PLEURAL SYNDROMES Flashcards
CLASSIFICATION
- Pleural effusion
- Pleuritic syndrome (“dry”)
- Pleural fibrosis/ Pachypleuritis
- Pneumothorax
Pleura=
a thin membrane that covers the inner surfaces of the
thoracic cavity. It consists of a layer of mesothelial cells
supported by a network of connective and fibroelastic tissue.
1.Parietal pleura
2.Visceral pleura
Anatomy
- Pleural space
- Pleural fluid: 5 -20 ml
Parietal + Visceral Pleura
Parietal pleurae
• cover the inner surface of the thoracic cavity
Visceral pleurae
• cover all surfaces of the lungs
PLEURAL FLUID
Acts as a lubricant to minimize friction between the chest wall and
lung as they move against each other during inspiration and expiration
FUNCTIONS OF PLEURAL FLUID ( total 7 functions)
- spreads into interpleural space
- facilitate movement between the lung and chest wall
- enters from systemic capillaries -> parietal pleurae
- exits via parietal pleural stomas and lymphatic
- depends on the oncotic and hydrostatic pressures within the parietal and visceral pleura as well as the pressure within the pleural space itself
- Hydrostatic pressure in the parietal pleura is similar to systemic circulation (30 cm H2O), whereas that of the
- visceral pleura is similar to the pulmonary circulation (10 cm H2O)
- composition ≈ plasma, but lower in protein (< 1.5 g/dL)
Characteristics of
Normal pleural fluid ( total 6 characteristics)
- clear plasma ultra filtrate
- pH 7.60-7.64
- protein content less than 2% (1-2 g/dL)
- fewer than 1000 WBCs /cmm
- glucose content similar to that of plasma
- LDH level less than 50% of plasma
- Na, K, Ca concentration similar to interstitial fluid
Analysis
- Macroscopic Appearance
- Biochemistry
- Cytology
- Cellularity
- Cultures
Symptoms + signs
Symptoms:
- Pleuritic chest pain
- Dry cough
- Dyspnea
Signs:
- Pleural friction rub
- Particular signs - Pleural effusion syndrome
- Pleural fibrosis syndrome
PLEURITIC CHEST PAIN
Character : a vague discomfort OR sharp pain
Worsens by deep inhalation, chest expansion
Location: depending on affected pleura
• indicates inflammation of the parietal pleura
• usually felt over the inflamed site E.g. or on radiation area
Diaphragmatic pleura → shoulder
Central pleura radiates → back, neck, shoulder
intra-abdominal referred from irritation of 6th intercostal nerve
Special situations:PLEURITIC CHEST PAIN
Missing in interlobar effusion, some chronic effusion
• Continuous, not influenced by respiration in:
• Pleural tumor
• Empyema
• Massive Pleural effusion
PLEURITIC CHEST PAIN : DIFFERENTIAL DIAGNOSIS
Rib fracture = Fixed location+ bone crepitation
• Costochondritis
• Herpes zoster = pain on nerves + vesicles
• Tracheobronchitis - burning over trachea + sputum
• Angina pectoris
• Pericarditis
PLEURITIC COUGH
- “dry”, without sputum production
- Irritative
- Associated usually with pleuritic chest pain
- DETERMINED by: Pleural irritation
DYSPNEA in pleural syndromes
Progressive
• Generated by pain
• Associated tachypnea ±
• Indicates a large effusion (usually > 500 ml)
• In pleural effusions: depends on pleural elasticity, time to accumulation (duration), quantity of the fluid and preexistent underlying pulmonary disease
DYSPNEA in pleural syndromes , Mechanism
Rapid installation of large effusion
• Compression of the lung when large eff.
• Displacement of mediastinum, if exceeds 2000 ml
• Interferences with diaphragmatic musculature activity
• ↓ Vital capacity (VC)
• + Hypoxemia that do not respond to oxygen administration
Pleural friction rub (Auscultation)
Corresponding to the pain location
• Maximum intensity on posterior axillary line
• Present throughout respiratory cycle
• Loudest at end inspiration and early expiration
• Great variability, Seldom present
• Best heard over the area of pleural inflammation
• Described as a
• Rubbing or grating (eg. leather rubbing on leather)
• Harsh
• Dry
• Scratchy sound
• Disappears with breath holding
Pleural effusion
an abnormal accumulation of fluid in the pleural space
Excess fluid results from the disruption of the equilibrium that exists across pleural membranes.
Intrapleural fluid
approximately 0.3 mL/kg of hypooncotic fluid (approximately 1 g/dL protein)
turnover 0.15 mL/kg/hour
When filtration exceeds maximum pleural lymphatic flow
pleural effusion occurs
estimated maximum pleural lymph flow in man could attain 30 mL/h,
equivalent to approximately 700 mL/day
MECHANISMS OF PLEURAL EFFUSION
- Altered permeability of the pleural membranes
- Reduction in intravascular oncotic pressure
- ↑ capillary permeability or vascular disruption
- ↑ capillary hydrostatic pressure in the systemic and/or pulmonary circulation
- ↓ pressure in pleural space; lung unable to expand
- Inability of the lung to expand (e.g., extensive atelectasis, mesothelioma)
- ↓ lymphatic drainage or complete blockage, including thoracic
duct obstruction or rupture - ↑ fluid in peritoneal cavity, with migration across the diaphragm
via the lymphatics - Movement of fluid from pulmonary edema across the visceral pleura
- Persistent increase in pleural fluid oncotic pressure from an existing
pleural effusion, causing accumulation of further fluid - Iatrogenic causes
TRANSUDATIVE AND EXUDATIVE PLEURAL EFFUSIONS
are distinguished
by measuring the LDH & Protein levels in the pleural fluid
Pleural effusions : clinical spect
- Manifestations related to the underlying disease process
- Dyspnea
• Most common clinical symptom at presentation
• Can be determined by other underlying lung disease - Chest pain
• Intensity: mild → severe
• Character: sharp or stabbing (typically)
• Localized to the chest wall or referred to the ipsilateral
shoulder or upper abdomen because of diaphragmatic involvement
• Exacerbated by deep inspiration
• Diminishes in intensity as the effusion increases in size
→ Offers etiological clue
PLEURAL EFFUSION LARGER THAN 300 ML
- INSPECTION: Asymmetric expansion of thoracic cage, with lagging
expansion on the affected side (i.e., Hoover sign) - PALPATION:↓ tactile fremitus
- PERCUTION: Dullness or ↓ resonance to percussion
- AUSCULTATION: Diminished or inaudible breath sounds
- AUSCULTATION: Pleural friction rub
- If compression of adiacent parenchyma (its condensation) at the upper
edge of the fluid may occur:
Egophony
Bronchophony
Aphonic pectoriloquy
Pleuretic murmur (expiration)
Mediastinal shift >1000ml
For small pleural effusion (< 500 ml)
DULL AREA • Posterior only (usual) • Basal • 3- 4 cm high • dullness upper limit = Horizontal line • Not mobile with respiration Diferential diagnosis with: • Ascended diaphragm ( perform Hirtz maneuver) • Atelectasis (dullness with increased tactile fremitus)
Medium pleural effusion (800- 1200 ml)
DULL AREA • Posterior Upper limit : the tip of scapula, “Damoiseau line” = parabolic line of which the highest point is on the middle axillary line
• Anterior:
Dullness up to the 5th rib
With every 500 ml accumulation
→ dullness ↑ with 1 intercostal sp. When dullness is up to the 1st rib = 3000 ml fluid Traube area disappears when fluid reaches 800 ml Mediastinal shift (usually >1000 mL)
IN LARGE PLEURAL EFFUSION (2000 ML)
Inspection: thoracic asymmetry, bulging of the affected chest, deviation of the sternum on the same side as the pleural fluidl (Pitres sign)
• Palpation: Tactile fremitus- absent
• Percution: Dull area greater then previous, compensatory hipersonority abo matite dull area,
• Auscultation: Vesicular sound Absent
• Infraclavicular tympanism; skodism= timpanic sound
• Mediastinal shift
• with massive effusions only (usually >1000 mL)
• displacement of trachea and mediastinum to the contralateral side of the pleural effusion (on Chest Xray)
(In contrast with complete atelectasis of the ipsilateral lung, when the trachea deviates toward the affected side and is most commonly seen with complete
obstruction of ipsilateral mainstem bronchus caused by bronchogenic carcinoma.)
Pleural effusion diagnosis
1.Clinical suspicion- anamnesis
2.Physical examination
3.Chest x-ray
4.Ultrasonography
can be used to detect as little as 5-50 mL of pleural fluid,
with 100% sensitivity for effusions of 100 mL or more.
1.Chest CT scanning
2.Thoracentesis
3.Evaluation of pleural fluid to determine cause
Parietal collection
- Diminished respiratory movement
* Diminished tactile fremitus
Interlobar collection
- Suspended dullness in medium part of axila
* Without pain
Diaphragmatic collection
• Pain by phrenic nerve irritation
Empyema
purulent pleural effusions
present on X-ray of 20-60% of patients with bacterial pneumonia
Empyema Stages
- Exudative stage: free flowing pleural fluid, very amenable to treatment with closed tube drainage
- Fibrinopurulent stage: formation of fibrin strands through the pleural fluid resulting in loculations, makes adequate drainage with single chest tube unlikely
- Organizational stage: fibrosis is much more extensive forming a pleural peel that restricts expansion even if fluid can be evacuated
Empyema
Diagnosis
Clinical (anamnesis + Physical ex) Decubitus Xray fluid is loculated Pleural fluid gross pus with positive cultures or gram stain pH<7.1 glucose<40 mg/dl LDH>1000 iu/L
Empyema
Treatment:
- drainage of pus by chest tube
- eradication of the infection
- surgical intervention with removal of the fibrous peel
Pleural involvement without effusions
Dry pleuritic syndrome
Pleuritic chest pain
• Cough: not productive, irritative
• Pleural friction rub
• RX: + / - diminished diaphragmatic movement
Pleural fibrosis and calcification
Pachypleuritis ; Definition + types
destruction of normal pleural tissue architecture due to an excessive deposition of matrix components → compromised pleural function
Type :
• pleural plaques (discrete localised lesions)
• diffuse pleural thickening
Pachypleuritis : Etiology + Diagnosis
Etiology:
1. Postinflammatory (pleural infection, tuberculous pleurisy, drug-
induced pleuritis, rheumatoid pleurisy, uraemic pleurisy, haemothorax)
- Asbestos exposure
Diagnosis:
• By chance on chest x-ray
• Rarely: breathlessness, chest pain or both, rarely cianosis
Pachypleuritis
Physical exam
Inspection: retraction of the intercostal spaces, reduction of the amplitude of respiratory movements
Palpation: reduced tactile fremitus
Percution: dullness (less than completely dull)
Auscultation:
Diminished vesicular sounds
Sometimes pleural rub
Diagnostic: radiology
Pneumothorax
Pneumothorax refers to the accumulation of air in the pleural space between the parietal pleura lining the rib cage and visceral pleura lining the lung
- the presence of air within the pleural space results in collapse of the lung on the affected side
Pneumothorax classification
1. Spontaneous pneumothorax • Primary • Secondary 2. Traumatic pneumothorax 3. Iatrogenic pneumothorax (biopsy/herapeutic procedure) 4. Catamenial pneumothorax 5. Pneumothorax in AIDS 6. Other: tension PNX, ex vacuum PNX
Pneumothorax
History
• CHEST PAIN with Acute (sudden) onset
• intensity: severe and/or stabbing character
• radiating to ipsilateral shoulder
• increasing with inspiration (pleuritic)
• DYSPNEA: Sudden
• ± Dry cough, Cianosis
# Anxiety, cough, and vague presenting symptoms (e.g., general malaise, fatigue) are less
commonly observed.
# Dyspnea tends to be more severe with secondary spontaneous pneumothoraces because of
decreased lung reserve.
Pneumothorax Pulmonary Signs
MILD pneumothotax → no obvious signs
VOLUMINOUS pneumothotax→ on the affected →
INSPECTION:
• Fullness of the chest, bulged, immobile hemithorax
• Wide intercostal spaces
• Diminished respiratory movement
PALPATION: Diminished or no vocal fremitus or resonance
PERCUTION: Tympanic sound on percussion
AUSCULTATION: Breath sound: diminished/ disappeared
Coin sign is positive
Trachea and heart displace toward the healthy side
Liver dullness edge displaces downward when pnx is on the right side
Respiratory failure with contralateral lung compression
Coin sign ( pneumothorax )
a coin held against the chest is tapped by another coin on the side where the puncture is suspected. A stethoscope is placed on the
back to listen to breath sounds and the sound of the coins. If a tinkling sound is heard, it is likely that air or fluid has found its way into the pleural cavity
Massive Pneumothorax
General appearance/ Inspection with tension pneumothoraxes
• Diaphoretic
• Splinting chest wall to relieve pleuritic pain
• Cyanotic
Vital signs are altered
• Tachypnea
• Tachycardia (most common finding)
- If > 135 (bpm), tension pneumothorax is likely.
• Pulsus paradoxus
• Hypotension (often with tension pneumothorax) by inferior cava vein ICV compression
Massive Pneumothorax
Respiratory Physical exam
( sign + symptoms )
Asymmetric lung expansion - Mediastinal and
tracheal shift to the contralateral side with a large
tension pneumothorax
Decreased/ Absent tactile fremitus
Hyper resonance on percussion with timpany
vesicular sounds: distant or absent, amphoric
murmur on auscultation
• Cardiovascular - Jugular venous distension (tension
pneumothorax)
• Neurologic - Altered mental status
