Pleural Diseases

Pleural Diseases: 

Pleural Diseases

Embryology : 

Embryology Originates from the celomic cavity. Celomic cavity becomes divided by 3 partitions: - septum transversum - pleuroperitoneal membranes - pleuropericardial membranes The primordial buds (lungs) invaginate the pleura from the median mass of mesenchyme

Histology : 

Histology Parietal pleura over the ribs and intercostal spaces: - thickness: 20-25 µm - loose irregular CT layer covered by a single layer of mesothelial cells. - within the pleura : - Blood vessels - Lymphatic lacunas

PowerPoint Presentation: 

Visceral pleura: Thickness 25-85 µm - Humans have a thick visceral pleura. . Systemic blood supply 2 layers: i- CT: dense CT bundles interlaced between the mesothelium and the bl. Vessels. ii- mesothelium

PowerPoint Presentation: 

Mesothelium : flat cells, 6-12 µm 2 , bumpy or flattened according to the underlying structure. Covered by microvilli. Microvilli : - 0.1 µm in diameter, 0.5-3 µm in length - density: from few : >600/100 µm 2 - more on the inferior parts of the visceral pleura & anterior and inferior mediastinum on parietal pleura - function: lubrication by enmeshing glycoproteins, not absorption of fluid. I

Pleural Fluid: 

Pleural Fluid Minute amounts: 0.01 ml/kg/hr Normal cells: ~1500 cells/mm 3 70% monocytes, 9% mesothelial cells, 7% macrophages, and 2% PNLs. Small amount of protein with more abundant low molecular weight proteins (e.g., albumin)

PowerPoint Presentation: 

Ionic content: Pleural fluid Serum HCO 3 - 25% more Na + 3-5% more Cl - 6-9% more K + Equal Glucose Equal

Blood Supply: 

Blood Supply - Parietal pleura: Arterial Supply: . Costal pleura: branches of intercostal art. . Mediastinal pleura: pericardiophrenic art. . Diaphragmatic pleura: superior phrenic and musculophrenic art.. Venous Drainage: Intercostal veins to the inferior vena cava or the brachiocephalic trunk.

PowerPoint Presentation: 

Visceral pleura: Arterial Supply: Species with thick visceral pleura: systemic circulation via the bronchial arteries. - Venous drainage: Pulmonary veins.

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Pleural lymphatics: - Parietal pleura: - Nodes along int. thoracic art. - Internal intercostal nodes - Visceral pleura: . Superficial system: floats on the surface of the lung to the tracheobronchial lymph nodes and then to the mediastinal LNs.. . Deep system: follows the bronchial circulation to the tracheobronchial lymph nodes.

PowerPoint Presentation: 

Stomas: 2-6 µm round or slit like openings. More on the mediastinal pleura and over the intercostal spaces just below the ribs. Lacunas: dilated spaces underlying the stomas and connected to lymph vessels.

PowerPoint Presentation: 

Kampmeier’s foci: Small milky spots on the dorsal and caudal portion of the mediastinum. They are aggregates of lymphocytes, plasma cells, histiocytes, and other mononuclear cells around a central lymphatic or vascular vessels. Innervation: - visceral pleura: insensitive to pain. - Parietal pleura: - central portion of the diaphragm: phrenic nerve - The rest of the parietal pleura: intercostal nerves

PowerPoint Presentation: 

Pleural pressure: - How to measure ? - Gradient is 0.5 cm H 2 O in vertical distance. - In upright position: >12 cm H 2 O difference in pressure between apex and base of the lungs. Results of pleural pressure: i- larger alveoli at the apex ii- Unevenness of distribution of ventilation.

Pleural fluid formation: 

Pleural fluid formation Origin: 1- Pleural Capillaries: Parietal pleura Pleural space Visceral pleura +30 cm H 2 O Hydrostatic pr. -5 cm H 2 O +24 cm H 2 O 35 29 6 +34 cm H 2 O +5 cm H 2 O +34 cm H 2 O Oncotic pr.

PowerPoint Presentation: 

2- Interstitial origin: - In patients with heart failure. - Pleural effusion develops when the extravascular lung water exceeds 5-8 gms of fluid/gm dry lung. 3- Peritoneal cavity: Via openings in the diaphragm, because of the –ve pressure gradient (hepatic hydrothorax, Meig’s synd., peritoneal dialysis) 4- Thoracic duct or blood vessel disruption.

Pleural Fluid Absorption: 

Pleural Fluid Absorption 1- Parietal pleural lymphatics: - Stomas and lacunas remove cells, proteins and particulate matter. - Rate of removal: 0.2 ml/kg/hr (20 times more than the rate of formation) 2- Visceral pleura: not a valid theory anymore.

Pleural Effusion Occurs When Rate Of Pleural Fluid Formation Exceeds Capacity Of Lymphatics To Remove Fluid: 

Pleural Effusion Occurs When Rate Of Pleural Fluid Formation Exceeds Capacity Of Lymphatics To Remove Fluid Increased formation Increased interstitial fluid in lungs Increased intravascular pressures in pleura Increased pleural fluid protein level Decreased pleural pressure Increased fluid in peritoneal cavity Ruptured thoracic duct Ruptured blood vessel Decreased absorption Lymphatic obstruction parietal pleura Diseased lymph nodes Increased systemic vascular pressure

How Important Is The Pleural Space?: 

How Important Is The Pleural Space? Patients before and after decortication: Mean VC and Max breathing capacity unchanged. Elephants ?!! Clearing fluid from the pleural space, most probably originating from wet pulmonary interstitium (e.g., Lt sided failure)

Pleural Effusions in Practice: 

Pleural Effusions in Practice

Transudate or Exudate ?: 

Transudate or Exudate ? Light’s criteria: Exudates meet at least one of the following: - Pl. Fluid ptn/ Serum ptn > 0.5 - Pl. Fluid LDH/ serum LDH > 0.6 - Pl. Fluid LDH > 0.66 upper limit of normal serum LDH. Specific gravity: > or < 1015 (3gm % protein) Other criteria: - cholesterol > 60 mg/dl ( ? >45mg/dl), - serum : pl. Fl. albumin > 1.2 g /dl - pl. Fl. : serum cholinesterase ratio > 0.23 - Bilirubin - Cholinesterase

Transudative Pleural Effusion: 

Transudative Pleural Effusion Occurs when the hydrostatic pressure and oncotic pressure across the pleural membrane are altered so that the rate of formation exceeds that of absorption. Endothelium is intact and so the cellular and protein content are low. If the underlying problem is corrected, the effusion is resolved with no sequalae.

Congestive Heart Failure: 

Congestive Heart Failure Most common cause of pl. effusion. Best correlates with the presence of pulmonary venous hypertension. High pulmonary venous pr. causes alveolar edema and pleural fluid formation. When the Lt. atrial pr. is transmitted to the Rt. atrium, systemic venous pressure rises and causes more filtration from the capillaries and decreased absorption of fluid via lymphatics.

PowerPoint Presentation: 

Usually bilateral Usually, cardiomegaly on CXR. Bilateral effusion without cardiomegaly are not due to CHF. Indications of thoracentesis: i- unilateral effusion or effusions of evident disparate size ii- effusions without cardiomegaly iii- fever or pleuritic chest pain.

Hepatic Hydrothorax: 

Hepatic Hydrothorax In 6-10% of patients with Liver cirrhosis Most commonly Rt sided Due to hypoalbuminemia. However , they are invariably associated with ascites. Fluid moves from the abdomen to the pleura via defects in the diaphragm, following the negative pressure gradient in the pleura. Treatment : treat the cause + tube thoracostomy (beware of severe hypoalbuminemia), or pleuroperitoneal shunts, or thoracoscopy and talc poudrage, or thoracotomy (or VATS) and repair of diaphragmatic defects.

PowerPoint Presentation: 

Peritoneal dialysis: pleural transudate with extremely low protein ( dialysate). Urinothorax: due to retroperitoneal urine leak that enters the pleura via diaphragmatic lymphatics in cases of obstructive uropathy. Pleura fluid creatinine is higher than serum creatinine. Nephrotic syndrome: due to hypoalbuminemia ( oncotic pr.) and salt and water retention ( hydrostatic pr)

: 

Atelectasis: produces in pleural pressure as in patients with upper abdominal surgery (basilar atelectasis). They are known as “ex-vaco” effusions. Miscellaneous: - iatrogenic - hypothyroidism - pulmonary embolism - Meig’s synd. - pleural amyloidosis (? Cardiac amyloidosis)

Pleural Effusions Related To Metastatic Malignancy: 

Pleural Effusions Related To Metastatic Malignancy A malignant pleural effusion is diagnosed when exfoliated malignant cells are present in pleural fluid or in pleural tissues on biopsy. Pl. effusions can occur without direct pleural involvement with tumor “paramalignant effusions”. Effusions can result from the systemic effects of the tumor and averse effects of therapy.

Pathogenesis : 

Pathogenesis Interruption of the lymphatic system anywhere between the stomata and the mediastinal LNs may result in pleural effusion. Pleural effusions do not develop in pleural involvement in sarcomas because of the absence of lymphatic spread. The bloody nature of the effusion may result from: - direct invasion of blood vessels - Occlusion of venules - VEGF (tumor-induced angiogenesis) - increased capillary permeability due to vasoactive substances

PowerPoint Presentation: 

Effusions may be lymphocytic (60-70%) (less than with TB >90%). Mesothelial cells are more abundant early, and tend to disappear later on. The origin of pleural metastasis is the visceral pleura. Bronchogenic ca. invades and embolize pulmonary art. Extrapulmonary cancers cause tumor emboli to the visceral pleura and then to the pleural space.

PowerPoint Presentation: 

Pleural metastases from primary sites below the diaphragm are generally a manifestation of a tertiary spread from established liver metastases. Two mechanisms are operative in breast cancer with chest wall lymphatic invasion resulting in an ipsilateral effusion, and hepatic spread with bilateral or contralateral disease. Lymphomas: - Hodgkin’s: lymphatic obstruction - Non-Hodgkin’s: pleural infiltration.

Related to tumor load: 

Related to tumor load Pleural fluid characteristics: - usually an exudate (transudate in 10%) - RBCs: 30,000-50,000 c/cmm - malignant cells may be rare. - LDH : high. Effusions that meet Light’s criteria only with LDH are either malignant or parapneumonic. - pH: acidic - Glucose: reduced

Plasmacytoma : 

Plasmacytoma

Metastatic melanoma: 

Metastatic melanoma

Primary Tumors of the Pleura: 

Primary Tumors of the Pleura Malignant Mesothelioma: - pleural fluid is a cellular exudate with low sugar and pH and contains differentiated and undiff. mesothelial cells, lymphocytes, and PNLs. - may contain high levels of hyaluronates which make the fluid viscid.

Mesothelioma or Adenocarcinma ?: 

Mesothelioma or Adenocarcinma ? Mesothelioma: true papillary aggregation, multinucleation with atypia, and cell-to-cell apposition. Metastatic adnecarcinomas: acinus-like structures and balloon-like vacuolation. Immunohistochemistry: -Mesothelioma: +ve for calretinin, cytokeratin, -ve for PAS-d, mucicarmine - Adenocarcinoma: +ve PAS-d, CEA, Leu-M1

PowerPoint Presentation: 

By E.M.: - Mesothelioma: microvilli are long and numerous - Adenocarinoma: microvilli are sparse and short Primary effusion lymphoma (body cavity lymphoma) Pyothorax-associated lymphoma (pneumothorax-associated lymphoma).

Parapneumonic Effusion & Empyema: 

Parapneumonic Effusion & Empyema Parapneumonic effusion Any pleural effusion secondary to pneumonia (bacterial or viral) or lung abscess Empyema - pus in the pleural space Pus by definition is thick viscid fluid which appears to be purulent Complicated parapneumonic effusion - a parapneumonic pleural effusion for which tube thoracostomy is necessary for its resolution and/or on which the bacterial cultures are positive

Evolution Of Parapneumonic Effusion: 

Evolution Of Parapneumonic Effusion STAGE 1 - EXUDATIVE STAGE - rapid outpouring of fluid into pleural space due to increased pulmonary interstitial fluid or increased permeability of pleural capillaries STAGE 2 - FIBROPURULENT STAGE - pleural fluid becomes infected and progressively loculated -when loculated difficult to drain STAGE 3 - ORGANIZATION STAGE - fibroblasts grow into the exudate from both the visceral and parietal pleura producing a thick pleural peel

CLASSIFICATION OF PARAPNEUMONIC EFFUSIONS: 

CLASSIFICATION OF PARAPNEUMONIC EFFUSIONS It is important to realize that not all parapneumonic effusions are the same The following classification was developed to assist the practicing physician. It is based on the following: Amount of fluid Biochemical characteristic of fluid Gross appearance of the pleural fluid Presence or absence of loculations

CLASSIFICATION OF PARAPNEUMONIC EFFUSIONS AND EMPYEMA: 

CLASSIFICATION OF PARAPNEUMONIC EFFUSIONS AND EMPYEMA Class 1 - NON-SIGNIFICANT less than 10 mm thick on decubitus - no treatment. Class 2 - typical parapneumonic : glucose > 40 mg/dl, pH> 7.20, stain and culture negative. Class 3 - borderline complicated : LDH > 1000, 7.00 < pH < 7.20, glucose > 40, gram stain and culture negative. Class 4 - simple complicated pH < 7.00, glucose < 40, gram stain or culture positive, free flowing, thin

CLASSIFICATION OF PARAPNEUMONIC EFFUSIONS AND EMPYEMA (CONTINUED): 

CLASSIFICATION OF PARAPNEUMONIC EFFUSIONS AND EMPYEMA (CONTINUED) Class 5 - COMPLEX COMPLICATED pH < 7.00, glucose < 40, gram stain or culture positive, multiloculated. Class 6 - simple empyema frank pus is present, single locule or free flowing. Class 7 - complex empyema frank pus is present and there are multiple locules.

PLEURAL SPACE ANATOMY: 

PLEURAL SPACE ANATOMY A 0 minimal, free-flowing effusion (<10 mm on lateral decubitus A 1 small to moderate free-flowing effusion (>10 mm and < ½ hemithorax) A 2 large, free-flowing effusion (> ½ hemithorax) or loculated effusion or effusion with thickened parietal pleura Accp consensus, 2000, 118:115-1171.

PLEURAL FLUID BACTERIOLOGY: 

PLEURAL FLUID BACTERIOLOGY B x culture and gram stain results unknown B 0 negative culture and gram stain B 1 positive culture or gram stain B 2 pus Accp consensus, 2000, 118:115-1171.

PLEURAL FLUID CHEMISTRY: 

PLEURAL FLUID CHEMISTRY C X pH unknown C 0 pH > 7.20 C 1 pH < 7.20 pH must be measured with blood gas machine IF pH unavailable, a glucose of 60 mg/dl can be used Accp consensus, 2000, 118:115-1171.

TREATMENT VIA CATEGORY: 

TREATMENT VIA CATEGORY 1 – A O AND B X AND C X NO DRAINAGE 2 – A 1 AND B 0 AND C O NO DRAINAGE 3 – A 2 OR B 1 OR C 1 DRAINAGE 4 - B 2 (PUS) DRAINAGE Therapeutic thoracentesis or chest tube alone are insufficient for most patients with category 3 or 4 Fibrinolytics, thoracoscopy or thoracotomy are acceptable approaches for managing patients with category 3 or 4 ACCP consensus, 2000, 118:115-1171.

TREATMENT OPTIONS FOR PARAPNEUMONIC EFFUSION: 

TREATMENT OPTIONS FOR PARAPNEUMONIC EFFUSION Observation Diagnostic thoracentesis Therapeutic thoracentesis Tube thoracostomy (tt) Tt with fibrinolytics Thoracoscopy with debridement Thoracotomy with decortication

Pleural Tuberculosis: 

Pleural Tuberculosis Tuberculous pleural effusions occur in up to 30% of patients with tuberculosis. Tuberculous pleural effusion in HIV infected patients occur early in the course of the disease, when the CD4+ T-lymphocyte counts are >200 cells . mL -1 , which directs the attention towards a more competent immunological response.

PATHOGENESIS: 

PATHOGENESIS - It starts when subpleural caseous focus ruptures into the pleural space 6-12 weeks after a primary infection. - Mycobacterial antigens enter the pleural space and interact with T-cells previously sensitized to Mycobacteria, resulting in a delayed type hypersensitivity reaction and the accumulation of fluid.

PowerPoint Presentation: 

This reaction in the pleura results in increase in the permeability of the pleural capillaries to to serum proteins, increasing the pleural fluid oncotic pressure. The pleural lymphatics are also involved and so clearance of proteins out of the pleural space is hampered. The diffuse affection of the parietal pleural surfaces with the resultant obstruction of the stomata is an important cause of pleural fluid accumulation.

IMMUNOLOGY: 

IMMUNOLOGY Delayed type hypersensitivity rather than tuberculous infection is the accepted hypothesis. - Cultures of pleural specimens are frequently negative, - Pleural effusion can be produced by intrapleural injection of PPD in sensitized guinea pigs. - These effusions can be prevented by the administration of anti-lymphocyte serum.

PowerPoint Presentation: 

Neutrophils are the first cells responding to mycobacterial antigens, and they are responsible for the recruitment of blood monocytes. The pleural mesothelial cells also share in the recruitment of neutrophils and lymphocytes. After 3 days, lymphocytes predominate, they are mainly CD4+ with a mean CD4:CD8 ratio of about 4.3 in pleural fluid.

Diagnosis : 

Diagnosis PPD skin test Fluid analysis: - Exudate - Lymphocytes >90-95% - Mesothelial cells <5% - ADA : . >70 U/L: TB . 40-70 U/L: ??? . <40: not TB - IFN-Gamma : > 140pg/ml

Pleural Effusion Due To Fungal Infections: 

Pleural Effusion Due To Fungal Infections Aspergillosis: previous artificial pneumothorax. Blastomycosis Coccidioidomycosis Histoplasmosis Cryptococcosis actinomycosis

Pleural Effusion Due To Parasitic Infections: 

Pleural Effusion Due To Parasitic Infections Hydatid disease: Echinococcosis -rupture hepatic or splenic cyst - ruptured pulmonary hydatid cyst ? Anaphylactic shock at time of rupture. Dx is made by showing the scolices and hooklets in the pleural fluid, Casoni skin test (75%), Weinberg complement fixation (>75%). Amebiasis paragonimiasis

Pleural effusion & AIDS: 

Pleural effusion & AIDS Kaposi’s sarcoma Primary effusion lymphoma Parapneumonic effusions Effusions due to PCP : Rare. Viral infections: - hantavirus - infectious mononucleosis - Influenza virus Mycoplasma pneumonia

Pleural Effusions Due To Pulmonary Embolism: 

Pleural Effusions Due To Pulmonary Embolism Two mechanisms: i- Rt. Heart failure and increased capillary pressure in the parietal pleura (transudate). ii- Increase capillary permeability (exudate) Diagnosis: - clinically - Spiral CT - Duplex studies

Pleural Effusions Due To Diseases Of The GIT: 

Pleural Effusions Due To Diseases Of The GIT 1- Pancreatic diseases: Pl. fluid amylase > 1000U/ml - Acute pancreatitis - pancreatic abscess - pancreatic pseudocyst - Pancreatic ascites

PowerPoint Presentation: 

2- Intrahepatic and subphrenic abscess 3- Esophageal perforation: emergency. - Instrumentation - Boerhaave’s synd. after vomiting. . Dx: elevated salivary amylase level, low pH, presence of squamous epithelial cells, and sometimes food. 4- Esophageal variceal sclerotherapy (extravasation)

Pleural Diseases Secondary To Cardiac Causes: 

Pleural Diseases Secondary To Cardiac Causes Congestive heart failure Post-CAGB surgery Post-cardiac injury (Dressler’s synd.) Pericardial diseases (constrictive pericarditis)

Pleural Diseases In OB&GYN: 

Pleural Diseases In OB&GYN Ovarian hyperstimulation syndrome (OHSS) Fetal pleural effusion (mostly chylothoraces) Postpartum pleural effusion Meig’s synd. Endometriosis: mostly due to ascitic origin.

Pleural Effusion Due to Collagen Vascular Diseases: 

Pleural Effusion Due to Collagen Vascular Diseases Rheumatoid arthritis: - effusion in 3% (7.9% men, 1.6% women) - on thoracoscopy, the pleura looks gritty and thickened (non-sp.) - histologically: lack of normal mesothelium, pseudostratified layer of multinucleated giant cells, rheumatoid nodules with palisading cells and fibrinoid necrosis

PowerPoint Presentation: 

Pleural fluid in RA: - exudate - pH <7.2, glucose <40 mg%, LDH >700 IU/L, low complement level, high rheumatoid factor titers (>1:320), and high cholesterol. - predominantly: PNLs or monocytes depending on acuity of the process. - may contain “ragocytes” (RA cells)

PowerPoint Presentation: 

Systemic Lupus: -16 % of SLE pts, 54% had pleuritic chest pain. - histology: non-sp ( chronic inflammation) - drugs associated with lupus-like syndrome: . Hydralazine, procainamide, INH,… Familial Mediterranean Fever (FMF): paroxysmal polyserositis: fever, pleuritic pain. CSS Wegner’s Granulomtosis

PowerPoint Presentation: 

RA and SLE Incidence 3%-7% 15%-44% Sex 80% male Female 80% with SQ nodules Effusion Exudate Exudate Glucose < 20 mg/dl – 63% > 70 mg/dl < 50 mg/dl – 83% C4 Low Low Pleural RF + LE cells immunology or + ANA Treatment NSAID/Steroids Steroids Response Variable response Excellent Characteristics RA SLE

Pleural Effusion due to Drugs: 

Pleural Effusion due to Drugs Nitrofurantoin Dantrolene Methysergide Ergot alkaloids Amidarone Methotrexate Others

Miscellaneous Causes Of Pleural Effusion: 

Miscellaneous Causes Of Pleural Effusion Asbestos exposure (benign asbestos effusion) Yellow Nail synd.: lymphedema, deformed yellow nails, and pleural effusions. Post-lung transplantation (interruption of lymphatics) Post-bone marrow transplantation (graft versus host disease) Sarcoidosis: non-sp. , occasionally. Trapped lung Others

Chylothorax & Pseudochylothorax: 

Chylothorax & Pseudochylothorax Chylothorax: is the occurrence of chylus in the pleural space, and is due to damage or blockage of the thoracic duct. The diagnosis is made by analysis of the pleural fluid, which contains high levels of triglycerides, and is confirmed by the finding of chylomicrons. "Chylus", or chyle, is lymph, mainly from the gastrointestinal tract, which explains its composition.

PowerPoint Presentation: 

Dx: - Appearance: milky white, odorless (D.D. empyema. Empyema clears on centrifuge and ether, while chylothorax remains opaque) - Triglycerides: if > 110 mg% and pleural fluid : serum cholesterol is <1 : chylothorax - 50-110: do a pleural fluid lipoprotein analysis. If chylomicrons +ve: chylothorax. - lipophylic dye ingestion: and thoracentesis later

PowerPoint Presentation: 

LAM : proliferation of immature smooth ms throughout the lung tissue leading to obstruction of lymphatics and chylothorax. Gorham’s synd : hemangiomatosis, disppearing bone disease, and massive osteolysis due to intraosseous proliferation of lymphatic channels. These patients have chylothorax.

PowerPoint Presentation: 

"Pseudochylothorax" or "cholesterol pleurisy" or "chyliform effusion" is a fluid which has a very high content of cholesterol. Triglycerides or chylomicrons are, however, not present and the entity has nothing to do with lymphatic vessels or chyle. It can occur when a fluid has been present for a long time in the pleural space and, more especially, in a fibrotic pleura.

Approach To The Patient With Pleural Effusion: 

Approach To The Patient With Pleural Effusion

Gross examination of pleural fluid: 

Gross examination of pleural fluid Appearance Yellow - if cloudy centrifuge Cloudy supernatant - chylothorax or pseudochylothorax Clear supernatant - cells or debris responsible for cloudiness Pink- blood-tinged Deep red - obtain hematocrit. Hemothorax if hct > 50% Odor : Putrid - anaerobic empyema Urine - urinothorax

Chylothorax and pseudochylothorax: 

Chylothorax and pseudochylothorax Two diagnoses to consider when pleural fluid is turbid post centrifugation Usually distinguished by history With pseudochylothorax, effusion has been present for years and pleura is markedly thickened With chylothorax, an acute process If doubt, measure triglycerides and cholesterol in serum and pleural fluid. Chylothorax exists if: Triglycerides > 110 mg/dl and Pleural fluid/serum triglyceride > 1.0 Pleural fluid/serum cholesterol < 1.0

Initial Laboratory Tests For An Undiagnosed Pleural Effusion : 

Initial Laboratory Tests For An Undiagnosed Pleural Effusion Protein and LDH in pleural fluid and serum for separation of transudates and exudates Pleural fluid smears and culture Cell count and differential Pleural fluid glucose, pH Pleural fluid cytology Marker for TB pleuritis ADA, gamma interferon or PCR

Differential Diagnosis Low Glucose (< 40 Mg/Dl): 

Differential Diagnosis Low Glucose (< 40 Mg/Dl) Complicated parapneumonic effusion Malignant pleural effusion Tuberculous pleural effusion Rheumatoid pleural effusion Paragonimiasis Hemothorax Churg Strauss syndrome

Pleural Fluid pH: 

Pleural Fluid pH Particularly useful in patients with suspected parapneumonic effusion A pH < 7.00 indicates that patient is likely to require tube thoracostomy Low pH (<7.20) also seen with malignancy (poor prognosis), rheumatoid pleuritis, TB, hemothorax, urinothorax, paragonimiasis and the churg-strauss syndrome Must be measured with blood gas machine

Options If No Diagnosis After Initial Thoracentesis: 

Options If No Diagnosis After Initial Thoracentesis First spiral CT Then what? Observation Needle biopsy of the pleura Thoracoscopy Bronchoscopy Open pleural biopsy

Observation: 

Observation Probably the best option if patient improving and no parenchymal abnormalities Remember no diagnosis ever in 10 - 20 % If patient has malignancy, patient probably will not improve If patient has PE, diagnosis should have been made with CT If patient has TB, a pleural fluid TB marker should have been positive

Needle Biopsy Of Pleura: 

Needle Biopsy Of Pleura Most common way to diagnose TB pleuritis over past 40 years Easier to diagnose TB with pleural fluid tests at the present time Also can diagnose pleural malignancy Cytology much better in most series In one series of patients with malignancy, pleural biopsy positive in only 20/118 (17%) with negative cytology Rarely is needle biopsy indicated where thoracoscopy is readily available

Thoracoscopy For The Diagnosis Of Pleural Disease: 

Thoracoscopy For The Diagnosis Of Pleural Disease Very efficient (>90%) at establishing the diagnosis of malignancy including mesothelioma Also good (>80%) at establishing the diagnosis of tuberculosis Rarely establishes the diagnosis of other benign causes of pleural effusion Concomitantly procedure can be done to create a pleurodesis Pleural abrasion or talc insufflation

Bronchoscopy: 

Bronchoscopy Useful if patient has a parenchymal abnormality or hemoptysis Hemoptysis indicates endobronchial lesion Useful with massive pleural effusion Otherwise not useful for the undiagnosed pleural effusion Not useful if pleural fluid cytology positive and no parenchymal abnormality or hemoptysis

Open Pleural Biopsy: 

Open Pleural Biopsy In general has been supplemented by thoracoscopy At times is needed to make diagnosis of mesothelioma Should perform a procedure to create pleurodesis as is done with thoracoscopy

PNEUMOTHORAX: 

PNEUMOTHORAX

PowerPoint Presentation: 

Pneumothorax is the presence of air in the pleural space. Incidence is ~7/100,000 / year. It is closely related to smoking and the number of cigarettes smoked/day. Familial tendency Either: i- spontaneous: 1ry or 2ry ii- Traumatic

Spontaneous Pneumothorax: 

Spontaneous Pneumothorax Primary: - due to rupture of subpleural blebs - subpleural blebs are due to airway inflammation as with centriacinar emphysema in smokers. - blebs termed emphysema-like changes (ELCs) - recurrence rates: ~50% - Quantification: (diameter of lung) 3 : (diameter of hemithorax) 3

PowerPoint Presentation: 

Treatment: - Observation - Supplemental oxygen - Manual aspiration - Tube thoracostomy (tt) - Tt with pleurodesis. - Autologous blood patch or intrapleural fibrin glue for persistent airleak. - medical thoracoscopy or VATS - Open thoracotomy

Secondary spontaneous pneumothorax: 

Secondary spontaneous pneumothorax Rate is ~6/100,000/year Serious condition due to poor pulmonary reserve. Conditions associates with 2ry Pnthx: - COPD - PCP with AIDS - LAM - cystic fibrosis ~6% - TB ~1% - Catamenial pneumothorax - Neonatal pneumothorax

Traumatic Pneumothorax: 

Traumatic Pneumothorax 1- Iatrogenic: thoracentesis, CT guided biopsy, Subclavian vein cannulation, MV 2- Non-iatrogenic: - Penetrating or non-Penetrating trauma - 2ry to drug abuse - Pneumothorax ex-vaco - Tension pneumothorax - Bronchopleural fistula with MV.

Hemothorax : 

Hemothorax Traumatic: Iatrogenic: Swan-Ganz, aortography Non-traumatic: - anticoagulation for P.E. - Catamenial hemothorax. If pleural fluid hematocrit >50% peripheral blood hematocrit…..hemothorax

Thoracoscopy : 

Thoracoscopy

PowerPoint Presentation: 

Thank you

References For The Interested:: 

References For The Interested: Pleural Diseases. Ed. Richard Light. Lippincott Williams & Wilkins 2001. Series : the pleura. Eur Respir J 1997-1998 Practical Thoracoscopy: Ed. P. Astoul. Atlas of Diagnostic Thoracoscopy: Ed, R. Loddenkemper Textbook of pleural diseases. Eds. R. Light, YC Gary Lee. 2003