1. Chapter 25 Pleural Diseases
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2. Learning Objectives
Describe important anatomic features and physiologic function of the visceral and parietal pleural membranes.
Describe how pleural effusions occur and the difference between transudative and exudative effusions.
Identify common causes of transudative and exudative pleural effusions.
Write definitions of “chylothorax,” “hemothorax,” and “pneumothorax.”
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3. Learning Objectives (cont.)
Describe the impact of moderate to large pleural effusions on lung function.
State the role of the chest radiograph in recognizing pleural effusions.
State the purpose of thoracentesis and the potential complications.
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4. Learning Objectives (cont.)
Identify the definitions of spontaneous, secondary, and tension pneumothorax.
Describe the diagnosis and treatment of pneumothorax.
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5. The Pleural Space Overview & definitions
Visceral pleura cover each lung, while parietal pleura covers outer structures that bound lungs
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6. The Pleural Space (cont.)
Overview & definitions (cont.)
Pleural fluid about 10 to 20 mm thick separates visceral from parietal pleura
~8 mL of fluid per hemithorax
Pleural fluid is very similar to interstitial fluid
Fluid minimizes friction caused by expanding lungs in thorax during inspiration
Pleural pressure is typically negative due to outward thoracic recoil & inward recoil of lung
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7. The Pleural Space (cont.)
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8. The greatest negative pressure in the pleural space can be found at the level of:
A. The mediastinum
B. The lung bases
C. Apex of the Lung
D. The heart
Answer: C
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9. Pleural Effusions
Any abnormal accumulation of fluid in pleura is considered pleural effusion
Fluid enters pleural space from visceral & parietal pleurae, particularly in light of increased pressure
Stomata connecting to lymphatic system remove fluid from this space
Either increased fluid production or blockage of drainage can result in pleural effusions
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10. Pleural Effusions (cont.)
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11. Pleural Effusions (cont.)
Transudative effusions
Effusions forming while pleural space is undamaged will have [protein] <50% of serum level & LDH <60% of serum level
Specific causes of transudative effusions:
CHF: high hydrostatic pressure increases pleura fluid production, most common cause of effusions
Nephrotic syndrome: protein loss in urine results in low capillary oncotic pressure & fluid third spacing
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12. Pleural Effusions (cont.)
Specific causes of transudative effusions (cont.):
Hypoalbuminemia: different cause but mimics CHF & nephrotic syndrome
Liver disease: ascites fluid moves through small holes in diaphragm, almost always on right side
Atelectasis: cause pleural pressures to become more negative resulting in small effusions
Lymphatic obstruction: blockage prevents drainage & results in accumulation
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13. Which of the following are the primary causes of a transudative pleural effusion? 1. rupture of the pleural space 2. abnormal hydrostatic pressure 3. increased plasma protein concentration 4. abnormal oncotic pressure A. 1, 2 and 3 only B. 1, 3 and 4 only C. 1, 2, 3, and 4 D. 2 and 4 only
Answer: D
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14. Pleural Effusions (cont.)
Exudative effusions
Occur due to inflammation of lung or pleura & have higher protein & inflammatory cell content
Account for 70% of all pleural effusions
Thoracentesis may be performed to determine type
Specific causes of exudative effusions
Parapneumonic: secondary to lung inflammation associated with pneumonia
Complicated if clots form & loculate fluid
Persistent fever may signal an empyema - must be drained for recovery
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15. Pleural Effusions (cont.)
Specific causes of exudative effusions (cont.)
Viral pleurisy: presents with pleural inflammation (pleurisy) & pleural pain (pleurodynia)
Pain may result in atelectasis & hypoxemia
Tuberculous pleurisy: occurs when caseous granulomas rupture viscera pleura & drain into pleural space
Patients need to be isolated
Malignancy: most common cause of large unilateral effusions, most require pleurodesis to treat
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16. Pleural Effusions (cont.)
Specific causes of exudative effusions (cont.)
Postoperative: common following abdominal or thoracic surgery
Chylothorax: caused by rupture of thoracic duct, 50% malignant, 20% surgical
Fluid may be white or yellow, sometimes bloody
Hemothorax: trauma or blood vessel hemorrhage into pleura space
Hematocrit > 50% of serum level
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17. C. pulmonary solitary nodules D. ascites
Complications from a parapneumonic pleural effusion may often lead to the formation of:
A. empyema
B. lung access
C. pulmonary solitary nodules
D. ascites
Answer: A
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18. Physiological Importance of Pleural Effusions
Mechanics of ventilation
Effusions cause atelectasis due to limited thoracic space resulting in restrictive pattern on PFTs
Patients commonly dyspneic, even with small effusions
Rarely cause fibrothorax with true restrictive impairment
Hypoxemia
Most effusions cause increased P(A – a)O2 - may worsen following thoracentesis
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19. Diagnostic Tests for Pleural Effusions
Chest radiography
Most common method of detecting effusions
Upright PA & lateral decubitus are useful
1-cm meniscus lung to rib allows for thoracentesis
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20. Diagnostic Tests for Pleural Effusions (cont.)
Ultrasonography & computed tomography
Ultrasound is very sensitive to pleural effusions
May use to localize & direct for thoracentesis
Contrast-enhanced CT is most sensitive study for effusions
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21. Diagnostic Tests for Pleural Effusions (cont.)
Thoracentesis
Percutaneous needle aspiration of effusion sample
Drainage for lung reexpansion involves placement of chest tube
Risks include:
Artery laceration
Infection
Pneumothorax
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22. Diagnostic Tests for Pleural Effusions (cont.)
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23. B. CT scanning of the chest C. ultrasonography D. Chest x-ray
Which of the following is considered the most sensitive procedure to assess size and location of a pleural effusion?
A. thoracentesis
B. CT scanning of the chest
C. ultrasonography
D. Chest x-ray
Answer: B
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24. Diagnostic Tests for Pleural Effusions (cont.)
Thoracoscopy (video-assisted)
Ideally designed for diagnostic & therapeutic pleural procedures
Allows visualization of surfaces, drainage of effusion, biopsy, & pleurodesis if needed
Perform under local anesthesia & conscious sedation
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25. Management for Pleural Effusions
Pleurodesis
Process fusing parietal & visceral pleurae - prevents further formation of effusions
Can be performed by surgical abrasion or introduction of chemical irritant, most commonly talc
Not recommended for non-malignant pleural effusions
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26. Management for Pleural Effusions (cont.)
Pleuroperitoneal shunt & Pleurex catheter
For effusions refractory to all other treatment options
Small pump moves fluid from pleura to peritoneal cavity
Pleurex catheter connects to suction at home to drain persistent effusions
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27. Management for Pleural Effusions (cont.)
Chest thoracotomy tubes
Designed for tight fit in tissues to avoid leaks & allow drainage of effusion & subsequent lung reexpansion
Tube is attached to chest drainage unit
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28. A lab report shows a pleura effusion protein level of 10 g/dL together with the presence of malignant cells on the cytology report. You would classify this effusion as a:
A. transudate
B. chylothorax
C. exudate
D. normal
Answer: C
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29. Pneumothorax
Defined as air in pleural space - can occur through number of mechanisms
Chest pain is typically sharp & abrupt
Palpation of & chest wall does not worsen pain
Dyspnea occurs in 2/3rd of patients
May decrease vital capacity & PaO2
Hypoxemia may persist after evacuation of pneumothorax
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30. Pneumothorax (cont.) Traumatic pneumothorax Penetrating chest trauma
Common secondary to bullet or knife penetration
Chest tube is usually adequate to treat
May require surgery if bleeding is severe
Blunt trauma
Broken ribs puncture lung with air escape into pleura
Chest tube is all that is generally required
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