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Pleural DiseasesPleural Diseases

Pleural effusionPleural effusion

PneumothoraxPneumothorax

By : John J. Beneck PA-C, MSPA

“Is that supposed to be in there?”

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Case 1Case 1

72 year old female with history of heart 72 year old female with history of heart failure presents with DOE. Recently failure presents with DOE. Recently stopped her evening furosemide because stopped her evening furosemide because she was “sick of going to the bathroom all she was “sick of going to the bathroom all night”.night”.

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Case 2Case 2

52 Year old male who presents with slowly 52 Year old male who presents with slowly worsening DOE, vague CP, and weight worsening DOE, vague CP, and weight loss. Hx reveals long term occupation as loss. Hx reveals long term occupation as auto mechanic specializing in brake work.auto mechanic specializing in brake work.

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Case 3Case 3

19 year old male awakened with vague right 19 year old male awakened with vague right chest pain, worse with inspiration. Steadily chest pain, worse with inspiration. Steadily worsening throughout the day. Now severe worsening throughout the day. Now severe (9/10) and short of breath.(9/10) and short of breath.

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ObjectivesObjectives

Definition/types/classificationsDefinition/types/classifications EpidemiologyEpidemiology PresentationPresentation Etiology/pathologyEtiology/pathology Diagnosis/StudiesDiagnosis/Studies Interventions/TherapeuticsInterventions/Therapeutics

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AbbreviationsAbbreviations

Abx - AntibioticsAbx - Antibiotics AFB – Acid fast BacilliAFB – Acid fast Bacilli BPD – Brochopulmonary BPD – Brochopulmonary

DysplagiaDysplagia Bx - BiopsyBx - Biopsy CF – Cystic FibrosisCF – Cystic Fibrosis COPD – Chronic Obstructive COPD – Chronic Obstructive

Pulmonary DiseasePulmonary Disease CXR – Chest X rayCXR – Chest X ray

CP – CostophrenicCP – Costophrenic DOE – Dyspnea on exertionDOE – Dyspnea on exertion DDx – Differential diagnosisDDx – Differential diagnosis Dz – DiseaseDz – Disease HA - HeadacheHA - Headache LDH – Lactate dehydrogenaseLDH – Lactate dehydrogenase PMN – PolymorphonucleocytePMN – Polymorphonucleocyte Tx – TreatmentTx – Treatment

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Pleural EffusionPleural Effusion

Excessive pleural fluidExcessive pleural fluid

– Fluid in the space between the lung and the Fluid in the space between the lung and the

chest wall.chest wall.

UpToDate: April 2009 8

Pleural Effusion - EpidemiologyPleural Effusion - Epidemiology

Can result from over 50 Pleuropulmonary Can result from over 50 Pleuropulmonary or systemic disordersor systemic disorders

Source is NOT evident following diagnostic Source is NOT evident following diagnostic thoracentesis in up to 25 percent of patientsthoracentesis in up to 25 percent of patients

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Normal Pleural FluidNormal Pleural Fluid

20ml/day produced20ml/day produced

<10ml present at any one time<10ml present at any one time

1-1.5 Grams/100ml protein1-1.5 Grams/100ml protein

Few mononuclear cellsFew mononuclear cells

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Effusion PresentationEffusion Presentation

Typically Associated with underlying DzTypically Associated with underlying Dz– DyspneaDyspnea

– Chest painChest pain

– HypoxemiaHypoxemia

– CXRCXR Blunt CP angle, forms meniscusBlunt CP angle, forms meniscus Lateral Decubitus filmLateral Decubitus film

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ExamExam

Decreased Expansion (Decreased Expansion (>> 750 ml) 750 ml) Decreased Fremitus (Decreased Fremitus (>> 750 ml) 750 ml) Dull/flat percussionDull/flat percussion Decreased Breath soundsDecreased Breath sounds EgophonyEgophony Mediastinal shift (>1500 ml)Mediastinal shift (>1500 ml)

UpToDate 2009 12

Pleural Effusion ImagingPleural Effusion Imaging

Merckmedicus 2008 13

Large EffusionLarge Effusion

UpToDate 2009 14

Left Pleural EffusionLeft Pleural Effusion

Notice the arc

UpToDate 2009 15

Loculated Pleural EffusionLoculated Pleural Effusion

UpToDate 2009 16

CT Evidence of EffusionCT Evidence of Effusion

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Diagnosis – Etiology is KeyDiagnosis – Etiology is Key

– Most pleural effusions require further Most pleural effusions require further

evaluation unless their origin is clear (e.g., evaluation unless their origin is clear (e.g.,

heart failure, ascites) and the patient is heart failure, ascites) and the patient is

responding well to therapyresponding well to therapy

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Pleural Effusion EtiologyPleural Effusion Etiology

Why does fluid accumulate?Why does fluid accumulate?– Abnormal productionAbnormal production– Leaking or dischargeLeaking or discharge– Abnormal absorptionAbnormal absorption

Narrowing the DDxNarrowing the DDx– HistoryHistory– Effusion sampling/analysisEffusion sampling/analysis

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Dx Starts With ClassificationDx Starts With Classification

TypesTypes

– TransudativeTransudative

– ExudativeExudative

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Pleural EffusionPleural Effusion

Transudative pleural effusions Transudative pleural effusions

– Formed when the normal hydrostatic or oncotic Formed when the normal hydrostatic or oncotic

pressures are disturbed.pressures are disturbed. Increased mean capillary pressure (heart failure)Increased mean capillary pressure (heart failure)

Decreased capillary oncotic pressure (cirrhosis or Decreased capillary oncotic pressure (cirrhosis or

nephrotic syndrome)nephrotic syndrome)

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Pleural Effusion Pleural Effusion

Exudative pleural effusions Exudative pleural effusions – Occur when there is damage or disruption of Occur when there is damage or disruption of

the normal pleural membranes or vasculature the normal pleural membranes or vasculature Increased capillary permeability (Inflamation, Increased capillary permeability (Inflamation,

neoplasm)neoplasm) Decreased lymphatic drainage (e.g., tumor Decreased lymphatic drainage (e.g., tumor

involvement of the pleural space, infection, involvement of the pleural space, infection, inflammatory conditions, or trauma)inflammatory conditions, or trauma)

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Exudative Effusion (cont.)Exudative Effusion (cont.)

– ChylothoraxChylothorax

– Pulmonary emboliPulmonary emboli

– ParapneumonicParapneumonic

– MalignancyMalignancy

– Drug or radiation reactionsDrug or radiation reactions

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Exudates – Light’s CriteriaExudates – Light’s Criteria

ExudatesExudates have at least one (and transudates have at least one (and transudates NONE) of the following:NONE) of the following:– (Pleural fluid : serum) protein ratio more than (Pleural fluid : serum) protein ratio more than

0.50.5

– (Pleural fluid : serum) lactate dehydrogenase (Pleural fluid : serum) lactate dehydrogenase (LDH) ratio more than 0.6(LDH) ratio more than 0.6

– Pleural fluid LDH more than two-thirds of the Pleural fluid LDH more than two-thirds of the upper limit of normal for serum LDHupper limit of normal for serum LDH

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Gross Analysis of Pleural FluidGross Analysis of Pleural Fluid

BloodBlood– Pulmonary infarctionPulmonary infarction

– TumorTumor

– TraumaTrauma

– (Pleural fluid : blood) hematocrit ratio more than 0.5 (Pleural fluid : blood) hematocrit ratio more than 0.5 establishes the diagnosis of a establishes the diagnosis of a HemothoraxHemothorax

OdorOdor ColorColor ViscosityViscosity

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Lab Analysis of Pleural FluidLab Analysis of Pleural Fluid

pHpH

GlucoseGlucose

LDHLDH

AmylaseAmylase

TriglyceridesTriglycerides

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Other Studies Other Studies Cell count and differentialCell count and differential ProteinProtein Microbiologic stainsMicrobiologic stains

– Wright’sWright’s– GramGram– AFBAFB– FungalFungal

CulturesCultures CytologyCytology

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Now… about these Now… about these studies… studies…

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pH Less Than 7.3pH Less Than 7.3

EmpyemaEmpyema

TuberculosisTuberculosis

MalignancyMalignancy

Connective tissue diseaseConnective tissue disease

Esophageal ruptureEsophageal rupture

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Glucose Concentration Less Glucose Concentration Less Than 40 mg/dlThan 40 mg/dl

EmpyemaEmpyema

TuberculosisTuberculosis

MalignancyMalignancy

Connective tissue diseaseConnective tissue disease

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Elevation of AmylaseElevation of Amylase

PancreatitisPancreatitis Pancreatic pseudocystPancreatic pseudocyst

MalignancyMalignancy Esophageal ruptureEsophageal rupture

PancreaticPancreatic

SalivarySalivary

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Elevation of Triglycerides Elevation of Triglycerides (>110 mg/dl)(>110 mg/dl)

Chylous effusionsChylous effusions

– Thoracic duct rupture from trauma, surgery, or Thoracic duct rupture from trauma, surgery, or

malignancy (usually lymphoma)malignancy (usually lymphoma)

Chyliform effusionsChyliform effusions

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Last Resort for DiagnosisLast Resort for Diagnosis

Closed Pleural BiopsyClosed Pleural Biopsy

– Exudative pleural effusion indeterminate by Exudative pleural effusion indeterminate by

thoracentesisthoracentesis

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Pleural Effusion Treatment Pleural Effusion Treatment -General--General-

Variable depending on effusion type and Variable depending on effusion type and

symptomatologysymptomatology

– To drain, or not to drainTo drain, or not to drain

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Symptomatic Pleural EffusionsSymptomatic Pleural Effusions

May require removal of large amounts of May require removal of large amounts of

pleural fluidpleural fluid

Rapid removal of > 1 liter of fluid may Rapid removal of > 1 liter of fluid may

rarely result in ipsilateral pulmonary edemararely result in ipsilateral pulmonary edema

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2 Specific Exudative Effusions2 Specific Exudative Effusions

Parapneumonic effusionsParapneumonic effusions

Malignant effusionsMalignant effusions

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Parapneumonic Effusions Parapneumonic Effusions

Associated with bacterial pneumoniaAssociated with bacterial pneumonia

Exudates with a leukocyte count usually more Exudates with a leukocyte count usually more

than 10,000/mmthan 10,000/mm3 3 and a predominance of PMNsand a predominance of PMNs

Thoracentesis is required to identify pathogen(s)Thoracentesis is required to identify pathogen(s)

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Parapneumonic Effusions (cont.)Parapneumonic Effusions (cont.)

Incidence/epidemiology:Incidence/epidemiology:– S. pneumoS. pneumo

40-60% 40-60%

– S. aureus S. aureus Most without empyemaMost without empyema 70% in infants70% in infants 40% in adults40% in adults

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Parapneumonic Effusions (cont.)Parapneumonic Effusions (cont.)

Incidence/epidemiology:Incidence/epidemiology:– S. pyogenesS. pyogenes

Uncommon etiology of pneumoniaUncommon etiology of pneumonia 55-95% have large effusion55-95% have large effusion

– Gram (-) Gram (-) KlebsiellaKlebsiella E. coliE. coli PseudomonasPseudomonas

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Parapneumonic Effusion TypesParapneumonic Effusion Types

ComplicatedComplicated

UncomplicatedUncomplicated

Helps differentiate the need for chest tube drainageHelps differentiate the need for chest tube drainage--Who cares?----Who cares?--

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Uncomplicated Parapneumonic Uncomplicated Parapneumonic EffusionEffusion

pH >7.30pH >7.30

Glucose >60 mg/dlGlucose >60 mg/dl

LDH of <500 IU/literLDH of <500 IU/liter

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UncomplicatedUncomplicated Parapneumonic Parapneumonic EffusionsEffusions

Should resolve with antimicrobial therapy Should resolve with antimicrobial therapy

for the underlying pneumoniafor the underlying pneumonia

Suspect “complicated” if:Suspect “complicated” if:

– Temp incr. despite abx txTemp incr. despite abx tx

– Pt develops incr. Pleural fluid despite txPt develops incr. Pleural fluid despite tx

– Loculated effusion developsLoculated effusion develops

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Complicated Parapneumonic Complicated Parapneumonic EffusionEffusion

pH <7.10pH <7.10

Glucose <40 mg/dlGlucose <40 mg/dl

LDH >1,000 lU/liter)LDH >1,000 lU/liter)

Merckmedicus 2008 43

Complicated Parapneumonic Complicated Parapneumonic EffusionEffusion

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ComplicatedComplicated Parapneumonic Parapneumonic EffusionsEffusions

Should be considered for immediate Should be considered for immediate drainagedrainage

Occasional patients (e.g., Occasional patients (e.g., Streptococcus Streptococcus pneumoniae pneumoniae infections) appear to do well infections) appear to do well without drainagewithout drainage

No established role for repeated therapeutic No established role for repeated therapeutic thoracenteses in the treatment of thoracenteses in the treatment of complicated parapneumonic effusions.complicated parapneumonic effusions.

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EmpyemaEmpyema

DrainDrain

AntibioticsAntibiotics

Consider thoracotomy with decorticationConsider thoracotomy with decortication

– Most effective for chronic empyema which Most effective for chronic empyema which

does not drain completelydoes not drain completely

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Malignant Pleural EffusionsMalignant Pleural Effusions

Tumor involvement of the pleura or Tumor involvement of the pleura or

mediastinummediastinum

Malignant mesotheliomaMalignant mesothelioma

Cytology is positive in approximately Cytology is positive in approximately 60%60%

of malignant effusionsof malignant effusions

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Malignant Pleural EffusionsMalignant Pleural Effusions

Therapeutic thoracentesisTherapeutic thoracentesis

Chemotherapy and mediastinal radiation Chemotherapy and mediastinal radiation

therapytherapy

ObservationObservation

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Recurrent Malignant EffusionsRecurrent Malignant Effusions

Repeated thoracenteses are reasonableRepeated thoracenteses are reasonable

Complete drainage via chest tube followed Complete drainage via chest tube followed

by adhesive therapyby adhesive therapy

– Pleurectomy or pleural abrasionPleurectomy or pleural abrasion Requires thoracotomyRequires thoracotomy

– Chemical sclerosisChemical sclerosis

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Epidemic Pleurodynia Epidemic Pleurodynia (Bornholm Disease)(Bornholm Disease)

Caused by Group B CoxsackievirusCaused by Group B Coxsackievirus Milder in childrenMilder in children Epigastric or lower anterior chest painEpigastric or lower anterior chest pain

– SuddenSudden

– SevereSevere

– Frequently intermittent and/or pleuriticFrequently intermittent and/or pleuritic

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Pleurodynia (cont.)Pleurodynia (cont.)

Fever, HA, sore throat, malaiseFever, HA, sore throat, malaise

Local tenderness, hyperesthesia, muscle Local tenderness, hyperesthesia, muscle

swellingswelling

MyalgiasMyalgias

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Pleurodynia (cont.)Pleurodynia (cont.)

Course:Course:– Subsides in 2-4 daysSubsides in 2-4 days– May relapse/recur for several weeksMay relapse/recur for several weeks

ComplicationsComplications– OrchitisOrchitis– Fibrinous pleuritisFibrinous pleuritis– PericarditisPericarditis– Asceptic meningitis (rare)Asceptic meningitis (rare)

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Pleurodynia (cont.)Pleurodynia (cont.)

DiagnosisDiagnosis– Usually epidemicUsually epidemic– Sporadic cases may be isolated from throat or Sporadic cases may be isolated from throat or

stoolstool TreatmentTreatment

– SymptomaticSymptomatic PrognosisPrognosis

– Good in uncomplicated casesGood in uncomplicated cases

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PneumothoraxPneumothorax

ClosedClosed

OpenOpen

TensionTension

Merckmedicus 2008 54

PneumothoraxPneumothorax

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Spontaneous PneumothoraxSpontaneous Pneumothorax

PrimaryPrimary

– No other concurrant lung dzNo other concurrant lung dz

SecondarySecondary

– Occurs with concurrent lung dzOccurs with concurrent lung dz BPD, CF, COPD, S. aureus infection, InfarcBPD, CF, COPD, S. aureus infection, Infarc

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Pneumothorax (other)Pneumothorax (other)

TraumaticTraumatic

IatrogenicIatrogenic

– ThoracentesisThoracentesis

– Pleural BxPleural Bx

– Central line placementCentral line placement

– Ventilator associatedVentilator associated

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Clinical PresentationClinical Presentation

Chest painChest pain DyspneaDyspnea HypoxemiaHypoxemia HypotensionHypotension Non-productive cough (10%)Non-productive cough (10%) Sudden or insidious onsetSudden or insidious onset

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ExamExam

Incr. resonanceIncr. resonance Decr. fremitousDecr. fremitous Decr. breath soundsDecr. breath sounds Hamman’s sign (<5%)Hamman’s sign (<5%)

– Crackling with heartbeatCrackling with heartbeat

Subcutaneous emphysema (rare)Subcutaneous emphysema (rare) CXRCXR

– Identify visceral pleural lineIdentify visceral pleural line

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X RayX Ray PneumothoraxPneumothorax

2 -UpToDate2 -UpToDate

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X RayX Ray

Tension PneumothoraxTension Pneumothorax

2 - UpToDate2 - UpToDate

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Treatment OptionsTreatment Options

ObserveObserve

Bed restBed rest

OxygenOxygen

Needle decompressionNeedle decompression

Tube thorocostomyTube thorocostomy

– Continue 24-48 hrs after last air leakContinue 24-48 hrs after last air leak

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Basis For Treatment DecisionBasis For Treatment Decision

Patient presentationPatient presentation Likelihood of resolutionLikelihood of resolution Likelihood of recurrenceLikelihood of recurrence

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ResolutionResolution

3-4 weeks3-4 weeks

1.25% hemithorax per day1.25% hemithorax per day

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In ReviewIn Review

Pleural diseases typically manifested as Pleural diseases typically manifested as

symptomatic effusionsymptomatic effusion

– TransudateTransudate

– ExudateExudate

– Presence of bacteriaPresence of bacteria

– Presence of malignant cellsPresence of malignant cells

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PneumothoraxPneumothorax

Spontaneous vs. nonspontaneousSpontaneous vs. nonspontaneous

Support & observe vs. decompressSupport & observe vs. decompress

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What about those cases…What about those cases…

72 year old female with history of heart failure presents 72 year old female with history of heart failure presents with DOE. Recently stopped her evening furosemide with DOE. Recently stopped her evening furosemide because she was “sick of going to the bathroom all night”.because she was “sick of going to the bathroom all night”.

52 Year old male who presents with slowly worsening 52 Year old male who presents with slowly worsening DOE, vague CP, and weight loss. Hx reveals long term DOE, vague CP, and weight loss. Hx reveals long term occupation as auto mechanic specializing in brake work.occupation as auto mechanic specializing in brake work.

19 year old male awakened with vague right chest pain, 19 year old male awakened with vague right chest pain, worse with inspiration. Steadily worsening throughout the worse with inspiration. Steadily worsening throughout the day. Now severe (9/10) and short of breath.day. Now severe (9/10) and short of breath.