Dr.Ahmed Al-AzzawiDr.Ahmed Al-Azzawi

M.B.Ch.B,F.I.C.M.SM.B.Ch.B,F.I.C.M.S

Cardiothoracic&Vascular SurgeonCardiothoracic&Vascular Surgeon

University of SulaimaniUniversity of Sulaimani

College of MedicineCollege of Medicine

Thoracic SurgeryThoracic Surgery

DISEASES OF THE DISEASES OF THE PLEURA AND PLEURA AND

PLEURAL SPACEPLEURAL SPACE

Dr . Ahmed AlazzawiDr . Ahmed Alazzawi College of Medicine College of Medicine

5th year students Lectures5th year students Lectures

2010-20112010-2011

Pleural cavityPleural cavity The The pleurapleura is a is a serous membraneserous membrane which folds which folds

back onto itself to form a two-layered, membrane back onto itself to form a two-layered, membrane structureThe two surfaces are normaly in structureThe two surfaces are normaly in apposition,lubricated by a thin layer of serous apposition,lubricated by a thin layer of serous fluid secreted by the mesothelium so that the fluid secreted by the mesothelium so that the steady motion of normal respiration is steady motion of normal respiration is accomplished without friction.accomplished without friction.

The pleural space the thin space between the two The pleural space the thin space between the two pleural layers is known as the pleural cavity; it pleural layers is known as the pleural cavity; it normally contains a small amount of pleural fluid. normally contains a small amount of pleural fluid.

The outer pleura (The outer pleura (parietal pleuraparietal pleura) is attached to ) is attached to the the chest wallchest wall. The inner pleura (. The inner pleura (visceral pleuravisceral pleura) ) covers the lungs and adjoining structures covers the lungs and adjoining structures blood vesselsblood vessels, , bronchibronchi and and nervesnerves..

The parietal pleura is highly sensitive to pain The parietal pleura is highly sensitive to pain while the visceral pleura is not, due to its lack of while the visceral pleura is not, due to its lack of sensory innervation.sensory innervation.

Pleural effusionPleural effusion

AA pleural effusion is an accumilation of fluid in the pleural pleural effusion is an accumilation of fluid in the pleural space .Normally ,the balance of hydrostatic and colloid space .Normally ,the balance of hydrostatic and colloid osmotic forces favores the movement of fluid from systemic osmotic forces favores the movement of fluid from systemic capillaries in the parietal pleura to pulmonary capillaries.It capillaries in the parietal pleura to pulmonary capillaries.It is estimated that between 5 and 10 L of protien- free fluid is estimated that between 5 and 10 L of protien- free fluid traverses the pleural space in 24 hr.traverses the pleural space in 24 hr.

Alterations in systemic hydrostatic or colloid osmotic Alterations in systemic hydrostatic or colloid osmotic pressure that disturb the balance of forces across normal pressure that disturb the balance of forces across normal pleural surfaces produce an effusion consisting of aprotein pleural surfaces produce an effusion consisting of aprotein poor ultrafiltrate of plasma classified as poor ultrafiltrate of plasma classified as atransudateatransudate.Changes in capillary permeability caused by .Changes in capillary permeability caused by inflammation or infiltration of the pleura produce a protein inflammation or infiltration of the pleura produce a protein rich effusion classified as an rich effusion classified as an exudateexudate

SymptomsSymptoms

Chest painChest pain, usually a sharp pain that , usually a sharp pain that is worse with cough or deep breaths is worse with cough or deep breaths

CoughCough Fever Fever Hiccups Hiccups Rapid breathing Rapid breathing Shortness of breath Shortness of breath

DiagnosisDiagnosis::

Chest x-ray:oblitration of Chest x-ray:oblitration of costophrenic angle suggests the costophrenic angle suggests the presence of at least 250 mL of presence of at least 250 mL of pleural fluidpleural fluid

Types of fluidsTypes of fluids

Four types of fluids can accumulate Four types of fluids can accumulate in the pleural space:in the pleural space:

Serous fluidSerous fluid ( (hydrothoraxhydrothorax) ) BloodBlood ( (haemothoraxhaemothorax) ) ChyleChyle ( (chylothoraxchylothorax) ) PusPus ( (pyothoraxpyothorax or or empyemaempyema

What Is a Malignant Pleural What Is a Malignant Pleural EffusionEffusion??

A A pleural effusionpleural effusion is defined as an is defined as an abnormal amount of fluid in the abnormal amount of fluid in the space between the layers of tissue space between the layers of tissue (the (the pleurapleura) that line the lungs. If ) that line the lungs. If cancer cells are present in this fluid, cancer cells are present in this fluid, it is called a it is called a malignantmalignant (cancerous) (cancerous) pleural effusion. pleural effusion.

Malignant pleural Malignant pleural effusionseffusions

Malignant pleural effusions are caused most commonly by Malignant pleural effusions are caused most commonly by carcinomas of the breast, lung, gastrointestinal tract or ovary and carcinomas of the breast, lung, gastrointestinal tract or ovary and by lymphomas. In male patients about half of malignant effusions by lymphomas. In male patients about half of malignant effusions are caused by lung cancer, 20% by lymphomas or leukemia, 7% are caused by lung cancer, 20% by lymphomas or leukemia, 7% from gastrointestinal primaries, 6% from genitourinary primaries, from gastrointestinal primaries, 6% from genitourinary primaries, and 11% from tumors of unknown primary site. In female patients, and 11% from tumors of unknown primary site. In female patients, about 40% of malignant effusions are caused by breast cancer, about 40% of malignant effusions are caused by breast cancer, 20% from tumors arising in the female genital tract, 15% from lung 20% from tumors arising in the female genital tract, 15% from lung primaries, 8% from lymphomas or leukemia, 4% from primaries, 8% from lymphomas or leukemia, 4% from gastrointestinal tract primaries, 3% from melanoma, and 9% from gastrointestinal tract primaries, 3% from melanoma, and 9% from tumors of unknown primary site. Effusions may be secondary to tumors of unknown primary site. Effusions may be secondary to impaired pleural lymphatic drainage from mediastinal tumor impaired pleural lymphatic drainage from mediastinal tumor (especially in lymphomas) and not due to direct pleural invasion. (especially in lymphomas) and not due to direct pleural invasion.

A malignant pleural effusion is a complication that occurs in 30% of A malignant pleural effusion is a complication that occurs in 30% of lung cancers lung cancers

Instruments for needle biopsy of the pleuraInstruments for needle biopsy of the pleura

TreatmentTreatmentThe free end of The free end of

the Chest the Chest Drainage Device Drainage Device

is usually is usually attached to an attached to an

underwater sealunderwater seal, , below the level below the level

of the chest. This of the chest. This allows the air or allows the air or fluid to escape fluid to escape

from the pleural from the pleural space, and space, and prevents prevents anything anything

returning to the returning to the chestchest

PleuralPleural empyemaempyema

Pleural Pleural empyemaempyema (also known as a (also known as a pyothoraxpyothoraxor or purulent pleuritispurulent pleuritis) is an ) is an accumulation of accumulation of puspus in the in the pleural cavitypleural cavity. . Most pleural empyemas arise from an Most pleural empyemas arise from an infection within the infection within the lunglung ( (pneumoniapneumonia), often ), often associated with associated with parapneumonic effusionsparapneumonic effusions. . There are three stages: There are three stages: exudativeexudative, , fibrinopurulent and organizing. In the fibrinopurulent and organizing. In the exudative stage, the pus accumulates. This is exudative stage, the pus accumulates. This is followed by the fibrinopurulent stage in which followed by the fibrinopurulent stage in which there is loculation of the pleural fluid (the there is loculation of the pleural fluid (the creation of pus pockets). In the final creation of pus pockets). In the final organizing stage, scarring of the pleural space organizing stage, scarring of the pleural space may lead to lung entrapment.may lead to lung entrapment.

CT chest showing large CT chest showing large right sided right sided

hydro-pneumothoraxhydro-pneumothorax from from pleural pleural empyemaempyema. . Arrows Arrows

A: air, B: fluidA: air, B: fluid

Encasement of the left lung by thick purulent exudate which is characteristic of pleural empyema

TreatmentTreatment Definitive treatment for pleural empyema entails drainage of the Definitive treatment for pleural empyema entails drainage of the

infected pleural fluid. A infected pleural fluid. A chest tubechest tube may be inserted, often using may be inserted, often using ultrasound guidance.ultrasound guidance.

IntravenousIntravenous antibioticsantibiotics are given. are given. If this is insufficient, surgical If this is insufficient, surgical debridementdebridement of the pleural space of the pleural space

may be required. This is frequently done using thoracoscopic may be required. This is frequently done using thoracoscopic techniques but if the disease is chronic, a limited thoracotomy techniques but if the disease is chronic, a limited thoracotomy may be necessary to fully drain the pus and remove the may be necessary to fully drain the pus and remove the filbrinopurulent excudate from the lung and from the chest wall.filbrinopurulent excudate from the lung and from the chest wall.

Occasionally, a full thoracotomy, formal decortication and Occasionally, a full thoracotomy, formal decortication and pleurectomy are required. Rarely, portions of the lung have to be pleurectomy are required. Rarely, portions of the lung have to be resected. Chest tubes in the setting of pleural empyema have a resected. Chest tubes in the setting of pleural empyema have a tendency to become clogged. To combat this problem, surgeons tendency to become clogged. To combat this problem, surgeons will often place large bore chest tubes, or more than one chest will often place large bore chest tubes, or more than one chest tube. Chest tube clogging in the setting of a pleural empyema can tube. Chest tube clogging in the setting of a pleural empyema can lead to re accumulation of pus and infected material, a worsening lead to re accumulation of pus and infected material, a worsening clinical picture, organ failure and even death. Thus managing clinical picture, organ failure and even death. Thus managing chest tube clogging is particularly important after the treatment of chest tube clogging is particularly important after the treatment of a pleural empyemaa pleural empyema

ChylothoraxChylothorax

A A chylothoraxchylothorax (or (or chyle leakchyle leak) is a ) is a type of type of pleural effusionpleural effusion. It results . It results from lymphatic fluid (chyle) from lymphatic fluid (chyle) accumulating in the accumulating in the pleural cavitypleural cavity

CausesCauses

Its cause is usually leakage from the Its cause is usually leakage from the thoracic ductthoracic duct or one of the main lymphatic vessels that drain to or one of the main lymphatic vessels that drain to it. The most common causes are it. The most common causes are lymphomalymphoma and and trauma caused by thoracic surgery. If the patient is trauma caused by thoracic surgery. If the patient is on a normal diet, the effusion can be identified by on a normal diet, the effusion can be identified by its white and milky appearance as it contains high its white and milky appearance as it contains high levels of triglycerides.levels of triglycerides.

The condition is rare but serious and appears in all The condition is rare but serious and appears in all mammals. In animals, chylothorax usually results mammals. In animals, chylothorax usually results from diseases that cause obstruction to the from diseases that cause obstruction to the thoracic duct preventing lymph from draining thoracic duct preventing lymph from draining normally into the venous system. Examples include normally into the venous system. Examples include tumors, heartworm disease, right sided cardiac tumors, heartworm disease, right sided cardiac failure, or idiopathic lymphangiectasiafailure, or idiopathic lymphangiectasia

TreatmentTreatment

Since the mechanism behind chylothorax is not well Since the mechanism behind chylothorax is not well understood, treatment options are limited. Drainage of the understood, treatment options are limited. Drainage of the fluid out of the pleural space is essential to obviate damage fluid out of the pleural space is essential to obviate damage to organs, esp. the inhibition of lung function by the counter to organs, esp. the inhibition of lung function by the counter pressure of the chyle. Another treatment option is pressure of the chyle. Another treatment option is pneumoperitoneal shunting (creating a communication pneumoperitoneal shunting (creating a communication channel between pleural space and peritoneal cavity). By channel between pleural space and peritoneal cavity). By this surgical technique loss of essential triglycerides that this surgical technique loss of essential triglycerides that escape the thoracic duct can be prevented. Omitting fat (in escape the thoracic duct can be prevented. Omitting fat (in particular FFA) from the diet is essential. Either surgical or particular FFA) from the diet is essential. Either surgical or chemical pleurodesis are options: the leaking of lymphatic chemical pleurodesis are options: the leaking of lymphatic fluids is stopped by irritating the lungs and chest wall, fluids is stopped by irritating the lungs and chest wall, resulting in swelling and closure of the pleural space. The resulting in swelling and closure of the pleural space. The medication octreotide has been shown to be beneficial and medication octreotide has been shown to be beneficial and in some cases will stop the chylothorax after a few weeks.in some cases will stop the chylothorax after a few weeks.

Pleural MesotheliomaPleural Mesothelioma

Pleural mesothelioma is the most common type of Pleural mesothelioma is the most common type of mesotheliomamesothelioma, a rare cancer that develops in the , a rare cancer that develops in the mesothelium (a membrane that lines many of the body’s mesothelium (a membrane that lines many of the body’s organs and cavities). In the case of pleural mesothelioma, organs and cavities). In the case of pleural mesothelioma, the cancer develops in the lining of the lungs, called the the cancer develops in the lining of the lungs, called the pleura or pleural membrane. Although a mesothelioma pleura or pleural membrane. Although a mesothelioma prognosis is typically poor for the majority of patients, some prognosis is typically poor for the majority of patients, some who are diagnosed early may qualify for a combination of who are diagnosed early may qualify for a combination of aggressive therapies to improve life expectancy. aggressive therapies to improve life expectancy.

In an effort to help patients understand pleural In an effort to help patients understand pleural mesothelioma, Asbestos.com offers a complimentary mesothelioma, Asbestos.com offers a complimentary packet that contains treatment information tailored to your packet that contains treatment information tailored to your specific diagnosis. The packet also covers the nation's top specific diagnosis. The packet also covers the nation's top mesothelioma doctors and cancer centers, as well as mesothelioma doctors and cancer centers, as well as financial assistance options to help cover medical costs. To financial assistance options to help cover medical costs. To receive your packet in the mail, please enter your receive your packet in the mail, please enter your information belowinformation below

Pleural Mesothelioma Pleural Mesothelioma SymptomsSymptoms

Once trapped in the body, asbestos fibers cause cancerous Once trapped in the body, asbestos fibers cause cancerous cells to divide abnormally, resulting in the thickening of the cells to divide abnormally, resulting in the thickening of the pleural membrane. This has the potential to encourage pleural membrane. This has the potential to encourage build-up of fluid (called pleural effusion). The fluid begins to build-up of fluid (called pleural effusion). The fluid begins to place pressure on the lungs and the respiratory system in place pressure on the lungs and the respiratory system in general, preventing normal breathing. general, preventing normal breathing. SymptomsSymptoms of pleural of pleural mesothelioma are largely caused by these developments mesothelioma are largely caused by these developments and may include the following: and may include the following:

Persistent dry or raspy cough Persistent dry or raspy cough Coughing up blood (hemoptysis) Coughing up blood (hemoptysis) Difficulty in swallowing (dysphagia) Difficulty in swallowing (dysphagia) Shortness of breath that occurs even when at rest (dyspnea) Shortness of breath that occurs even when at rest (dyspnea) Persistent pain in the chest or rib area, or painful breathing Persistent pain in the chest or rib area, or painful breathing Development of lumps under the skin on the chest Development of lumps under the skin on the chest Night sweats or fever Night sweats or fever Unexplained weight loss Unexplained weight loss Fatigue Fatigue

Pleural Mesothelioma Pleural Mesothelioma TreatmentsTreatments

The on-going development of new drugs and The on-going development of new drugs and detection techniques is improving the outlook for detection techniques is improving the outlook for patients with pleural mesothelioma. Since pleural patients with pleural mesothelioma. Since pleural mesothelioma is the most common form of the mesothelioma is the most common form of the cancer, more research and knowledge about this cancer, more research and knowledge about this type of mesothelioma is available to utilize when type of mesothelioma is available to utilize when discussing a treatment plan. discussing a treatment plan.

In general, pleural mesothelioma patients have In general, pleural mesothelioma patients have three options: three options: surgerysurgery, , chemotherapychemotherapy and and radiationradiation therapy. Typically, patients will receive therapy. Typically, patients will receive a combination of two or more of these types of a combination of two or more of these types of treatmenttreatment

Spontaneous Spontaneous pneumothoraxpneumothorax

Definition Definition Spontaneous pneumothorax is a Spontaneous pneumothorax is a

collection of air or gas in the space collection of air or gas in the space between the lungs and the chest that between the lungs and the chest that "collapses" the lung and prevents it "collapses" the lung and prevents it from inflating completely from inflating completely

CausesCauses

There are two types of spontaneous There are two types of spontaneous pneumothorax:pneumothorax:

Primary spontaneous pneumothorax Primary spontaneous pneumothorax Secondary spontaneous pneumothoraxSecondary spontaneous pneumothorax Spontaneous means there is no traumatic Spontaneous means there is no traumatic

injury to the chest or lung. Primary injury to the chest or lung. Primary spontaneous pneumothorax occurs in spontaneous pneumothorax occurs in people without lung disease. It occurs people without lung disease. It occurs most often in tall, thin, young people.most often in tall, thin, young people.

SymptomsSymptoms

Symptoms often begin suddenly, and may occur during rest Symptoms often begin suddenly, and may occur during rest

or sleep. They can include: or sleep. They can include: Abnormal breathing movement Abnormal breathing movement

Restricting chest wall motion when breathing to protect Restricting chest wall motion when breathing to protect against pain against pain

Splinting -- bending over or holding the chest to protect Splinting -- bending over or holding the chest to protect against painagainst pain

Cough Cough Rapid respiratory rate Rapid respiratory rate Shortness of breath Shortness of breath Sudden chest pain or chest tightness Sudden chest pain or chest tightness

Breathing or coughing makes pain worse Breathing or coughing makes pain worse Chest pain may be dull, sharp, or stabbing Chest pain may be dull, sharp, or stabbing

THANK YOUTHANK YOU