PLEURAL DISEASES
FARHAD MAZDISNIAN, MD, FCCP
PULMONARY AND CRITICAL CARE MEDICINE
VA LONG BEACH MEDICAL CENTER
OBJECTIVES
•
•
•
•
Understand the normal anatomy and physiology of the
pleura and the differences between parietal and visceral
surfaces
Understand the basic principles behind pleural fluid
formation and the factors that can alter either pleural
fluid formation or reabsorption
Be able to differentiate between transudates and
exudates
Understand the general approach to assessing a pleural
effusion
CASE
67 YO man presents with increased
shortness of breath. He was well until
one month prior to his presentation to
the ER. His dyspnea was initially on
exertion, however has progressed to
dyspnea at rest, orthopnea and a
nonproductive cough. His past medical
history is significant for Hypertension
and COPD. His medication include ASA,
Lisinopril, Albuterol, Symbicort and
Spiriva.
He has a significant h/o of smoking.
2packs per day for 40 yrs.
On exam is sitting upright and breathing
with difficulty. He is afebrile. BP=150/85;
HR=124; RR=26; oxygen saturation is
91% on ambient air. He has diminished
breath sounds on the right, ½ way up
the chest. There is non JVD or
peripheral edema.
ANATOMY
Sheep lung
Clinics in chest
medicine 2006
HISTOLOGY
Clinics in chest medicine 2006
PHYSIOLOGY OF PLEURAL SPACE
•The pleural cavity
contains a small amount of
pleural fluid (<10ml in a 70
kg man)
•Normal rate of production
is app. 17ml/day
•Estimated maximal
absorptive capacity of 0.20.3ml/kg/hr into the
lymphatic channels
PATHOPHYSIOLOGY



Transudative effusions accumulate of an increase
in hydrostatic pressure and/or reduction in plasma
oncotic pressure. The pleura usually remains
normal.
Exudative effusions usually result from various
pathologic condition in pleura, resulting in
increased vascular permeability and/or impaired
fluid reabsorption(e.g. lymphatic obstruction).
Extrapleural sources: Transdiaphragmatic
migration of peritoneal fluid; Abnormal
communication between pleural cavity and the
thoracic duct (chylothorax); esophagus; Hepatic
hydrothorax; pancreas; and renal
tract(urinothorax).
LEADING CAUSES OF PLEURAL
EFFUSIONS
Causes
Annual
Incidence
Transudate
Exudate
Congestive heart
failure
500,000
Yes
No
Pneumonia
300,000
No
Yes
Cancer
200,000
No
Yes
Pulmonary embolus
150,000
Sometimes
Sometimes
Viral disease
100,000
No
Yes
Coronary artery bypass
surgery
60,000
No
Yes
Cirrhosis with ascites
50,000
Yes
No
Light RW. Pleural diseases. 4th ed. Lippincott Williams &Wilkins, 2001
DIAGNOSTIC APPROACH
 Detailed
history and physical
examination.
 Radiologic imaging: CXR; Ultrasound
Chest CT.
 Pleural fluid/tissue analysis.
INDICATIONS FOR DIAGNOSTIC
THORACENTHESIS

Presence of a clinically significant pleural
effusion of unknown cause.
> 10mm thick on US or Lateral decub. CXR
Unilateral Pleural effusion.
 Effusion persists for > 3 days

INVESTIGATIVE PARAMETERS OF
PLEURAL EFFUSIONS
Obligatory
• Appearance /smell
• Total Protein/LDH
• Cell count with
differential
For Specific Purposes
Assay
Suspected
Pathology
Glucose/pH
Pleural Infxn
Microbiology
Pleural Infxn
TB
Cytology
Malignancy
Amylase
Pancreatitis
HCT
Hemothorax
Chol/TG
Chylothorax
Adenosine deaminase(ADA)
TB
Creatinine
Urinothorax
• GS/CX
• AFB
• Fungi/parasites
PLEURAL FLUID APPEARANCE
Resp Med. 2009
EXUDATE VS.TRANSUDATE
LIGHT’S CRITERIA
Light RW. Pleural effiusion, NEJM ,6/2002
PLEURAL FLUID
EXUDATE
TRANSUDATE
LYMPHOCYTE PREDOMINANT
EXUDATIVE PLEURAL EFFUSIONS
CAUSES OF PLEURAL FLUID EOSINOPHILIA
INCIDENCE AND RANGE OF LOW PH IN DISEASES
WITH PLEURAL FLUID ACIDOSIS (PH<7.30)
INCIDENCE AND RANGE OF PLEURAL FLUID
GLUCOSE IN DISEASES WITH LOW GLUCOSE
CONCENTRATION
CASE
PLEURAL FLUID ANALYSIS
67 yo man with dyspnea and Rt. Pleural effusion
Pleural Fluid
Serum
Nucleated Cell Count
1700; >90%Lymphocytes
Total protein: 4.0 g/dl
Total protein: 6.3 g/dl
LDH: 242 U/L
LDH: 143 U/L
Cytology : negative
Simple
Thoracenth
esis(%)
Blind
Abrams
Biopsy(%)
Thora +
Abrams
(%)
CTguided
Pleural
BX(%)
Medical
Thoracos
copy(%)
55-87
(usually 60)
57
70-90
87
>95-97
Mesothelioma
32
50
40-50
87
>90-96
Tuberculosis
Smear 20
CX 25-50
75-80
(+CX)
90
NA
>99-100
Disease
Carcinoma
Thoracoscopy for physicians, Buchanan D.R. 2004
Adenocarcinoma
METASTATIC CARCINOMA
Pleural metastasis are common in patients with
malignant tumors.
 Malignant pleural effusion Poor PX.
 Median survival following DX 3-12 months.
 Lung and breast Cancers account for 2/3 of
malignant effusions.

Stomach;colon;ovary;kidney;lymphoma;melanoma
Malignant nodules
Breast cancer metastasis
MESOTHELIOMA
Rare neoplasm that commonly arises from the
mesothelial surfaces of the pleural cavity.
 Extremely poor prognosis
 The median survival: 4-13 months for untreated
patients, 6-18 months for treated patients.
 There are limited data from randomized trials.
 Treatment recommendations are somewhat
empiric.

CLINICAL PRESENTATION
BOUTIN ET AT CANCER 1993;72 389-93
Pleural effusion: 92%
 Pleural tumors: 6%
 Spontaneous pneumothorax: 0.5%
 Empyema: 1%

SYMPTOMS
Non specific and insidious.
 Average time for diagnosis 2-3 months
(25% more than 6 months).
 Weight loss (30%); Cough (10%).
 Dyspnea (40-70%).
 Non pleuritic chest pain (60%).

IMAGING
CXR:
Unilateral pleural effusion +/- pleural thickening
Large visible mass (occasionally).
 CT SCAN:
For malignancy: Sensitivity 93%/Specificity
87%
Most suggestive: Mediastinal involvement;
Circumferential thickening; Nodularity of
pleural contour; Infiltration of the chest wall,
and/or diaphragm.

THERAPEUTIC APPROACH
1 Year
%
3 Year
%
5 Year
%
(months)
Thoracotomy
41
0
-
7
Pleurectomy
38
24
-
8.8
EPP
39
16
11
10.2
Medical
24
0
-
5.8
EPP: Extrapleural penumonectomy
Probst G et al 1990
Median
SCLEROSING AGENT
MALIGNANT PLEURAL EFFUSIONS
WALKER-RENARD PB ANN INTERNAL MED 1994;120(1):5664
Sclerosing agent
Success rate
n/n(%)
Bleomycin
108/199(54%)
Tetracycline
240/359(67%)
Doxycycline
43/60(72%)
Minocycline
6/7(86%)
TALC:SCLEROSING AGENT
Talc Slurry: Talc in Suspension
 Talc Poudrage: Insufflated Talc
 Dose:
Malignant pleural effusion: 4 g
Pneumothorax: 2 g
 Boutin, 1991 experience of 300 cases success
of > 90%.
 Mean duration of CT drainage 4.7 days.

TALC
Hydrated Magnesium Silicate sheet Mg3Si4O10(OH).
 Was 1st used in 1935
 Pharmaceutical Talc is inert, asbestose free and
sterilized by exposure to dry heat ethylene oxide and
gamma radiation.
 Less than 5% of particles should be under 5
microns.

COMPLICATIONS
Minor pleuritic pain and fever (Common).
 Pneumonia (Rare).
 Respiratory failure (Rare).
 Talc pneumonitis/ARDS ( Rare: 0.71%).

Sahn S. Am J Respir Crit Care Med. 2000;162(6),2023-4
Secondary empyema (Rare).
 Local tumor implantation at port site in
mesothelioma.

TALC PLEURODESIS
TUBERCULOUS EFFUSIONS

Presents as an exudate with
lymphocyte predominance.

Cultures positive in <20%

Pleural biopsy demonstrates
granuloma is 95% predictive
of TB.

Pleural fluid ADA > 70 IU/L is
diagnostic. <40 IU/L R/O
disease

Most effusions will resolve
spontaneously w/o TX.

w/o TX, most will develop
active TB at another site
within 5 yrs.
PARAPNEUMONIC EFFUSIONS
Pleural effusions occur in up to 57% of patients
with pneumonia.
 They range from sterile “Simple” to
“Complicated” parapneumonic effusion and
frank pus or “empyema”.
 Approximately 10% of simple parapneumonic
effusions may evolve into complicated
effusions or empyema.

PARAPNEUMONIC EFFUSIONS
CT FINDINGS
PARAPNEUMONIC EFFUSIONS
Exudative
Fibropuru
-lent
Organized/
Fibrous
PULMONARY EMBOLISM
50% of pts with PE have a pleural effusion
 Usually small and unilateral
 Can be a transudate or an exudate
 Transudate: Due to vascular obstruction and
increase in hydrostatic pressure
 Exudate: Due to ischemia, release of
vasoactive amines and increase permeability

MEDICATIONS ASSOCIATED WITH PLEURAL
EFFUSIONS
Medication
Comment
Nitrofurantoin
Pleural effusion: 25% of cases
CXR with B/L interstitial
infiltrates
Methylsergide
B/L pleural effusions in 50%
of cases
Dantrolene
Similar to nitrofurantoin
Bromocriptine
B/L pleural effusions and
pleural thickening
Procarbazine
B/L pleural effusions and
infiltrates. Rare
Amiodarone
Pulmonary infiltrate more
common than effusions
CHYLOTHORAX
Mechanism:
1.
2.
3.
4.
Disruption of thoracic duct: Large amounts of
cholesterol or lecithin globulin complexes
accumulate to produce pseudochylothorax.
Traumatic: Secondary to cardiac surgery,
penetrating injuries.
Tumors: Lymphomas, pulmonary
lymphangiomyomatosis, filariasis,
lymphangitis of the thoracic duct.
Idiopathic.
CHYLOTHORAX

Large pleural effusion, no odor, no chest pain

Triglycerides > 110mg/dl; 50-110 mg/dl,
lipoprotein analysis; + chylomicrons diagnostic
< 50 mg/dl R/O chylothorax.

Repeat thoracenthesis leads to malnutrition
and compromised immune system.
CHYLOTHRAX
TREATMENT
Pleuroperitoneal shunt
 Surgical exploration with ligation of the
thoracic duct.
 Radiation therapy.
 Chemical pleurodesis.

Light RW. Pleural effiusion, NEJM ,6/2002