1. PLEURAL DISEASE

2. Pleural Diseases Pleural effusions Pleural malignancy Hemothorax
Pneumothorax

3. The Mechanisms of Pleural Effusion
Increased hydrostatic pressure (Cardiac failure)
Decreased oncotic pressure (Protein deficiency)
Decreased pleural cavity negative pressure (Atelectasis)
Increased permeability in microvascular circulation (İnfections, inflammation)
Impaired lymphatic drainage of pleural space (Tumor, fibrosis)
Transperitoneal route (Congenital defects, ascite)

4. Chest pain (inspiratory)
Symptoms
Chest pain (inspiratory)
Decreases when the fluid increases
Dyspnea
Cough
Symptoms of the underlying disease
Fever
Hemoptysis
Weight loss
...
Physical signs
No physical signs can be detected when the fluid is less than 300 ml
İncreased size of the affected hemithorax
İpsilateral restriction of chest wall motion
VT absent
Dullness (> ml)
Diminished breath sounds or inaudible
Pleural friction rub

5. Radiology
The fluid initially accumulates in the more dependent recesses of the thoracic cavity forming a Damoiseau Line
ml of pleural effusion can be detected on standard chest radiograph as blunting of the costophrenic angle

7. Massive pleural fluid often shifts the mediastinum to the opposite side

8. Accumulation of the fluid between the diaphragm and the interior surface of the lung (Subpulmonic fluid):
The hemidiaphragm appears to be elevated (Widening the distance between the top of the gastric bubble and the top of the left hemidiaphragm (>2 cm) and flatened
Blunting of the posterior costophrenic angle on the lateral chest radiograph

9. Pleural effusion in a lateral decubitus radiograph
Smaller amounts of pleural fluid can be detected on lateral decubitus radiography as the free intrapleural fluid moves from top of the diaphragm to the dependent chest wall
Pleural effusion in a lateral decubitus radiograph

10. Unusual localized pleural effusions can be seen due to the localized obliteration of the pleural space often by inflammatory conditions

11. Ultrasound is able to demonstrate smaller amounts of fluid as 100 ml
CT has similar sensitivity to ultrasound, not routine but can be performed to evaluate concomitant paranchymal lesions
CT is sensitive in identifying pleural thickening and calcification

13. Thoracentesis
Thoracentesis is indicated in all cases of pleural efusion of unknown origin
The site should be selected according to clinical examination
If the effusion is small thoracentesis can be performed under ultrasound guidance

14. Thoracentesis is usually performed for diagnosis
Apperiance of the fluid (Serous, bloody, purulent)
Biochemical, microbiological, cytological examination of the fluid
It can also be performed for the drainage of excess fluid (Therapotic) to relieve dyspnea
The amount of fluid should not exceed cc at a time to avoid hemodynamic complications and reexpansion pulmonary edema

15. Pleural Fluid analysis
Appereance
Serous (light to dark, clear)
Serosangineous (Blood tinged can be due to thoracentesis itself)
Hemorrhagic (hemothorax if hct>50% of blood hct)
Purulent (fetid odor in aerobic infections)
Chylous (milky)

16. Biochemical evaluation
Exudative
Transudative
Some special hints
Microbiological evaluation
Cellular structure
Special stains and culture
Cytologic evaluation

17. Biochemical Evaluation
Exudate
Dark yellow color
Total protein >3 gr/dl
Density >1016
Light Criteria:
Protein pl/s >0.5
LDH pl/s >0.6
LDH >200 or >2/3 of normal upper value of serum
Transudate
Light yellow color
Total protein <3 gr/dl
Density <1016
Light Criteria:
Protein pl/s <0.5
LDH pl/s <0.6
LDH <200

18. Pleural Cholesterol >60 mg/dl: Eksudate
Albumine Gradient:
Serum albumine- Pleural fluid albumine
<1.2 gr/dl Eksudate
>1.2 gr/dl Transudate
Pleural Cholesterol >60 mg/dl: Eksudate
Pl/S bilirubine >0.6: Exudate

19. Microbiologic evaluation
RBC > /mm3
Trauma,
Pulmonary infarction
malignancy
WBC > 1000/mm3 : exudate
> /mm3 : emphyema, parapnomonic effusion (PNL predominates)
Lymphocytes >50% : tuberculosis, malignancy, lymphoma, fungus, myxedema

20. Gram staining
Ziehl-Neelsen staining
Cultures for specific and nonspecific infections
PCR

21. Transudative Pl. Eff. Exudative Pl. Eff.
Increased hydrostatic pressure
Congestive heart failure
Constrictive pericarditis
Pericardial effusion
Pulmonary thromboemboli
Decreased oncotic pressure
Cirrhosis
Nephyrotic syndrome
Malnutrition
Increased capillary permeability
Myxedema
Transperitoneal transport
Peritoneal dialysis
Ascites
Exudative Pl. Eff.
Infectious diseases
Pnomonia, lung abscess
Tuberculosis
Fungal infections
Subphrenic abscess
Neoplastic diseases
Metastatic
Mesothelioma
Lymphoma
Immunologic reactions
Dressler syndrome
Sistemic Lupus Er.
Rheumatoid artritis
Churg strauss syndrome
Wegener granulomatosis

22. Exudative Pl Eff Gastrointestinal disease Drug induced Postsurgical
Pancreatitis
Causes of peritoneal exuda
Drug induced
Nitrofurantoin
Dantrolene
Methysergide
Bromocriptine
Procarbasine
Amiodorone
Postsurgical
Pulmonary thromboembolism

23. Exudative Pl Eff Sarcoidosis Uremic pleuritis Asbestos exposure
Chylothorax
Hemothorax
Yellow nail syndrome

24. Special characteristics: Milky appearance
Chylothorax
Triglyceride >110 mg/dl
Pl TG/sTG>1
Cholesterol crystal (-)
Chylomicrons (+)
Sterile (bacteriostatic)
Noniritative (do not cause pleural thickening)
Ety: Trauma, surgery, lymphoma
Pseudochylothorax
Triglyseride <50 mg/dl
Pl TG/sTG<1
Cholesterol>250 mg/dl
Pl Ch/s Ch>1
Ety: RA, Tbc
Emphyema
PH<7.20
Low Glucose
Pseudochylothorax forms in chronic pleural effusions usually caused by tuberculosis or rheumatoid artritis.

25. Special characteristics
Low Glucose values (<60 mg/dl)
Emphyema, complicated parapneumonic effusion
Tuberculosis
Rheumatoid artritis
Malign effusions
Lupus pleuritis
Churg strauss syndrome
Less frequent

26. High amylase (over the upper limit of normal serum values)
pH<7.20
Parapneumonic effusion, emphyema
Esophageal perforation
Rheumatoid artritis
Tuberculosis
Malignancy
Urinothorax
High amylase (over the upper limit of normal serum values)
Esophageal perforation
Acute pancreatitis
Fistula in chronic pancreatitis
Adenocarcinoma (salivary amylase)

27. Eosinophilia >10 % of the total cells
Air or blood in the pleural space
Recurrent punctions
Pulmonary embolism
Benign asbestos effusions
Resolving pleural infections
Echinococus infection
Loeffler syndrome
Hodgkin’s lymphoma
Drug induced pleural eff.

28. If the effusion is transudative the main cause should be treated
If the effusion is exudative and not emphyema further diagnostic procedures should be considered
Cytologic examination
Closed pleural needle biopsy
Thoracoscopy (VATS)
Thoracotomy

29. Treatment Treatment of the specific cause Drainage of the excess fluid
Pleurodesis (Performed to achieve fusion between visceral and parietal pleural layers. Main indications are malignant effusions, rarely recurrent benign effusions when other treatments have failed. After the removal of pleural fluid completely by thoracal tube, special sclerosing agents (tetracycline, doxycycline, bleomycine, talc etc) are injected to the pleural cavity)
Surgical pleurectomy
Pleuroperitoneal shunt

30. Cardiac effusions
Predominantly caused by left ventricular failure, elevated pulmonary capillary pressure
>50% are bilateral effusions or 27% right sided only.
Usually the heart is enlarged on chest x ray, phantom tumor (pseudotumor) can be present on the right side
Resolves with diuretics and treatment for left ventricular failure

32. Infectious pleuresy, emphyema
Bacterial pneumonia is associated with an effusion in 40% of cases
The effusion may be parapneumonic without infection (uncomplicated) or culture positive (complicated, emphyema)
Parapneumonic effusions are treated with appropiate antibiotics
Antibiotic treatment + Tube drainage is indicated if emphyema occurs

33. Tube drainage indications in complicated parapneumonic effusion
Purulent appearance
Gram staining (+) for bacteria
Plevral fluid glucose<40 mg/dl
Pleural fluid pH<
Pleural fluid LDH>1000 IU/L

34. Tuberculosis pleurisy
Usually occurs soon after the primary infection and mainly affects children or teenager group
Pathogenetic mechanisms include direct invasion of AFB to pleura or delayed type hypersensitivity reaction
The onset of symptoms may be acute or subacute
Typical symptoms of pleural effusion and general symptoms of tb may be present
The affected population differs according to the prevalance of the disease in a population and the prevalance of AIDS or other immundeficient conditions

35. Exudative effusion, lymphocyte predominance, low glucose, low mesothelial cells (<5%), high ADA Tuberculin skin test can be (-) in 30%
Treatment: Pulmonary tb treatment + steroid

36. Other Pleural Diseases
Hemothorax
Plevral fluid htc>50% of serum
Can be traumatic or nontraumatic:
İatrogenic
Pulmonary infarction
Tumors
Rupture of aneurism
Anticoagulan treatment
Thoracic endometriosis
Treatment:
intrapleural drainage
thoracotomy

37. Chylothorax
Direct passage of chyle from the thoracic duct into the pleural cavity
TG>110 mg/dl
Cause:
Tumors (Lymphoma)
Trauma (surgery)
Congenital defects
Lymhangioleiomyomatosis
Tuberosclerosis
Treatment.
Pleural drainage
Parenteral nutrition
Bed rest (to decrease lymphatic drainage)
Surgical ligation of thoracic duct
Chemotherapy or RT

38. Fibrothorax A thick fibrous tissue formed on visceral pleura Cause:
Empyema
Tuberculosis
Hemothorax
Treatment: Decortication

41. Pneumothorax (Px)
Presence of free air between the visceral and parietal pleura
Divided into 3
Open Px ( Penetrating trauma)
Closed Px
Spontaneous (Primary, Secondary)
Closed trauma
iatrogenic
Tension Px (Penetrating trauma)

42. Physical examination:
Hypersonority on percusion
Reduced breath sounds
Hypotension and cardiac tamponade may occur depending on the size of the pneumothorax
Radiology:
Pleural line
Hyperlucency at the periphery
Mediastinal shift
Expiration film, lateral decubitus film can be used when the lesion is not apparent

47. Quantification of the size of the pneumothorax is helpfull in the decision of treatment
Measurement of the average diameters of the collapsed lung and the affected hemithorax can be used
100-(83/113)100=% 62
>2 cm pleural line from thoracic line in hiler region is large px
Simple observation with rest and supplemental oxygen can be used for asymptomatic patients with a small (<20%) px

48. Intercostal drainage is indicated in large or bilateral or tension px
A recurrent spontaneous pneumothorax (30-50% risk) is an indication for surgery
Smoking should be quited after first attack
A patient with px cannot travel by air until totaly expanded in chest x ray

49. Pleural Neoplasms Benign: Malign: Metastatic: Pleural lipoma
Local pleural fibroma (Fibrous mesothelioma)
Malign:
Diffuse malign mesothelioma
Metastatic:
Bronchial carcinoma (adenocarcinoma)
Lymphoma
Breast carcinoma
Other adenocarcinomas
The origin of Fibrous mesothelioma is submesothelial mezenchymal cells not mesothelial cells

50. -END-