Diseases of the Pleura and Chest wall

Prof S S Danbauchi

Objectives

• For the student to learn about the normal anatomy and physiology of the pleura
• For the student to learn about disorders of the pleura
• For the student to learn about disorders of the chest wall.
• For the student to learn about investigation of the pleura diseases
• For the student to learn about the treatment of pleura diseases

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Anatomic Concepts

Embryology :

►lung development starts from the gut 24 days after conception;

• diaphragm forms in cervical region at 3-4 weeks and moves progressively downwards carrying the phrenic nerves with it;
• lung lobes are identifiable at 12 weeks; bronchial tree is completed at 16 weeks and alveoli and capillaries appear at 24 – 28 weeks; surfactant appears at 35 weeks.
• Postnatal Alveolarization: intense first 8-10 yrs (alveolar buds – hyperplastic growth) and enlargement of all structures throughout adolescence and early adulthood ( hypertrophic growth)

Pleura

►Pleura is a large, thin sheet of tissue that wraps around the outside of the lungs and lines the inside of the chest cavity.

►Between the layers of the pleura is a very thin space. Normally it's filled with a small amount of fluid.

►The fluid helps the two layers of the pleura glide smoothly past each other as the lungs breathe air in and out.

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Your pleura is a large, thin sheet of tissue that wraps around the outside of your lungs and lines the inside of your chest cavity. Between the layers of the pleura is a very thin space. Normally it's filled with a small amount of fluid. The fluid helps the two layers of the pleura glide smoothly past each other as your lungs breathe air in and out.

normal

Pleura

• The pleura and pleural spaces are only visible when abnormal
• There should be no visible space between the visceral and parietal pleura
• Check for pleural thickening and pleural effusions
• If you miss a tension pneumothorax you risk your patient's life - as well as your result at finals!

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CHEST EXAMINATION

• Inspection
• Palpation
• Percussion
• Auscultation

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Causes of Pleura Diseases

• Disease of the underlying lung extending to pleura: (Pneumonia, lung abscess, TB, pulmonary embolism and infarction).
• Collagen vascular disease
• Infective pleurodynia
• Metabolic
• Malignancy
• Primary

Disorders of the Pleura

• Pleurisy - inflammation of the pleura that causes sharp pain with breathing (pleuritic chest pain)
• Pleural effusion - excess fluid in the pleural space
• Pneumothorax - buildup of air or gas in the pleural space
• Hemothorax – accumulation of blood in the pleural space
• Tumors either primary or metastatic

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Pneumothorax

• A pneumothorax forms when there is air trapped in the pleural space. This may occur spontaneously, or as a result of underlying lung disease.
• The most common cause is trauma, with laceration of the visceral pleura by a fractured rib- RTA commonly.

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Pneumothorax

• If the lung edge measures more than 2 cm from the inner chest wall at the level of the hilum, it is said to be 'large.'
• If there is tracheal or mediastinal shift away from the pneumothorax, the pneumothorax is said to be under 'tension.' This is a medical emergency!
• Missing a tension pneumothorax may harm your patient

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A pleural effusion is a collection of fluid in the pleural space. Fluid gathers in the lowest part of the chest, according to the patient's position. If the patient is upright when the x-ray is taken, a pleural effusion will obscure the costophrenic angle and hemidiaphragm. If a patient is supine a pleural effusion layers along the posterior aspect of the chest cavity and becomes difficult to see on a chest x-ray.

A pleural effusion is a collection of fluid in the pleural space. Fluid gathers in the lowest part of the chest, according to the patient's position. If the patient is upright when the x-ray is taken, a pleural effusion will obscure the costophrenic angle and hemidiaphragm. If a patient is supine a pleural effusion layers along the posterior aspect of the chest cavity and becomes difficult to see on a chest x-ray.

Spontaneous Pneumothorax�-Definition & Factors

• Definition

Accumulation of intra-pleural air as the result of a break in either the visceral or parietal pleura

• Factors determining gas re-absorption
• Diffusion properties of the gases
• Pressure gradients
• Area of contact
• Permeability of pleural surface

• Spontaneous

Primary pneumothorax

Secondary pneumothorax

Airway and pulmonary disease (COPD, asthma)

Interstitial lung disease (Pulmonary fibrosis)

Infection ( TB..)

Neoplastic

Catamenial ( Endometriosis)

• Iatrogenic
• Post-Traumatic

Spontaneous Pneumothorax�-Clinical investigation

• Signs and symptoms
• Sudden onset chest pain
• Shortness of breathing
• Cough
• Cyanosis (blue tongue or mucous membrane)
• Diagnosis
• CXR
• Auscultation
• CT or MRI
• Differential diagnosis
• Skin fold
• Giant bulla

Tension Pneumothorax

= air in the pleural space, which pressure exceeds the atmospheric pressure throughout expiration (inspiration).

CAUSES – any type of Pneumothorax:

• with mechanical ventilation / NIPPV
• during cardiopulmonary resuscitation
• in divers
• in air travel
• in spontaneously breathing person at constant pressures (airway, environment)
• improper chest tube handling- iatrogenic

Tension Pneumothorax

Patophysiology:

• impaired venous return and decreased cardiac output
• V/Q mismatch - profound hypoxia

Clinical manifestations:

• sudden deterioration
• dyspnoea, cyanosis, tachicardia, profuse sweating
• hypotension, low O₂ saturation, distended neck veins
• subcutaneous emphysema, unilateral hyperinflation
• respiratory acidosis, hypoxemia
• sudden increase in plateau and peak pressures (volume – type vent)
• sudden drop of tidal volumes (pressure – type vent.)

Tension Pneumothorax

hyperinflation

collapsed lung

mediastinal shift

low hemidiaphragm

Treatment

• Medical emergency – clinical diagnosis
• Do not wait for CXR
• 100% O₂
• Observation, auscultation, percussion
• Needle & syringe with saline – 2nd anterior ICS
• Bubbles? – replace with large - bore needle
• Prepare for tube thoracostomy

Tension Pneumothorax

Treatment Options for Pneumothorax

• Early complication

Prolonged air leakage

Non re-expansion of the lung

Bilateral

Hemothorax

Tension

Complete pneumothorax

• Potential hazard

Occupational hazard

Absence of medical facilities in isolated areas

Associated single bulla

Psychological

• Second Episode

Ipsilateral recurrence

Contralateral recurrence after a first pneumothorax

Surgical indication for primary spontaneous pneumothorax

Complication of Pneumothorax

• Tension pneumothorax
• Re-expansion pulmonary edema
• Persistent air leak
• Hemothorax (less than 5%)
• Pneumo-mediastinum

PLEURA EFFUSION

• A pleural effusion is a collection of fluid in the pleural space. Fluid gathers in the lowest part of the chest, according to the patient's position.
• If the patient is upright when the x-ray is taken, a pleural effusion will obscure the costophrenic angle and hemidiaphragm. If a patient is supine a pleural effusion layers along the posterior aspect of the chest cavity and becomes difficult to see on a chest x-ray.

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Tiny effusion

Very mild Pleural effusion

Pleural effusion with pleural thickening Right side of the chest

Pleural effusion

Frontal

Lateral

Moderate Pleural effusion

Massive pleural effusion

mediastinal shift

distension

Exudates Vs transudates

Light’s criteria

• Pleural fluid protein/serum protein >0.5
• Pleural fluid LDH/serum LDH >0.6
• Pleural fluid LDH more than two-thirds normal upper limit for serum

Pleural fluid cholesterol >60mg/dl

Serum albumin and pleural fluid albumin </= 1.2 mg/dl

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Transudative Pleural effusions

• Congestive heart failure
• Cirrhosis
• Pulmonary embolism
• Nephrotic syndrome
• Peritoneal dialysis
• Superior vena cava obstruction
• Myxedema
• Urinothorax

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Exudative Pleural Effusions

• Neoplastic diseases

Metastatic disease

Mesothelioma

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• Infectious diseases

Bacterial infections

Tuberculosis

Fungal infections

Viral infections

Parasitic infections

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Exudative Pleural Effusions

Collagen-vascular diseases

Rheumatoid pleuritis

Systemic lupus erythematosus

Drug-induced lupus

Immunoblastic lymphadenopathy

Sjögren's syndrome

Wegener's granulomatosis

Churg-Strauss syndrome

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Treatment

• Thoracentesis for symptomatic relief (500 – 1000 ml)
• Consider chest tube and pleurodesis
• Avoid rapid evacuation of all pleural fluid (reexpansion lung edema, PTHX)

Massive pleural effusion

Leading causes of pleural effusion in Nigeria

In decreasing order of incidence

• Pulmonary tuberculosis
• Congestive heart failure
• Pneumonia(bacterial, viral, parasitic)
• Cancer
• Pulmonary embolism
• Viral disease- HIV
• Cirrhosis with ascites

Haemothorax

= pleural fluid with Ht > 50% blood Ht

CAUSES:

• chest trauma: penetrating / non – penetrating

(lung blood vessels, chest wall, diaphragm, pleural adhesions, mediastinum, large vessels, abdomen)

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• iatrogenic

(pleural biopsy, subclavian or jugular CVC placement, thoracentesis, transthoracic or transbronchial NA, esophageal variceal TH,...)

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• nonthraumatic

(pleural malignancy, anticoagulant TH, spontaneous rupture of vessel (AO aneurism), bleeding disorder, thoracic endometriosis,...)

Haemothorax

Diagnosis:

• CXR
• chest CT – for all patients with severe chest trauma
• thoracentesis

transudate

haemothorax with higher attenuation (> 35 HU)

Haemothorax

Treatment

• Immediate tube thoracostomy
1. evacuation of blood
2. stop bleeding by apposition of pleural surfaces
3. evaluation of blood loss
4. may decrease incidence of empyema or fibrothorax
5. autotransfusion possible
• Thoracotomy (cca 15%)
• immediate drainage of > 20 ml/kg of blood
• persistent bleeding > 200 ml/h
• cardiac tamponade, vascular injury, pleural contamination, major air leaks,...
• Tx of shock, blood and fluid replacement,...

Haemothorax

Complications:

1. -retention of clotted blood (evacuation if > 30% of hemithorax)

2. - empyema (3 – 5%)

– shock, contamination, prolongued drainage, abdominal injuries

3. -exudative pleural effusion (15 – 30%)

4. -fibrothorax (< 1%)

Pleura and Covid-19

• Pleural effusions and pneumothoraces are infrequent findings in patients admitted due to COVID-19 pneumonia, worsened outcomes in these patients likely reflect an interplay between the severity of inflammation and parenchymal injury due to COVID-19 disease and underlying comorbidities.
• Pleural diseases encompass pleural effusion and pneumothorax (PTX), both of which were uncommon in coronavirus disease of 2019 (COVID-19)

Indication of Chest Intubation

Drain pleural fluid or air to promote lung expansion

1. Pneumothorax

2. Hydrothorax

3. Hemothorax

4. Chylothorax

5. Pyothorax

6. Post-thoracotomy etc.

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Miscellaneous Diseases of chest wall

• Tietze diseases (Costochondritis)
• Bornholm Disease (Viral inflammation- Coxsackie B)
• Shingles (Herpes Zoster)

Asbestos-Associated Diseases

• Respiratory diseases:
• Parenchymal (lungs) asbestosis
• Asbestos-related pleural abnormalities
• Lung carcinoma
• Pleural mesothelioma

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• Non-respiratory diseases:
• Peritoneal mesothelioma
• Possibly, other extra-thoracic cancers
• Rarely, cor pulmonale or constrictive pericarditis

Asbestos-Related Pleural Abnormalities

• Four types of abnormalities:
• Pleural plaques
• Benign asbestos pleural effusions
• Diffuse pleural thickening
• Rounded atelectasis
• Mostly asymptomatic, though some can cause dyspnea or cough
• Latency periods: 10-30 years �(shorter latency is for pleural effusion)

Malignant Pleural Mesothelioma

• Tumor arises from the thin serosal membrane surrounding the lungs
• Rapidly invasive
• Rare, although incidences are increasing
• Long latency period: Usually 30-40 years

Chest Radiograph Findings: �Parenchymal Asbestosis

• Small, irregular oval opacities

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• Interstitial fibrosis

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• “Shaggy heart �sign”

List of certified B Readers: http://www.cdc.gov/niosh/pamphlet.html

Chest Radiograph Findings: �Mesothelioma

• Pleural effusions

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• Pleural mass

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• Diffuse pleural

thickening

Neoplastic disease

• Bronchus Ca: squamous, small cell ca, adeno ca, large cell ca, broncho-alveolar ca
• Mesothelioma
• Metastatic ca
• Rare tumours: lymphoma, malt-lymphoma
• Benign tumours

Asbetosis

• This PA radiograph shows some of the typical findings of asbestosis including a "shaggy heart", pleural plaques and diaphragm calcification

Cardiopulmonary Syndromes Overview�

• Cardiopulmonary syndromes are conditions of the heart and lung that may be caused by cancer or by other health problems. Five cardiopulmonary syndromes that may be caused by cancer
• summary:
• Dyspnea (shortness of breath).
• Chronic cough.

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Cardiopulmonary Syndromes Overview

• Malignant pleural effusion (extra fluid around the lungs caused by cancer).
• Malignant pericardial effusion (extra fluid in the sac around the heart caused by cancer).
• Superior vena cava syndrome (a blocked superior vena cava, the large vein that takes blood back to the heart).

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Abnormal chest shapes

Chest wall abnormalities

Chest deformities

Clinical Manifestations

• Dyspnea, PND, orthopnea
• Cough: productive vs non-productive, volume, character, blood, post-nasal discharge
• Chest pain: ischaemic, pleuritic, chest wall, GE reflux, tearing of tissue
• Constitutional: fever, night sweats, weight loss
• RHF: swelling, pain R hypochondrium, abdominal distention, palpitations

Physical signs

• General: Cyanosis, anaemia, jaundice, oedema, lymphadenopathy, clubbing
• Respiratory examination:
• Observation
• Palpation
• Percussion
• Auscultation

Pleural disease- Investigations

• Pleural effusion: alb, LDH, pleural/serum, cholesterol, glucose, ADA, pH.
• exudate: infection, inflammation, neoplastic, blood (↑ permeability)
• transudate: hypoproteinemia (renal, liver - ↓ oncotic pressure), systemic venous hypertension (↑ hydrostatic pressure - Heart failure)
• Empyema
• Chylothorax, pseudo-chylothorax

Respiratory system

• signs of respiratory distress,
• hyperinflation,
• consolidation,
• pleural effusion,
• pneumothorax,
• sup vena cava obstruction

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End

• Study and work hard