Chapter 25
Pleural Diseases
Michael Haines, MPH, RRT-NPS, AE-C
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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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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Objectives (cont.)

Identify the definitions of spontaneous,
secondary, and tension pneumothorax.

Describe the diagnosis and treatment of
pneumothorax.
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The Pleural Space
Overview and definitions
 Visceral pleura cover each lung, while the
parietal pleura covers the outer structures
that bound the lungs.
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The Pleural Space (cont.)
Overview and definitions (cont.)

Pleural fluid about 10 to 20 mm thick separates the
visceral from parietal pleura.
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


There is ~8 ml of fluid per hemithorax.
Pleural fluid is very similar to interstitial fluid.
This fluid minimizes the friction caused by the lungs to
expanding in the thorax during inspiration.
Pleural pressure is typically negative due to outward
thoracic recoil and inward recoil of lung.
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Pleural Effusions

Any abnormal accumulation of fluid in the
pleura is considered a pleural effusion.

Fluid enters the pleural space from visceral
and parietal pleurae, particularly in face of
increased pressure.



Stomata that connect to lymphatic system remove
fluid from this space.
Either increased fluid production or blockage of
drainage can result in pleural effusions.
http://video.about.com/lungcancer/Pleural-Effusion.htm
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Pleural Effusions (cont.)
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Pleural Effusions (cont.)
Transudative effusions

Any effusion that forms while pleural space is
undamaged will have [protein] <50% of serum level
and 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 and fluid third spacing
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Pleural Effusions (cont.)
Specific causes of transudative effusions (cont.)
 Hypoalbuminemia: different cause but mimics above

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
and results in accumulation
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Pleural Effusions (cont.)
Exudative effusions
 Occur due to inflammation of lung or pleura and will
have a higher protein and inflammatory cell content
Thoracentesis may be performed to determine type.
Specific causes of exudative effusions
 Parapneumonic: secondary to lung inflammation
associated with pneumonia



Complicated if clots form and loculate fluid
Persistent fever may signal an empyema, which must be
drained for recovery
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Pleural Effusions (cont.)
Specific causes of exudative effusions (cont.)
 Viral pleurisy: presents with inflammation and pain


Tuberculous pleurisy: occurs when caseous
granulomas rupture viscera pleura and drain into
pleural space


Pain may result in atelectasis and hypoxemia.
Patients need to be isolated.
Malignancy: most common cause of large unilateral
effusions, most require pleurodesis to treat
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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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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, which
may worsen following thoracentesis.
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Pleural effusions may not produce any symptoms in some patients.
Others may experience shortness of breath, a dry, non-productive
cough, or pleuritic-type chest pain (a sharp pain, usually on
breathing in, which worsens with coughing).
Other patients may complain of symptoms stemming from the cause
of their effusion, for example swollen legs or feet in congestive
heart failure..
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Diagnostic Tests for
Pleural Effusions
Chest radiography
 Most common method of detecting effusions

Upright PA and lateral decubitus are useful.

1-cm meniscus lung to rib allows for thoracentesis
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Diagnostic Tests for Pleural
Effusions (cont.)
Ultrasonography and computed tomography
 Ultrasound is very sensitive to pleural
effusions.


May use to localize and direct for thoracentesis
Contrast-enhanced CT is most sensitive
study for effusions.
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Diagnostic Tests for Pleural
Effusions (cont.)
Thoracentesis
 Percutaneous needle aspiration of effusion sample

Drainage for lung reexpansion involves placement of
a chest tube

Risks include
 Artery laceration
 Infection
 Pneumothorax
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Diagnostic Tests for Pleural
Effusions (cont.)
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Diagnostic Tests for Pleural
Effusions (cont.)
Thoracoscopy (video-assisted)
 Ideally designed for diagnostic and
therapeutic pleural procedures
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
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Allows visualization of surfaces, drainage of
effusion, biopsy, and pleurodesis if needed
http://www.youtube.com/watch?v=-qAnqeg0zHg
http://www.youtube.com/watch?v=wV6pyYCjo1M&feature=related
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Management for Pleural
Effusions
Chest thoracotomy tubes
 Designed for tight fit in tissues to avoid leaks
and allow drainage of effusion and subsequent
lung reexpansion

Tube is attached to chest drainage unit.
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Management for Pleural
Effusions (cont.)
Pleurodesis
 Process fusing parietal and visceral pleurae,
which prevents further formation of effusions

Can be performed by surgical abrasion or
introduction of chemical irritant, most commonly
talc
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Management for Pleural
Effusions (cont.)
Pleuroperitoneal shunt and Pleurex catheter
 For effusions refractory to all other treatment
options
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Small pump moves fluid from pleura to
peritoneal cavity.
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Pleurex catheter connects to suction at home
to drain persistent effusions.
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Pneumothorax

Defined as air in the pleural space which can occur
through a number of mechanisms
Traumatic pneumothorax
 Penetrating chest trauma
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

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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Pneumothorax (cont.)

Blunt trauma (cont.)
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Tracheal fracture and esophageal rupture
• These are two special causes of pneumothorax that
require surgical repair.
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Iatrogenic
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Most common cause of traumatic pneumothorax
Common iatrogenic causes are
• Needle aspiration lung biopsy
• Thoracentesis
• Central venous catheter placement
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Pneumothorax (cont.)
Neonatal
 Spontaneous pneumothorax occurs in 1–2% of
infants

Likely caused by high transpulmonary pressures and
transient bronchial blockage (i.e. meconium)

Recognition is difficult
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
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Contralateral heart sounds may be a clue.
Transillumination of thorax may be useful.
Most neonates with this condition require chest
tubes.
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Pneumothorax (cont.)
Spontaneous
 Pneumothorax with no obvious cause
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Primary spontaneous pneumothorax
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Occurs with no underlying lung disease
Most (80%) have small subpleural blebs
Typically happens in tall, thin, young adults
>90% have had short-term smoking history
• Smoking cessation recommended
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Pneumothorax (cont.)

Secondary spontaneous pneumothorax
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Occurs with underlying lung disease
• Most common associated disease is COPD
• Also seen during exacerbations of asthma and CF
• Interstitial lung diseases with normal lung volumes



Sarcoidosis, BOOP
Depending on extent of disease, pneumothorax
can be devastating
• 43% 5-year mortality
Evacuation, not observation, should be the
standard of care with these patients.
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Pneumothorax (cont.)
Complications

Tension pneumothorax
 Pleural air pressure exceeds atmospheric
pressure
 Radiographic appearance
• Mediastinal shift, diaphragmatic depression, flattened
ribs

Clinical presentation
• Venous return and cardiac output decrease with
hypotension and tachycardia
• Hypoxemia due to alveolar collapse

Treatment: emergency needle decompression
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Pneumothorax (cont.)
Complications
 Reexpansion pulmonary edema

Occurs following rapid lung reexpansion
particularly:
• From low lung volumes
• Long duration pneumothorax
• High pressure gradient across lung
 May be related to reperfusion injury
 Lung reexpansion should be slow
• First, just waterseal, no suction
• If lung fails to reexpand, then apply suction
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Pneumothorax (cont.)
Diagnosis
 Chest radiography
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

Requires good quality film
In ICU, 30% of pneumothoraces are missed due
to:
• Low-quality film
• Supine position of patient on AP film
• Air hidden behind thoracic or mediastinal structures
CT may be used to confirm size and
presence of pneumothorax.
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Pneumothorax (cont.)
Therapy
 Oxygen
 Should be administered to all patients
 Supplemental O2 speeds absorption of air from
pleural space

Observation of stable patients
 Primary: observe 4 hours, if no enlargement:
home
 Secondary and iatrogenic: hospitalize and observe
carefully,
• If there is any deterioration (SpO2, RR, etc) - drain
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Pneumothorax (cont.)
Therapy
 Simple aspiration
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Small catheter placed in pleural space
Connect to three-way stopcock
Slowly evacuate until no more air can be removed
This works as many leaks heal between time of
leak and its drainage.
If 4 L air is removed without resistance, chest
tube placement is required
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Pneumothorax (cont.)
Therapy
 Chest tubes buy time
 Resolution is mostly determined by lung healing
 Small bore: placed via small incision in second
intercostal space (ICS), midclavicular line or
laterally, fifth–seventh ICS
• Connected to underwater seal or Heimlich valve
 Large bore: placed via blunt dissection, usually
connected to “three-bottle” chest drainage system
 Chest tubes are sutured in place

Pleurodesis: consider with recurrent pneumothoraces
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Pneumothorax (cont.)
Bronchopleural fistula
 Usually used to refer to large, persistent air leaks

Most are on MV

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May require more than one chest tube
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PPV perpetuates the leak
Aids restoring lung proximity to chest wall and promotes
healing
Avoid auto-PEEP, consider bronchoscopic closure or
thoracoscopic surgery
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