Diseases of pleura
Beatrix Bálint MD.
Pleural cavity
Pleura
1. Apex
2. Lat. mellkasfal
3. Mediastinum
4. diafragma
Diseases of pleura
• Inflammation = pleurisy
• Pneumothorax
• Tumor
Inflammation of pleura
• 1. Pleuritis sicca
– Cause: viral infection
• Bornholm’s disease
• Coxsackie B
– Symptomes:
• Pleuritic chest pain
• Pleural friction rub
– Therapy:
• symptomatical
• 2. Pleural effusion:aetiology:multifactorial
– Symptomes
• Chest pain
• Dyspnoe
– Physical examination
• Percussion note: dull
• Auscultation: diminished/absent breath sounds
– X-ray
• Small fluid: blunting of costo-phrenic angleű
• Larger volume (>300 ml):homogenous shadow
– Therapy
• Thoracocentesis
• To treat the cause of the pelural effusion
Pleurisy
Pleural effusion
Definition: An accumulation of fluid between the layers
of the membrane lining the lung and the chest cavity.
Alternative names: Fluid in the chest; Transudative pleural
effusion; Exudative pleural effusion
Causes: Pleural fluid is normally formed in small amounts
to lubricate the surfaces of the "pleura," the thin
membrane that lines the chest cavity and surrounds the
lungs. A "pleural effusion" is an abnormal collection of
this fluid.
Pleural effusion
Pleural effusion
Pleural effusion
Pulmonary embolism
Pathophysiology of pleural effusion
•  of pulm. capill. wedge pressure: cong. heart
failure
•  onc. pressure in microvas. circulation: low Se
albumin
•  in pressure in the pelural space: lung collapse
due to ptx
•  permeability of microvasc. circ.:due to inflam.
mediators
• Impaired lymphatic drainage from pl. space: due
to tu / fibrosis
• Occlusion of pariet. pleura stomata with fibrin,
debris and mesoth. swellings: due to pneumonia
• Movement of fluid from peritoneal space through
diaphr. lymph. / diaphr. defect
Thoracocentesis
Definition: A procedure to remove fluid from the
space between the lungs and the wall of the chest.
How to prepare for the test: No special preparation
is needed before the procedure. A chest X-ray is
may be performed before and after the test. Do not
cough, breathe deeply, or move during the test to
avoid injury to the lung.
Risks: pneumothorax (collapse of the lung),
fluid re-accumulation, pulmonary edema,
bleeding,infection, and respiratory distress.
Pleural effusion: analysis
• Quantity
• Quality: color, density, opacity
• Lab. analysis
– Chemical
– Cytological
– Bacteriological: culture
• Spec
• Aspec.
Lab. analysis of pleural effussion
Exsudate
Transudate
3%
protein
3%
+
Rivalta
-
0.5 
Protein in pl. eff./ 0.5 
Se protein
0.6 
LDH in pl.eff/Se
LDH
0.6 
1014 
Specific gravity
1014 
inflammation
Cause
 syst./pulm.
venous pressure
Common Causes of Exudative Effusion
Tuberculosis
Lung cc
Pneumonia
Pulm. Infarction
Lymphoma
Metastatic tumor
Mesothelioma
Trauma
Unilateral
Bloody, large,
parenchymal lesion on
the X-ray, rapid. Reprod.
X-ray:infiltr.
Bloody, pleural pain
E.g.:Hodgkin disease,
+mediast. Lg.
Large, rapid. Reprod.
Bloody, Large, rapid.
Reprod.
Bloody
Common Causes of Transudative
Effusion
Congestive heart failure
Bilateral
Cirrhosis
Ascites, Se protein low,
usually on the right side
Nephrotic syndrome
Hypoproteinaemia,
Generalized oedema,
ascites
• 3.Empyema = pus in the pleural space
– Cause:bacteria: Staphylococcus aureus,
Klebsiella pn, E. Coli, Mycobact. Tb, anaerobic
bact.
– Appear: as the complication of bacterial
pneumonia, subdiaphragmatic abscess,
oesophageal perforation, following thoracic
surgery
– Symptomes:
• Chest pain
• Dyspnoe
• Fever
• Night sweats
• Weight loss
Empyema 2.
– Physical examination: Signs of pleural
fluid
• Percussion note: dull
• Auscultation: diminished/absent breath
sounds
– X-ray: Signs of pleural fluid
– Therapy
• Drainage of pleural space
• Antibiotics
• In the case of uneffective th: thoracotomy,
pleural peel
II. Pneumothorax= air in the pleural space
complete or partial
• Symptomes:
collapse of the lung
• Chest pain
• Dyspnoe
• Physical sign
– Percussion note:Hyperresonance
– Breath sounds: diminished/absent
• X-ray: visible pleural edge with no lung markings
between this edge and the chest wall
• Therapy: depends on the size of the ptx
small: O2 th, close observation, suction of the air by
needle
large:consant tube drainage
pleurodesis
surgery
Potential causes of pneumothorax
• Air: from the
airways
– Idiopathic
– Rupture of
oesophagus
– COPD
– Pos.pressure
ventillation
– Infection, tumor,
foreign body
• Air: outside the
chest wall
– Trauma
– Thoracocentesis,
pleural biopsy, TTB
– Insertion of venous
catheter
Pneumothorax
Pneumothorax
Pneumothorax
Tension PTX
A tension PTX is a life-threatening condition that requires immediate
intervention.
Causes: penetrating chest injuries, fractures of the trachea or bronchi, a
ruptured esophagus, the presence of an occlusive dressing over an
open PTX, and PPV.
Progressive build-up of pressure in the pleural space pushes the
mediastinum to the opposite hemithorax, and obstructs venous return
to the heart. This leads to circulatory instability and may result in
traumatic arrest.
Symptomes: patient is tachycardic and tachypnoeic, and may be
hypoxic. These signs are followed by circulatory collapse with
hypotension and subsequent traumatic arrest with pulseless electrical
activity (PEA). Breath sounds and percussion note may be very
difficult to appreciate and misleading in the trauma room.
Mrtg: Deviation of the trachea away from the side of the tension.
• Shift of the mediastinum.
• Depression of the hemi-diaphragm.
Th:emergent chest decompression with needle thoracostomy. A 14-16G intravenous
cannula is inserted into the second rib space in the mid-clavicular line. The needle
is advanced until air can be aspirated into a syringe connected to the needle.
Constant tube drainage
Tension PTX
III. Pleural tumors
• 1. Primery tumor = mesothelioma
– Localised form: solitary growth on pleural
surface
• Th: surgical resection
– Diffuse mesorhelioma:highly malignant tu.
• Symptomes: chest pain, cough, dyspnoe
• X-ray: rapidly reproducated peural effusion
• Dg: cytological examination of the effusion
• Th: symptomatical
• 2. Metastatic tumor: malignant pleural effusion
caused by primery tumor of the body: breast cc., lung cc.
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