration is useful in peripheral lung lesions which are missed with sputum examination & Bronchoscopy.
Adv:OPD based, less expensive
Dis:invasive procedure, not hit the lesion,

64. Thank you