Pleural disease symptoms and treatment, What is the most common pleural disease?

Pleural diseases are conditions that affect the pleura, which is the thin membrane surrounding the lungs and lining the chest cavity. The pleura consists of two layers: the visceral pleura (which covers the lungs) and the parietal pleura (which lines the chest wall). These layers help the lungs expand and contract smoothly by producing a small amount of lubricating fluid.

Pleural Effusion

Pleural effusion is an abnormal collection of fluid in the pleural space. This may accumulate in the general pleura, or it may be encysted along the fissure or may be loculated by adhesions. Incidence: 300 cases / 100,000 populations annually.

Approximately 25% of all consultations in Pulmonary Medicine services concern pleural diseases.Cardiac failure, parapneumonic, and malignant effusions are the most common causes.

Mechanism of pleural effusion

  1. An increase in the capillary hydrostatic pressure.
  2. A decrease in the plasma oncotic pressure.
  3. An increase in the rate of filtration across the parietal pleura.
  4. A decrease in the rate of reabsorption of the pleural effusion.
  5. A decrease in the negative pressure within the pleural space.
  6. An increase in the permeability of the pleural capillaries.
  7. Impairment of lymphatic drainage of the pleura.
  8. Abnormal sites of entry e.g., passage of fluid from the peritoneal space through macro-diaphragmatic pores (as in hepatic hydrothorax) or misplaced central venous line.

Etiology

Pleural diseases

Pleural diseases

A. Transudates:

Congestive heart failure, liver cirrhosis, malnutrition, hypoproteinemia, myxedema, nephrotic syndrome, Meig’s syndrome, superior vena cava syndrome, constrictive pericarditis, and fluid from the peritoneal cavity.

B. Exudates:

Malignant pleural effusion, infectious diseases (TB, PN), pulmonary embolism (infraction), collagen vascular diseases (RA), sarcoidosis, uremia, drug-induced pleural diseases, radiation therapy, pancreatitis, and Meig’s syndrome.

To determine the origin of effusion, a classic and useful distinction is that between transudate and exudate. Pleural fluid is likely to exudate if one or more of the following Light’s criteria are met:

  1. Pleural fluid protein/serum protein ratio > 0.5.
  2. Pleural fluid LDH / serum LDH ratio > 0.6.
  3. Pleural fluid LDH is more than two-thirds the upper limit of the normal serum range. (> 200 U/L).

Serum-pleural fluid albumin gradient may be the most useful way to distinguish transudates from exudates from exudates in patients with congestive heart failure who have undergone diuresis. A gradient > 1.2 g/dl is indicative of a transudate.

Bacterial infection causes parapneumonic effusion which may end in a complicated parapneumonic effusion (empyema) by passing into 3 stages which are the exudative stage, the fibro purulent stage, and the organization phase leading to fibrothorax.

Clinical Picture

SYMPTOMS:

1. Stage of pleurisy:

  • Pleuritic chest pain: Stitching in character, its severity increases with inspiration and cough and decreases when lying on the diseased side. Diaphragmatic pleurisy radiates to the shoulder
  • Fever: inflammatory causes.

2. Stage of pleural fluid accumulation:

  • Pleural pain disappears.
  • Dull aching pain.
  • Fever: inflammatory causes
  • Dyspnea: mild to severe with massive effusion, increases on lying on the normal side (trepopnea).
  • Cough (dry).

SIGNS

A. Inspection:

  • Limited respiratory movements.
  • Decreased or absent Litten’s sign.
  • Wider half of the subcostal angle.

B. Palpation:

  • Decreased TVF.
  • Limited chest expansion.
  • Mediastinal shift (tracheal shift): Shift to the opposite side → large effusion. Central mediastinum with massive effusion: underlying atelectasis. Fixation of the mediastinum → LN, malignant infiltrations.

C. Percussion:

  • Pleural effusion: Stony dullness.
  • Above effusion: Hyperresonance (Skodiac resonance).
  • Grocco’s triangle: dullness over the Paravertebral triangle on the opposite side.
  • Dullness of the Traube’s area: left pleural effusion.

D. Auscultation:

  • Decreased intensity of breath sounds and VR.
  • Bronchial breathing at the upper border of the effusion (Garlen’s triangle).
  • Pleural rub: pleurisy.
  • Aegophony.
  • In Hydropneumothorax → shifting dullness, succession splash.
  • Neglected cases → Fibrothorax

Diagnosis

1. Imaging studies:

Chest X-ray

  • Small effusion:300-500→obliteration of costophrenic angle.
  • Lateral decubitus: for a small amount of effusion layered along the dependent chest wall.
  • Large effusion → homogenous opacity rising to the axilla.
  • Massive effusion (occupies 2/3 of hemithorax (up to the 2nd rib)).
  • Subpulmonic Effusion → elevated copula of diaphragm.
  • interlobar effusion → elliptical opacity along the course of the fissure (CHF).
  • loculated effusion → D shape
  • Hydropneumothorax → (Air fluid level).

CT scan

Visualize Underlying pathology, identify loculated effusion, Measurement of pleural thickness, identify bronchopleural fistula, and visualize small pneumothorax.

Ultrasonography

Diagnosis of subpulmonic effusion is helpful to locate small amounts and detect loculated effusion.

2. Diagnostic Thoracentesis -tests (pleural fluid analysis)

  • Physical examination:
  • Shape & color
  • Straw: transudate- some exudates.
  • Turbid: empyema.
  • Hemorrhagic effusion.
  • Milky.

Studies to differentiate transudate from exudate: pleural fluid LDH, total protein & possibly albumin. Studies to help sort out an exudate.

  • Cell count & differential,
  • Neutrophils empyema, early TB, pulmonary infarct.
  • Lymphocytes- TB, malignancy
  • Basophils>> leukemic infiltration.

3. Lab tests:

CEA, PRO-BNP, Mesothelin, RA, ANA

4. Pleural biopsy

  • ABRAM’S OR COPE’S NEEDLE.
  • US or CT-GUIDED TRANSTHORACIC BIOPSY.
  • MEDICAL THORACOSCOPY.
  • Video Assisted Thoracoscopy (VATS).
  • OPEN PLEURAL BIOPSY.

5. BRONCHOSCOPY (endobronchial mass, TB).

Special types of pleural effusion

1. Chylous pleural effusion:

Excess fat (triglyceride), stains red with Sudan III, dissolves in ether.

Causes:

  • Injury to the thoracic duct (surgery, trauma).
  • Obstruction of TD (lymphoma, filariasis).
  • Congenital abnormality.

Treatment: Ligation of TD.

2. Chyliform pleural effusion:

  • Excess cholesterol, not stained red with Sudan III, does not dissolve in ether.
  • Causes: Chronic pleural effusion Hypercholesterolemia

3. Hemothorax

Hemorrhagic pleural effusion: Blunt or penetrating trauma, HCT fluid/blood ≥ 0.5, Will coagulate lead to fibrothorax or empyema, if small will defibiranate and remain free flowing.

Treatment: ICT drainage.

Treatment

A. Indications for aspiration:

  • Massive effusion → severe dyspnea
  • 2nd infection → resisting treatment
  • Hemothorax
  • Empyema, complicated parapneumonic effusion (Ph < 7.2, LDH >1000 IU/ L, bacteria on Gm staining).

B. Treatment of the cause

TB effusion

  • Full anti-TB treatment
  • Corticosteroids for 3-4 weeks → help → reabsorption of fluid & decrease deposition of fibrous tissues.

Malignant effusion

  • Cytotoxic drugs.
  • Aspiration & pleurodesis
  • Pleurodesis: injection of sclerosing agent into the pleural space to promote adhesions between parietal and visceral pleura to prevent re-accumulation of fluid.
  • Chest tube.
  • Sclerosing agents as: Tetracycline, bleomycin talc, doxycycline, and iodopovidone.

Parapneumonic effusion

  • Uncomplicated effusion → proper antibiotics.
  • Complicated effusion → antibiotics + closed chest tube drainage underwater seal.
  • If sill drains → open drainage with a rib resection.
  • Decortication: if unable to achieve drainage & the lung is trapped in the fibrinous peel.
  • Bronchopleural fistula → surgical closure.

Hemothorax

  • Small: removed by lymphatics.
  • Large: tube drainage.
  • Persistent bleeding → surgical closure of the vessel.
  • Chylothorax → surgical ligation of the thoracic duct, or radiation if due to tumor.
  • Meig’s syndrome → Removal of the pelvic tumor
  • Neglected case (fibrothorax) Pleurectomy.

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