Pleural Disorders pdf - D. Usama

D. Usama Surgery

Fifth Stage

Pleural Disorders L2

Pleural Effusion

Pleural effusion is accumulation of fluid in the pleural space.

Pathophysiology:

Passage of protein free fluid through the pleural membrane depends on hydrostatic and colloid
oncotic pressure across the pleura

Therefore protein free fluid normally flows from the systemic capillaries in the parietal pleura
into the pleural space then to the pulmonary capillaries in the visceral pleura

5-10 L of fluid normally traverse the pleural space over 24 hours. And normally only 15-20 ml of
pleural fluid is present in the pleural space at any given time

Mechanism of abnormal accumulation of pleural fluid:

  Increased hydrostatic pressure e.g.; CHF
  Decreased plasma oncotic pressure e.g.; hypoalbuminemia
  Increased capillary permeability e.g.; pneumonia, inflammatory pleuritis
  Increase intrapleural negative pressure e.g.; atelactasis
  Impaired lymphatic drainage owing to obstruction of the lymphatics by tumor,

irradiation or fungal infection.

So any disturbance between fluid formation and absorption → pleural effusion

Pleural effusion are divided into transudate and exudate.

Transudative pleural effusion:

Protein poor ultrafiltrate of plasma occurs when there is:

 Increase in systemic or pulmonary capillary hydrostatic pressure
 Decrease in plasma osmotic pressure

Causes of transudative pleural effusion:

CHF

: most common, 80% of patients with transudate have CHF. CXR → cardiomegally

and bilateral. 75% resolve within 48 hours with the use of diuretics

2. Hypoalbuminemia

3. Liver cirrhosis

4. Renal insufficiency and nephritic syndrome

5. Myxedema

6. Peritoneal dialysis

D. Usama Surgery

Fifth Stage

Meig's syndrome

: pleural effusion plus ascitis and ovarian fibroma. It may be transudate

or exudate.

8. Sarcoidosis

Exudative pleural effusion:

Protein rich pleural fluid

Pleural effusion of one or more of the following is considered an exudate:

1.  Pleural fluid protein / serum protein > 0.5
2.  Pleural fluid LDH / serum LDH > 0.6
3.  pH < 7.0

Causes:

1. Neoplastic disease: Lung cancer,Breast cancer, Mesothelioma, Chest wall tumors
2. Infections: Bacterial pneumonia,TB,Fungal, Paracytic

3. Pulmonary infarction
4. Collagen vascular disease: Rheumatoid arthritis,SLE

5.  Trauma and hemothorax
6.  Gastrointestinal disease: Pancreatitis,Esophageal rupture,Subphrinic abscess
7.  Cardiac disease: Post CABG,Pericardial disease
8.  Obstetric  and  gynecological  disease:  Meig's  syndrome,Post  partum  pleural

effusion,Endometriosis

9. Drug induced: Ergot alkaloids ,Amiodarone

Clinical presentation:

Symptoms:

 Asymptomatic
 or symptomatic with dyspnea and pleuretic chest pain

Signs:

Inspection: decreased chest wall movement on the affected side

Palpation: Tracheal and mediastinal shift to the contralateral side -
Decreased chest expansion - Decreased vocal fremitus

Percussion: Decrease resonance (stony dullness)

Auscultation: Decrease or absent breath sounds

Diagnosis

1- CXR: concave meniscus sign.About 250-500 ml of fluid must be present to obliterate the

costodiaphragmatic recess

D. Usama Surgery

Fifth Stage

2- Pleural fluid analysis

A. Volume :massive effusion seen in(Malignant , CHF&TB)

B. Color:

  Straw (pale) color→ mostly transudate
  Cloudy → mostly exudate due to high WBC
  Yellow → chronic empyema
  Milky fluid → chylothorax
  Black pleural fluid → aspergillosis
  Brownish → rupture of amebic liver abscess into the pleural space
  Bloody → Trauma. Pulmonary infarction &Malignancy

C. Glucose : in the pleural fluid is less than serum in: TB ,Empyema &Ca
D. pH: low pH < 7.2 suggest effusion contaminated with bacteria

3-  Pleural biopsy
4-  Ultrasound
5-  CT scan: to detect small abnormalities

6-  Bronchoscopy
7-  VATS
8-  Sputum examination

Management of pleural effusion

1-  Treatment of the underlying cause
2-  Thoracocentesis
3-  Tube thoracostomy + chemical pleurodesis
4-  Surgical pleurodesis and pleurectomy
5-  Radiotherapy
6-  Pleuro-peritoneal shunt

Hemothorax

Presence of blood in the pleural space.

Causes:

I-Traumatic

II-Spontaneous: It is due to:

a. Pulmonary: Necrotizing infection,Pulmonary embolism ,TB, Arterio-venous

malformation

b.  Pleural: Torn pleural adhesions,Neoplasm,Endometriosis
c.  Neoplasm: Primary neoplasms or Metastatic
d.  Blood dyscrasia: Thrombocytopenia ,Hemophilia

D. Usama Surgery

Fifth Stage

Clinical presentation

Dyspnea ,chest pain &Syncope

Treatment:

Management of hemothorax depends on:

  Rate of bleeding
  Amount of bleeding
  Underlying cause

Small bleeding usually ceases spontaneously so that only observation is required

Moderate (amount of blood loss is 500 cc or more): thoracostomy.

Continuing active bleeding (200 ml/hr or more):

 Open thoracotomy.
 VATS

Indications for thoracotomy in hemothorax:

1-  Initial chest tube output more than 1500 ml
2-  Continuous bleeding 200-300 ml/hr for 3 consecutive hours
3-  Retained clot

Chylothorax

The presence of lymph in the pleural cavity

Etiology

I-Trauma

A.  Blunt trauma:Sudden hyperextension
B.  Penetrating trauma to thoracic duct
C.  Surgery: like LN excision
D.  Diagnostic procedures : Left central venous line
E.  Exaggerated physiological maneuvers:

Vomiting episodes or violent coughing especially after the duct is distended after a fatty meal
can lead to spontaneous chylothorax

II -Neoplasm: Lymphangioma, Lymphosarcoma

III- Infection: TB, Filariasis

IV- Congenital: Thoracic duct atresia, Birth trauma

D. Usama Surgery

Fifth Stage

Clinical picture:

  Chest pain dyspnea and fatigue
  Prolonged leakage lead to
  Dehydration
  Malnutrition
  Decrease immunity

Diagnosis:

1. Aspiration of milky white odorless fluid from the pleural space is virtually diagnostic

Characteristics of chyle

Milky

Alkaline and odorless

Triglyceride (TG) > 110 mg/dl

Cholesterol/TG < 1

2. Lymphangiography

Treatment

1. Tube Thoracostomy
2. Correction of

a.  Fluid loss
b.  Electrolyte imbalance
c.  Nutritional support: TPN and avoid long chain fatty acids

3. Surgical opeative : failure of previous measures after 2 weeks thoracotomy or VATS

(Pleurectomy or Pleuro-peritoneal shunt)

D. Usama Surgery

Fifth Stage

Clinical presentation

Asymptomatic or Symptomatic

 Dyspnea
 Pain

On examination:

Small pneumothorax may have no abnormal finding

Inspection: dyspnea ± cyanosis

decrease or absence chest wall movement

Palpation: Trachea shifted to the other side,Decreased chest wall expansion,Decreased or absent
tactile vocal fremitus

Percussion: hyperresonance (tympanic)

Auscultation: decrease or absent breath sounds

Investigation:

1- CXR: Standard PA view in deep inspiration

Rhea method

2-  CT scan
3-  Arterial blood gas analysis
4-  Pulmonary function test
5-  Bronchoscopy

Management

1-  Observation: for vey mild or trivial cases
2-  Thoracocentesis: for minimum one
3-  Chest tube ± suction for moderate cases
4-  Chemical pleurodesis via chest tube for recurent pneumothorax
5-  Thoracotomy or VATS with blebectomy and pleural ablation or pleurectomy

D. Usama Surgery

Fifth Stage

Indication for thoracotomy in pneumothorax

1-  Massive air leak that prevent lung expansion
2-  Recurrent same side pneumothorax
3-  Previous contralateral pneumothorax
4-  Bilateral simultaneous pneumothorax
5-  Presence of large cyst on CXR or bullae
6-  History of previous tension pneumothorax
7-  History of Previous pneumonectomy

Mubark A. Wilkins