chapter 25 pleural diseases. mosby items and derived items © 2009 by mosby, inc., an affiliate of...

Chapter 25Chapter 25

Pleural DiseasesPleural Diseases

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2

ObjectivesObjectives Describe important anatomic features and physiologic Describe important anatomic features and physiologic

function of the visceral and parietal pleural membranes.function of the visceral and parietal pleural membranes.

Describe how pleural effusions occur and the difference Describe how pleural effusions occur and the difference between transudative and exudative effusions.between transudative and exudative effusions.

Identify common causes of transudative and exudative Identify common causes of transudative and exudative pleural effusions.pleural effusions.

Write definitions of “chylothorax,” “hemothorax,” and Write definitions of “chylothorax,” “hemothorax,” and “pneumothorax.”“pneumothorax.”


Objectives (cont.)Objectives (cont.)

Describe the impact of moderate to large Describe the impact of moderate to large pleural effusions on lung function.pleural effusions on lung function.

State the role of the chest radiograph in State the role of the chest radiograph in recognizing pleural effusions.recognizing pleural effusions.

State the purpose of thoracentesis and the State the purpose of thoracentesis and the potential complications.potential complications.


Objectives (cont.)Objectives (cont.)

Identify the definitions of Identify the definitions of spontaneousspontaneous, , secondarysecondary, and , and tension pneumothoraxtension pneumothorax..

Describe the diagnosis and treatment of Describe the diagnosis and treatment of pneumothorax.pneumothorax.


The Pleural SpaceThe Pleural Space

Overview and definitionsOverview and definitions Visceral pleura cover each lung, while the Visceral pleura cover each lung, while the

parietal pleura covers the outer structures parietal pleura covers the outer structures that bound the lungs.that bound the lungs.


The Pleural Space (cont.)The Pleural Space (cont.)

Overview and definitions (cont.)Overview and definitions (cont.) Pleural fluid about 10 to 20 mm thick separates the Pleural fluid about 10 to 20 mm thick separates the

visceral from parietal pleura.visceral from parietal pleura. There is ~8 ml of fluid per hemithorax.There is ~8 ml of fluid per hemithorax. Pleural fluid is very similar to interstitial fluid.Pleural fluid is very similar to interstitial fluid. This fluid minimizes the friction caused by the lungs to This fluid minimizes the friction caused by the lungs to

expanding in the thorax during inspiration.expanding in the thorax during inspiration.

Pleural pressure is typically negative due to outward Pleural pressure is typically negative due to outward

thoracic recoil and inward recoil of lung.thoracic recoil and inward recoil of lung.


Pleural EffusionsPleural Effusions

Any abnormal accumulation of fluid in the Any abnormal accumulation of fluid in the pleura is considered a pleural effusion.pleura is considered a pleural effusion.

Fluid enters the pleural space from visceral Fluid enters the pleural space from visceral and parietal pleurae, particularly in face of and parietal pleurae, particularly in face of increased pressure.increased pressure. Stomata that connect to lymphatic system remove Stomata that connect to lymphatic system remove

fluid from this space.fluid from this space. Either increased fluid production or blockage of Either increased fluid production or blockage of

drainage can result in pleural effusions.drainage can result in pleural effusions.


Pleural Effusions (cont.)Pleural Effusions (cont.)



Transudative effusionsTransudative effusions Any effusion that forms while pleural space is Any effusion that forms while pleural space is

undamaged will have [protein] <50% of serum level undamaged will have [protein] <50% of serum level and LDH <60% of serum leveland LDH <60% of serum level

Specific causes of transudative effusionsSpecific causes of transudative effusions CHF: high hydrostatic pressure increases pleura fluid CHF: high hydrostatic pressure increases pleura fluid

production, most common cause of effusionsproduction, most common cause of effusions

Nephrotic syndrome: protein loss in urine results in Nephrotic syndrome: protein loss in urine results in low capillary oncotic pressure and fluid third spacinglow capillary oncotic pressure and fluid third spacing


Pleural Effusions (cont.)Pleural Effusions (cont.)Specific causes of transudative effusions (cont.)Specific causes of transudative effusions (cont.) Hypoalbuminemia: different cause but mimics aboveHypoalbuminemia: different cause but mimics above

Liver disease: ascites fluid moves through small holes Liver disease: ascites fluid moves through small holes in diaphragm, almost always on right sidein diaphragm, almost always on right side

Atelectasis: cause pleural pressures to become more Atelectasis: cause pleural pressures to become more negative resulting in small effusionsnegative resulting in small effusions

Lymphatic obstruction: blockage prevents drainage Lymphatic obstruction: blockage prevents drainage and results in accumulationand results in accumulation



Exudative effusionsExudative effusions Occur due to inflammation of lung or pleura and will Occur due to inflammation of lung or pleura and will

have a higher protein and inflammatory cell contenthave a higher protein and inflammatory cell content

Thoracentesis may be performed to determine type.Thoracentesis may be performed to determine type.Specific causes of exudative effusionsSpecific causes of exudative effusions Parapneumonic: secondary to lung inflammation Parapneumonic: secondary to lung inflammation

associated with pneumoniaassociated with pneumonia Complicated if clots form and loculate fluidComplicated if clots form and loculate fluid Persistent fever may signal an empyema, which must be Persistent fever may signal an empyema, which must be

drained for recoverydrained for recovery



Specific causes of exudative effusions (cont.)Specific causes of exudative effusions (cont.) Viral pleurisy: presents with inflammation and painViral pleurisy: presents with inflammation and pain

Pain may result in atelectasis and hypoxemia.Pain may result in atelectasis and hypoxemia.

Tuberculous pleurisy: occurs when caseous Tuberculous pleurisy: occurs when caseous granulomas rupture viscera pleura and drain into granulomas rupture viscera pleura and drain into pleural spacepleural space Patients need to be isolated.Patients need to be isolated.

Malignancy: most common cause of large unilateral Malignancy: most common cause of large unilateral

effusions, most require pleurodesis to treateffusions, most require pleurodesis to treat



Specific causes of exudative effusions (cont.)Specific causes of exudative effusions (cont.) Postoperative: common following abdominal or Postoperative: common following abdominal or

thoracic surgerythoracic surgery

Chylothorax: caused by rupture of thoracic duct, 50% Chylothorax: caused by rupture of thoracic duct, 50% malignant, 20% surgicalmalignant, 20% surgical Fluid may be white or yellow, sometimes bloodyFluid may be white or yellow, sometimes bloody

Hemothorax: trauma or blood vessel hemorrhage into Hemothorax: trauma or blood vessel hemorrhage into pleura spacepleura space Hematocrit > 50% of serum levelHematocrit > 50% of serum level


Physiological Importance of Physiological Importance of Pleural EffusionsPleural Effusions

Mechanics of ventilationMechanics of ventilation Effusions cause atelectasis due to limited thoracic Effusions cause atelectasis due to limited thoracic

space resulting in restrictive pattern on PFTs.space resulting in restrictive pattern on PFTs.

Patients commonly dyspneic even with small effusionsPatients commonly dyspneic even with small effusions

Rarely cause fibrothorax with true restrictive impairmentRarely cause fibrothorax with true restrictive impairment

HypoxemiaHypoxemia Most effusions cause increased P(A – a)OMost effusions cause increased P(A – a)O22, which may , which may

worsen following thoracentesis.worsen following thoracentesis.


Diagnostic Tests for Diagnostic Tests for Pleural EffusionsPleural Effusions

Chest radiographyChest radiography Most common method of detecting effusionsMost common method of detecting effusions

Upright PA and lateral decubitus are useful.Upright PA and lateral decubitus are useful. 1-cm meniscus lung to rib allows for thoracentesis1-cm meniscus lung to rib allows for thoracentesis


Diagnostic Tests for Pleural Diagnostic Tests for Pleural Effusions (cont.)Effusions (cont.)

Ultrasonography and computed tomographyUltrasonography and computed tomography Ultrasound is very sensitive to pleural Ultrasound is very sensitive to pleural

effusions.effusions. May use to localize and direct for thoracentesisMay use to localize and direct for thoracentesis

Contrast-enhanced CT is most sensitive Contrast-enhanced CT is most sensitive study for effusions.study for effusions.



ThoracentesisThoracentesis Percutaneous needle aspiration of effusion samplePercutaneous needle aspiration of effusion sample

Drainage for lung reexpansion involves placement of Drainage for lung reexpansion involves placement of a chest tubea chest tube

Risks includeRisks include Artery lacerationArtery laceration InfectionInfection PneumothoraxPneumothorax



Thoracoscopy (video-assisted)Thoracoscopy (video-assisted) Ideally designed for diagnostic and Ideally designed for diagnostic and

therapeutic pleural procedurestherapeutic pleural procedures

Allows visualization of surfaces, drainage of Allows visualization of surfaces, drainage of effusion, biopsy, and pleurodesis if neededeffusion, biopsy, and pleurodesis if needed


Management for Pleural Management for Pleural EffusionsEffusions

Chest thoracotomy tubesChest thoracotomy tubes Designed for tight fit in tissues to avoid leaks Designed for tight fit in tissues to avoid leaks

and allow drainage of effusion and subsequent and allow drainage of effusion and subsequent lung reexpansionlung reexpansion

Tube is attached to chest drainage unit.Tube is attached to chest drainage unit.


Management for Pleural Management for Pleural Effusions (cont.) Effusions (cont.)

Pleurodesis Pleurodesis Process fusing parietal and visceral pleurae, Process fusing parietal and visceral pleurae,

which prevents further formation of effusionswhich prevents further formation of effusions

Can be performed by surgical abrasion or Can be performed by surgical abrasion or introduction of chemical irritant, most commonly introduction of chemical irritant, most commonly talctalc


Management for Pleural Management for Pleural Effusions (cont.)Effusions (cont.)

Pleuroperitoneal shunt and Pleurex catheterPleuroperitoneal shunt and Pleurex catheter For effusions refractory to all other treatment For effusions refractory to all other treatment

optionsoptions

Small pump moves fluid from pleura to Small pump moves fluid from pleura to peritoneal cavity.peritoneal cavity.

Pleurex catheter connects to suction at home Pleurex catheter connects to suction at home to drain persistent effusions.to drain persistent effusions.


PneumothoraxPneumothorax Defined as air in the pleural space which can occur Defined as air in the pleural space which can occur

through a number of mechanismsthrough a number of mechanisms

Traumatic pneumothoraxTraumatic pneumothorax Penetrating chest traumaPenetrating chest trauma

Common secondary to bullet or knife penetrationCommon secondary to bullet or knife penetration Chest tube is usually adequate to treat.Chest tube is usually adequate to treat. May require surgery if bleeding is severeMay require surgery if bleeding is severe

Blunt traumaBlunt trauma Broken ribs puncture lung with air escape into pleura.Broken ribs puncture lung with air escape into pleura. Chest tube is all that is generally required.Chest tube is all that is generally required.


Pneumothorax (cont.)Pneumothorax (cont.)

Blunt trauma (cont.)Blunt trauma (cont.) Tracheal fracture and esophageal ruptureTracheal fracture and esophageal rupture

• These are two special causes of pneumothorax that These are two special causes of pneumothorax that require surgical repair.require surgical repair.

IatrogenicIatrogenic Most common cause of traumatic pneumothoraxMost common cause of traumatic pneumothorax Common iatrogenic causes areCommon iatrogenic causes are

• Needle aspiration lung biopsyNeedle aspiration lung biopsy

• ThoracentesisThoracentesis

• Central venous catheter placementCentral venous catheter placement


Pneumothorax (cont.)Pneumothorax (cont.)Neonatal Neonatal Spontaneous pneumothorax occurs in 1–2% of infantsSpontaneous pneumothorax occurs in 1–2% of infants

Likely caused by high transpulmonary pressures and Likely caused by high transpulmonary pressures and transient bronchial blockage (i.e. meconium)transient bronchial blockage (i.e. meconium)

Recognition is difficultRecognition is difficult Contralateral heart sounds may be a clue.Contralateral heart sounds may be a clue. Transillumination of thorax may be useful. Transillumination of thorax may be useful.

Most neonates with this condition require chest tubes.Most neonates with this condition require chest tubes.



SpontaneousSpontaneous Pneumothorax with no obvious causePneumothorax with no obvious cause

Primary spontaneous pneumothoraxPrimary spontaneous pneumothorax Occurs with no underlying lung diseaseOccurs with no underlying lung disease Most (80%) have small subpleural blebsMost (80%) have small subpleural blebs Typically happens in tall, thin, young adultsTypically happens in tall, thin, young adults >90% have had short-term smoking history>90% have had short-term smoking history

• Smoking cessation recommendedSmoking cessation recommended



Secondary spontaneous pneumothoraxSecondary spontaneous pneumothorax Occurs with underlying lung diseaseOccurs with underlying lung disease

• Most common associated disease is COPDMost common associated disease is COPD

• Also seen during exacerbations of asthma and CFAlso seen during exacerbations of asthma and CF

• Interstitial lung diseases with normal lung volumesInterstitial lung diseases with normal lung volumes Sarcoidosis, BOOPSarcoidosis, BOOP

Depending on extent of disease, pneumothorax Depending on extent of disease, pneumothorax can be devastatingcan be devastating• 43% 5-year mortality43% 5-year mortality

Evacuation, not observation, should be the Evacuation, not observation, should be the standard of care with these patients.standard of care with these patients.


Pneumothorax (cont.)Pneumothorax (cont.)ComplicationsComplications Tension pneumothoraxTension pneumothorax

Pleural air pressure exceeds atmospheric pressurePleural air pressure exceeds atmospheric pressure Radiographic appearanceRadiographic appearance

• Mediastinal shift, diaphragmatic depression, flattened ribsMediastinal shift, diaphragmatic depression, flattened ribs

Clinical presentationClinical presentation• Venous return and cardiac output decrease with Venous return and cardiac output decrease with

hypotension and tachycardiahypotension and tachycardia

• Hypoxemia due to alveolar collapseHypoxemia due to alveolar collapse

Treatment: emergency needle decompression Treatment: emergency needle decompression



ComplicationsComplications Reexpansion pulmonary edemaReexpansion pulmonary edema

Occurs following rapid lung reexpansion Occurs following rapid lung reexpansion particularly:particularly:• From low lung volumesFrom low lung volumes

• Long duration pneumothorax Long duration pneumothorax

• High pressure gradient across lungHigh pressure gradient across lung

May be related to reperfusion injuryMay be related to reperfusion injury Lung reexpansion should be slowLung reexpansion should be slow

• First, just waterseal, no suctionFirst, just waterseal, no suction

• If lung fails to reexpand, then apply suctionIf lung fails to reexpand, then apply suction



DiagnosisDiagnosis Chest radiographyChest radiography

Requires good quality film Requires good quality film In ICU, 30% of pneumothoraces are missed due In ICU, 30% of pneumothoraces are missed due

to:to:• Low-quality filmLow-quality film

• Supine position of patient on AP filmSupine position of patient on AP film• Air hidden behind thoracic or mediastinal structuresAir hidden behind thoracic or mediastinal structures

CT may be used to confirm size and CT may be used to confirm size and presence of pneumothorax.presence of pneumothorax.



TherapyTherapy OxygenOxygen

Should be administered to all patientsShould be administered to all patients Supplemental OSupplemental O22 speeds absorption of air from speeds absorption of air from

pleural spacepleural space

Observation of stable patientsObservation of stable patients Primary: observe 4 hours, if no enlargement: homePrimary: observe 4 hours, if no enlargement: home Secondary and iatrogenic: hospitalize and observe Secondary and iatrogenic: hospitalize and observe

carefully, carefully, • If there is any deterioration (SpOIf there is any deterioration (SpO22, RR, etc) - drain , RR, etc) - drain



TherapyTherapy Simple aspirationSimple aspiration

Small catheter placed in pleural spaceSmall catheter placed in pleural space Connect to three-way stopcockConnect to three-way stopcock Slowly evacuate until no more air can be removedSlowly evacuate until no more air can be removed This works as many leaks heal between time of This works as many leaks heal between time of

leak and its drainage.leak and its drainage.

If 4 L air is removed without resistance, chest If 4 L air is removed without resistance, chest tube placement is requiredtube placement is required


Pneumothorax (cont.)Pneumothorax (cont.)TherapyTherapy Chest tubes buy timeChest tubes buy time

Resolution is mostly determined by lung healing Resolution is mostly determined by lung healing Small bore: placed via small incision in second Small bore: placed via small incision in second

intercostal space (ICS), midclavicular line or intercostal space (ICS), midclavicular line or laterally, fifth–seventh ICSlaterally, fifth–seventh ICS• Connected to underwater seal or Heimlich valveConnected to underwater seal or Heimlich valve

Large bore: placed via blunt dissection, usually Large bore: placed via blunt dissection, usually connected to “three-bottle” chest drainage systemconnected to “three-bottle” chest drainage system

Chest tubes are sutured in placeChest tubes are sutured in place

Pleurodesis: consider with recurrent pneumothoracesPleurodesis: consider with recurrent pneumothoraces



Bronchopleural fistulaBronchopleural fistula Usually used to refer to large, persistent air leaksUsually used to refer to large, persistent air leaks

Most are on MVMost are on MV PPV perpetuates the leakPPV perpetuates the leak

May require more than one chest tubeMay require more than one chest tube Aids restoring lung proximity to chest wall and promotes Aids restoring lung proximity to chest wall and promotes

healinghealing

Avoid auto-PEEP, consider bronchoscopic closure or Avoid auto-PEEP, consider bronchoscopic closure or thoracoscopic surgerythoracoscopic surgery

chapter 25 pleural diseases. mosby items and derived items © 2009 by mosby, inc., an affiliate of...

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