Pleural diseases Flashcards
DRY PLEURISY
Definition: Inflammation of the pleura
Causes:
Pulmonary causes:
- Pneumonias especially viruses:
- neoplasms - T.B.
- Infarctions - Trauma.
Uremia Vascular Collagen
Clinically: - Fever - Pleuritic pain - Dry cough and dyspnea
- Pleural rub on chest examination.
- CXR: normal or costophrenic angle affection.
Differential diagnosis:
Other painful chest cases e.g pneumothorax, embolism, infarction.
Treatment
The cause e.g. antibiotics in infections
Analgesics.
Pleural effusion definition, pathogenesis, aetiologies and c/p?
Definition:
Accumulation of fluid in the pleural space. Effusion is a sign of a disease and not a disease.
Pathogenesis:
A- Transudate: the pleura is healthy:
-Increased capillary hydrostatic pressure e.g. heart failure.
-Decreased serum osmotic (oncotic) pressure e.g. cirrhosis and nephrosis.
B- Exudate: The pleura is diseased:
-Increased permeability to proteins e.g. inflammation and tumours.
-Decreased lymphatic flow. e.g metastases.
- More negative pleural pressure e.g complete bronchial obstruction.
Aetiologies: (according to gross appearance)
1 Serous:
Transudate: heart failure, cirrhosis, nephrotic syndrome, myxoedema.
Exudate:
- Neoplasms - Infectious diseases e.g T.B.
- Pulmonary embolism
- GIT diseases.
- Collagen - vascular diseases.
- Drug induced e.g: Nitrofurantoin.
-Miscellaneous e.g. Meigs and yellow nail syndromes
2- Hemothorax: e.g. Trauma, malignancy, anticoagulants.
3- Chylothorax: e.g trauma, tumours.
- Breath sounds are usually diminished or absent on the affected side, and aegophony is often detected on the upper limit of the effusion.
Clinical presentation:
Symptoms:
- pleuritic pain and then heaviness dry cough.
- Dyspnea - Symptoms of original aetiology.
- May be symptomless.
Signs:
General signs related to the possible aetiology.
Local chest signs: bulge and diminished movement, decreased TVF, tracheal shift, flat stony dullness, diminished breath sounds and aegophony.
Sometimes, pleural effusion is loculated and gives no typical chest signs.
Investigations of pleural effusion + DD,complications and ttt.
1- Chest radiography:
Plain chest X-ray films: posteroanterior; homogenous opacity rising to axilla with obliteration of costophrenic angle and mediastinal shift.
Lateral view: localization of fluid.
Ultrasonography of chest : diagnosis even minimal effusions.
C.T chest : is of great help especially in encysted pneumothorax.
2- Aspiration of pleural fluid (thoracentesis): Sample is subjected to:-
A- Gross appearance examination:
Colour e.g.
straw colour : exudate (clot) or transudate (no clotting on standing)
Milky : chylothorax.
Chocolate : liver amoebiasis with hepatopleural fistula.
Reddish : hemorrhagic effusion (trauma or malignancy).
Odour: offensive odour in empyema
Aspect: turbid e.g high lipid (chyle) or cell content (empyema).
B- Cytological examination:
RBCs:
- 5000-100,000/mm3: blood tinged pleural fluid
- Hematocrit value > 50% of blood : Hemothorax (pancreatitis, T.B)
White blood cells:
- <1000/mm3(most transudates)
- >1000/mm3 (most exudates)
- >25000/mm3 (Empyema)
Differential:
o Neutrophils : increased in pneumonia and pancreatitis.
o Eosinophils: increased in:
- Following repeated aspiration.
- Traumatic hemothorax.
- Pulmonary embolism.
- Parasitic disease.
o Lymphocytes: TB, malignancy, lymphoma and chylothorax.
o Mesothelial cells
- < 5% : TB
- >5% : Other aetiologies
o L.E. cells : systemic lupus erythematosus.
o Plasma cells : multiple myeloma.
o Malignant cells.
C- Cytochemical examination:
prostatic metastases: Acid phosphatase
bone metastases: Alkaline phosphatase
D- Biochemical examination:
o Protein: < 3 g/dl : transudate (< 50% of plasma)
> 3 g/dl : Exudate (> 50% of plasma)
o Glucose: < 60 mg/dl þ TB, malignancy, rheumatoid disease and parapneumonic effusion .
o Lipids:
-Triglycerides > 110 mg/dl : chylous (high chylomicrons).
-Increased lecithin - globulin in chyliform effusion.
-increased cholesterol in pseudochylous effusion.
o Enzymes: e.g.:
- Amylase increase in pancreatitis, malignancy and ruptured oesophagus.
- Lactic dehydrogenase (LDH). pleural fluid LDH > 50 % of serum LDH : exudate.
- Adenosine deaminase: > 30 IU/L : TB effusion.
o Keratin and melanin:
Keratin : epidermoid carcinoma
Melanin : malignant melanoma.
o PH : < 7.2 TB, malignancy, rheumatoid, hemothorax, para-pneumonic, oesophageal rupture, acidosis.
E- Immunological studies:
complement decrease in (SLE and RA) e.g. ANA -> SLE
F- Bacteriological examination:
- Culture and sensitivity (under aerobic and anaerobic conditions)
- Acid fast bacilli.
G- Ancillary tests:
e.g. Tumour markers chromosomal studies.
3- Invasive surgical procedures
a- Pleural biopsy
- Using Abrams or Copes needles.
- > 80% of TB effusion : positive
- 40 - 60% of malignant effusions : positive
b- Pleuroscopy (thoracoscopy)
- Valuable in undiagnosed effusions.
- Better than pleural biopsy by needles.
c- Bronchoscopy:
Useful in pleural effusions with parenchymal affection.
d- Lung scans and pulmonary arteriogram in suspected pulmonary embolism.
e- Open pleural biopsy: may be needed.
4- Mantoux test In suspected tuberculosis etiology.
Differential diagnosis of pleural effusion:
1- Other pathologic entities causing dullness with mediastinal shift e.g. mass,
collapse.
2- pneumonia
Complications:
1- Mediastinal compression and cardiac embarrassment in massive effusions.
2- Infection of effusion : empyema
3- Pleural fibrosis
4- Pleural calcification
5- Iatrogenic complications.
Basic lines of treatment of pleural effusions:
1- Treat the cause and manage any immediate complications
2-Therapeutic aspiration of pleural fluid:
- As early and complete as possible especially if:
Cardiorespiratory embarrassment issues.
No response after adequate treatment.
Secondary infection sets in.
3- Adequate follow up of case clinically and radiologically and early interference with late complications e.g. pleural fibrosis.
Malignant effusion pathogenesis, characteristics and treatment ?
Pathogenesis:
1- Direct effect of tumour: e.g.
Metastases : increased permeability.
Metastases ; obstruction of lymphatics.
Mediastinal lymph nodes involvement: decreased lymphatic drainage.
Thoracic duct interruption : chylothorax.
Bronchial obstruction : more negative pleural pressure.
2- Systemic effect of tumour e.g. Hypoproteinemia. Pulmonary embolism.
3- Therapy: e.g. Radiation therapy Drug therapy
Common with lung carcinoma (34%) and breast carcinoma (25%)
Characteristics:
- Massive
- Rapidly accumulating after aspiration.
- Hemorrhagic
- Mediastinal shift to the same side (usually).
Pleural fluid examination:
- Usually exudate by LDH level.
- Lymphocytes predominates.
- Glucose: < 60 mg/dl.
- PH < 7.2
- Cytology positive in 40-80% of cases.
Pleural biopsy : positive in 60%.
CT and bronchoscopy are helpful in diagnosis.
Treatment:
1- Systemic chemotherapy: in effusions due to SCLC, lymphomas & breast carcinomas.
- Methotrexate is the drug of choice.
2- Mediastinal radiation: In chylothorax with thoracic duct affection.
3- Chemical pleurodesis: Tetracycline is the drug of choice.
4- Pleurectomy: In trapped lung.
5- Repeated thoracentesis.
tuberculosis pleural effusion pathogenesis , diagnostic features and ttt?
-Pathogenesis
1- Rupture of subpleural caseous primary focus.
2- Delayed hypersensitivity reaction.
3- Hematogenous dissemination of mycobacteria.
4- Direct extension of post primary lesion.
Diagnostic features:
Compatible age and suggestive history.
Positive mantoux test.
Pleural fluid:
- Exudate
- Glucose < 60 mg/dl.
- > 50% of WBCs are lymphocytes
- Mesothelial cells < 5%
- Adenosine deaminase > 30 IU/L
- AFB culture : positive in < 20 %.
Pleural biopsy : positive in 50 %
Treatment:
Antituberculous drugs .
Corticosteroids.
Repeated therapeutic thoracentesis.
Decortication in pleural thickening.
Empyma definition, etiology, complications, C/P, DD and ttt.
Definition:
A purulent pleural effusion. It may be acute or chronic, encysted or in the general pleural cavity.
:Aetiology
1-Infections :
-A Common organisms :
- Pneumococcus.
- Beta hemolytic streptococci
-Staph pyogenes
- Anaerobic streptococci.
B- Routes of infection:
1- Infection from surrounding structures.
a- Lungs : pneumonias, lung abscess, bronchiectasis.
b- Mediastinitis.
c- Chest wall abscess.
d- Subphrenic abscesses.
e- Thoracic spine and neck infections.
2- Instrumentations and traumas:
a- Foreign body.
b- Oesophagoscopy : rupture oesophagus.
c- Intrathoracic operations.
d- Traumas e.g. penetrating ones.
e- Thoracentesis of other effusions.
3- Pyemia or septicemia.
Complications:
-Empyema may involve the whole pleural space as in streptococcal infection producing fibrinolysin or encysted due to adhesions as in pneumococcal infection.
-Healing : fibrosis and later calcification.
-Pyopneumothorax after development of bronchopleural fistula.
-Pus may protrude under the skin as empyema necessitans and multiple sinuses may occur.
-Chronic empyema : amyloidosis and repeated aspiration of protein rich effusion: hypoproteinemia.
Clinical features:
A- Acute empyema:
Pleural effusion.
Toxemic features: fever, rigors
Aspiration of pus. Leucocytosis (commonly) : 15000 - 20000 mm3
CXR : dense opacity suggesting effusion or its complications.
B- Chronic empyema:
-Chronic from start. e.g. T.B. or actinomycosis.
-Acute to chronic.: Bronchopleural fistula ,Failure of management, Foreign body
Clinically:Cachectic, toxic, poor appetite.
- Sinus may be present
- Clubbing (toxic)
- Features of reduced size of hemithorax
C-Latent and persistent empyemas : sterile empyema. and if a cavity persists with discharges.
Differential diagnosis:
1- Delayed resolution of pneumonia.
2- Other suppurations.
3- Other conditions with systemic upset e.g. septicemia.
Treatment:
Aims :
- Controlling infection
- removal of pus
- Obliteration of empyema space.
Acute empyema (thin pus) :
Repeated aspiration + systemic and local antibiotics.
Persistent empyema with thin pus þ intercostal tube with underwater seal.
Chronic empyema (Thick pus)
Decortication:
- Underlying lung is healthy and no bronchopleural fistula : chemical
decortication by virdase enzyme.
- In fistula : surgical decortication
Open drainage by rib resection.
Pleuropneumonectomy
thoracoplasty if underlying lung is destroyed
CHYLOTHORAX
Presence of chyle in the pleural space.
Aetiology
1- Traumas : penetrating or non-penetrating or iatrogenic.
2- Tumours : lymphomas (75%).
3- Idiopathic
4- Miscellaneous: lymphangiomyomatosis.
Clinically:
latent period of 7-10 days after trauma.
Malnourished and immunocompromised pt.
Pleural fluid:
- Many lymphocytes.
- milky
- triglycerides and lipoprotein analysis : chylomicrons.
- stains red with sudan III.
- Ingestion of lipophilic dye : green fluid.
Treatment:
Tube thoracostomy + adequate nutrition + ligation of thoracic duct + pleurodesis.
Mediastinal radiation in lymphomas.
Chyliform and Pseudochylous effusions
Chyliform:
- Long standing pleural effusion e.g neglected empyema > 5 years
- Increased lecithin globulin
- Fatty and milky fluid.
Pseudochylous:
-increased cholesterol crystals
- Milky but not fatty
- Neglected effusion
Treatment:
- Drainage.
- Decortication may be tried.
- T.B. should be considered.
Hemothorax
Definition
Presence of significant amounts of blood in the pleural space.
Aetiology:
-Traumas: Penetrating or non-penetrating.
- Anticoagulants.
-Iatrogenic.
-Pulmonary embolism and infarction.
-Thoracic endometriosis
-Ruptured aortic aneurysm .
- Tearing of pleural adhesions.
Clinical features
Shock and effusion.
Blood aspiration and HCT > 50% of blood HCT.
Treatment
Thoracotomy and secure bleeder. Blood transfusion if needed.
Follow up and decortication if pleural peel develops.
PNEUMOTHORAX
Definition .: Air in the pleural space
Types and Aetiology:
1- Spontaneous: A- Primary : rupture of apical bleb. B- Secondary: e.g. COPD, TB…….
2- Traumatic: A- Iatrogenic : e.g. per-cutaneous lung biopsy.
B- Non-iatrogenic: penetrating and nonpenetrating chest trauma.
3- Artificial:
A- Diagnostic: Prior to thoracoscopy.
B- Therapeutic: in unilateral cavity of TB aetiology with hemoptysis.
According to movement of air across pleural breach:
1- Open: Air moves freely in and out.
2- Closed: No air movement.
3- Tension: Air moves inside in inspiration and not outside during expiration (valvular pneumothorax).
Clinical features:
Symptoms and signs : pain, dyspnea and cough.
Increased movement and bulge TVF and tracheal shift.
Increased Hyperresonance
Increased Breath sounds or bronchial breathing in tension pneumothorax with positive coin test
Investigations:
1- Chest X-ray : signs of free or localized air.
2- Chest needling : pressure measurement:
Open : zero pressure
Closed : Negative pressure
Tension : positive pressure.
Differential diagnosis:
From painful chest cases: e.g. pulmonary infarction, myocardial infarction and pneumonia with pleurisy. .
Complications:
pyo-or hemopneumothorax.
Recurrence
Pneumomediastinum and subcutaneous emphysema
Respiratory failure
Treatment:
Remove air from pleura by:
Aspiration : in simple pneumothorax.
Intercostal tube and underwater seal in tension pneumothorax.
Open : surgical closure.
Treat the possible underlying cause: e.g thoracotomy and tube in traumatic.
Management of any complications e.g recurrence : chemical pleurodesis.
Oxygen.
Antibiotics and analgesics.
Nursing care:
1- Care of intercostal tube and underwater seal.
2- Follow up of clinical status for any signs of deterioration to be reported
