pleural diseases

Pleural Disease

Pneumothorax
Classification
• Spontaneous
• PSP
• SSP
• Acquired
• Blunt trauma
• Penetrating trauma
• Barotrauma
• Iatragenic injury







Pathophysiology

• Primary Spontaneous Pneumothorax (PSP)

• Young men (teens – mid 20s)
• Tall and thin
• Families
• Smokers
• Secondary Spontaneous Pneumothorax (SSP)
• Older people (45 – 64 years)
• Pre-existing lung disease
• Higher incidence of respiratory failure
• Higher mortality rate

Clinical presentation

1. Asymptomatic

2. Symptomatic

• a. Pain (PSP)
• b. Dyspnea (SSP)
• c. Orthopnea, hemoptysis, cough


On examination
Inspection: Dyspnea ± cyanosis
• Decrease or absence chest wall movement
Palpation: Apex shifted to the other side
• Trachea shifted to the other side
• Decreased chest wall expansion
• Decreased or absent tactile vocal fremitus
Percussion: Hyper-resonance (tympanic)
Auscultation: Decrease or absent breath sounds

CXR:

closed Pneumothorax

Tension Pnenmothorax

What is the difference??

CT scan

Bronchoscopy



Pneumothorax

Emphysema

Complications
• Pleural effusion
• Hemothorax due to torn pleural adhesions
• Empyema
• Trapped lung (fibrothorax) due to failure of re-expansion
• Tension pneumothorax

Treatment

• Observation
• Pleurocenthesis or thoracocenthesis
• Chest tube thoracostomy
• Surgery
• Massive air leak
• Persistent air leak
• Recurrent pneumothorax
• Bilateral pneumothorax
• Previous pneumonectomy
• Occupational hazard
• Pleurodesis


Malignant pleural effusion
Causes
• lung cancer
• pleural malignancy
• mediastinal LN malignancy

Treatment of pleural effusion→physician or oncologist

• When to reffer to a surgeon →recurrent &/or a suspicion of being a malignant effusion

Why reffer →biopsy + prevent reccurence of effusion

Biopsy:
• Cytology of pleural effusion
• Abram's needle
• CT or U/S guided biopsy
• VATS biopsy
• Open biopsy

Prevent recurrence

• Repeated thoracocenthesis
• Chemical pleurodesis
• Surgical pleurodesis/pleurectomy
• Pleuro-peritoneal shunt (Denver's shunt)

Denver’s Shunt

What is the difference??

Massive effusion

Whole lung atelectasis

Empyema

Causes:
• Complication of pulmonary infection
• Following chest trauma
• Extrapulmonary spread
• Complication of pneumothorax
• Non sterile aspiration of pleural fluid


Pathogenesis
1. Acute or exudative phase
Thin pus, Thin pleura, Expandable lungs
Antibiotics and drainage
2. Transitional or fibrinopurulent phase
Pus thicker, fibrin deposition, lung less expandable
Antibiotics and drainage
3. Chronic or organization phase
Thick pus, thick pleura with fibrous coat, non expandable lungs
Surgery (decortication)

Clinical presentation

• fever, maliase, anorexia, weight loss
• pleuretic chest pain
• dyspnea, cough, purulent sputum
O/E: signs of infection + signs of pleural effusion

Investigations:

• CXR
• Thoracocenthesis
• CT scan


CXR:

Treatment

Objectives:
• Control infection
• Drain purulent material
• Restore lung function

Treatment line

• Chest tube thoracostomy + physiotherapy
• Decortication / pleurectomy
• Open drainage e.g., Eloesser's flap

Decortication

• Eloesser’s flap

Chylothorax
Etiology:
Disruption or tear in the thoracic duct during its coarse in the chest.

• Trauma including penetrating, blunt or iatrogenic injury

• Neoplasm with invasion of the thoracic duct
• Infection

Clinical presentation

• Dyspnea, orthopnea, and cough
• Malnutrition
• Dehydration
• Decreased immunity

Investigations:

• 1. Pleural fluid analysis: odorless milky white appearance with a creamy layer on standing.
• 2. Lymphangiography

Treatment

1. Conservative treatment
a. Chest tube drainage
b. Correct dehydration
c. Correct electrolyte imbalance
d. Nutritional support by TPN or fat free oral diet

2. Surgical repair or ligation of thoracic duct

3. Denver's shunt (pleuro-peritoneal shunt)

Pleural malignancy

• Primary pleural tumors are rare
• The most common primary tumor malignant mesothelioma (usually as a consequence of asbestos exposure).
• Poor prognosis
• Respiratory failure or symptoms of invasion of nearby organ.
• CXR: lung surrounded by thick irregular pleura with multiple nodules with extension to nearby structures.
• Curative treatment is surgery (extrapleural pneumonectomy).
• Both radiotherapy and chemotherapy are weakly effective.

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