Pleural diseases seminar presentation by resident

Pleural diseases seminar presentation by resident

1. Approach To Pleural Diseases Dr. Getamesay Atnafu , IMR2 Moderator: Dr. Hanan Yesuf , Consultant Internist & PCCM Subspecialist July 9, 2024 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 1

2. Outlines Introduction Pleural Effusion Transudative Exudative MPE Pneumothorax 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 2

3. Introduction The pleural space is the area between the visceral pleura , covering the lung and its fissures, and the parietal pleura , covering the chest wall, diaphragm and mediastinum. It’s a low pressure ( subatmospheric lung infilation ), high capacitance space Normal pleural cavity: Contain around 12ml (0.26ml/kg) of pleural fluid Serve as a coupling system 10-30um in width Provide a route by which edema can escape the lung 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 3

4. T he primary function of the pleural membranes is to allow extensive movement of the lung relative to the chest wall. The visceral pleura may also provide mechanical support for the lung: contributing to the shape of the lung, providing a limit to expansion, and contributing to the work of deflation distribute the forces produced by negative inflation pressures evenly over the lung 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 4

5. Pleural membrane Mesothelial cells Basement membrane Connective tissue Blood supply Bronchial arteries- visceral pleura Intercostal arteries- parietal pleura Lymphatic drainage Parietal side lymphatics- Right lymphatic and Thoracic duct Nerve supply- intercostal and phrenic nerves 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 5

6. Into this space, normal liquid and protein enter from the systemic circulation and are removed by the parietal pleural lymphatics . Most of the fluid both produced and absorbed on the parietal surface The lymphatic vessels in the parietal pleura are capable of increasing resorption by a factor of 20-30x 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 6

7. Why pleural effusion common (relatively)? the subatmospheric pleural pressure, the leaky pleural membranes, and the high capacitance of the pleural space . Excess accumulation of fluid in the pleural space due to both impaired reabsorption and increased production. Why? Extravasation? 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 7

8. Pleural Effusion Excess accumulation of fluid in the pleural space There are 2 types- exudative vs transudative effusions Transudates generally indicate that the pleural membranes and their microvessels are not themselves diseased . Exudates arise from inflamed or injured microvessels in the pleura, the lung, or other tissues . 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 8

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12. Clinical Feature Clinical presentation depends on the amount of fluid and underlying causes The 3 commonest symptoms Dyspnea- Mechanical effect Cough- due to the distortion of the lung with volume loss Pleuritic chest pain- inflammation, infection and malignant infiltration 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 12

13. Diagnosis To treat pleural effusion appropriately, it is important to determine its etiology. Initial patient workup should begin with a thorough history and physical examination. Chest imaging to diagnose its extent. Thoracentesis should be performed for new and unexplained pleural effusions. Laboratory testing helps to distinguish pleural fluid transudate from an exudate. However, the etiology of pleural effusion remains unclear in nearly 20% of cases 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 13

14. Thoracentesis Pleural effusions with greater than 1 to 2 cm of fluid separating the visceral and parietal pleura should undergo pleural drainage Rule out safety concerns prior to doing thoracentesis ( e.g. Uncorrectable coagulopathy, patient agitation ). Pleural fluid analysis(PFA ) Routine laboratory biomarkers (all patients) Specific biomarkers when a specific disease is suspected based on clinical findings or gross fluid appearance 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 14

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16. Pleural fluid only three-test combination ( PFO3 ) Pleural fluid protein greater than 3.0 g/ dL (30 g/L) Pleural fluid cholesterol greater than 55 mg/ dL (1.424 mmol /L) Pleural fluid LDH greater than 0.67 times the upper limit of the laboratory's normal serum LDH UpToDate prefers for PFO 3  is based on the advantages of obviating a need for blood sampling and avoiding the duplicativ e use of highly correlated criteria 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 16

17. PFO2 Pleural fluid cholesterol greater than 40 mg/ dL (1.034 mmol /L) Pleural fluid LDH greater than 0.60 times the upper limit of the laboratory's normal serum LDH PEO1- limited data, less sensitive than others Limitations These criteria misidentify ~25% of transudates as exudates. In this case the difference between the protein/albumin levels in the serum and the pleural fluid should be measured . SPPG >2.5gm/dl or SAPG >1.2gm/dl, confirms transudative 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 17

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19. Pleural Biopsy Can be considered for patients with an exudative effusion who remain undiagnosed after initial thoracentesis. The approachs are:- Minimally invasive ( i.e.,A closed needle biopsy with an abrams needle) Image-guided percutaneous pleural biopsy Medical thoracoscopy (also referred to as pleuroscopy ). Biopsy by video-assisted thoracoscopic surgery (VATS) 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 19

20. Transudative Effusions 1. CHF : the most common cause of pleural effusion Typically transudative however, up to 25-30 % of effusions fulfill lights criteria for an Exudate . Pathophysiology : clearance of pulmonary interstitial fluid across a leaky mesothelium into the pleural space . Clinical Manifestations Usually have symptoms and signs of heart failure Tend to be bilateral, with larger effusions on the right 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 20

21. Indications to do diagnostic thoracentesis Unilateral pleural effusion Bilateral effusions of not comparable in size Febrile patient. If the patient has pleuritic chest pain. If the patient does not have cardiomegaly. 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 21

22. Treatment Treat CHF If the patient is markedly dyspneic when first evaluated, a therapeutic thoracentesis to relieve the dyspnea should be considered. If persistent large effusions, control recurrent effusions with: 1.Pleurodesis using a sclerosing agent, such as talc, or 2.Insertion of an indwelling pleural catheter. 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 22

23. 2. HEPATIC HYDROTHORAX Incidence-approximately 6%. Mechanism:- movement of the ascitic fluid from the peritoneal cavity through defects in the diaphragm into the pleural space. Clinical manifestation is usually dominated by the cirrhosis. Are usually right sided (80%) but occasionally are left sided (17%) or bilateral (3%). Effusions can develop suddenly, presumably when the diaphragm becomes increasingly thinned and a rent develops 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 23

24. If the polymorphonuclear cell count is greater than 500 cells/ μl , the diagnosis of spontaneous bacterial pleuritis in conjunction with spontaneous bacterial peritonitis should be considered. The initial management should be directed toward treatment of the ascites. Low-salt diet Diuretics Chest tube insertion should be avoided TIPS If diet and diuretics cannot control the effusion, the treatment of choice is liver transplantation 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 24

25. Spontaneous bacterial pleuritis Is an infection of a preexisting hepatic hydrothorax in which a parapneumonic infection has been excluded. Originally termed spontaneous bacterial empyema. Treatment does not require tube thoracostomy . The diagnosis is made if the Pleural fluid culture is positive. Pleural fluid neutrophil count is greater than 250 cells/ μ l. Pneumonic process has been excluded Rx- Systemic antibiotics 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 25

26. 3. NEPHROTIC SYNDROME Pleural effusions may be seen in up to 21% of patients. Mechanism : combination of decreased plasma osmotic pressure and increased hydrostatic pressure due to salt retention and hypervolemia. Typically related to severe hypoalbuminemia (< 2 g/dl ). Usually bilateral and are frequently infrapulmonary in location. A diagnostic thoracentesis should be performed- to prove that the pleural fluid is a transudate. Treatment focuses on decreasing protein loss in the urine, use of diuretics, and a low-sodium diet . 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 26

27. 4. Urinothorax Is defined by the presence of urine in the pleural cavity and typically occurs secondary to obstructive uropathy . Predominantly unilateral and typically very large , occupying more than two-thirds of the hemithorax . PF has the odor of urine. Confirmed by demonstrating a pleural fluid–to–serum creatinine ratio of > 1 (ratio >1.7 confirms) along with imaging confirming obstructive uropathy . 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 27

28. 5. Trapped Lung It is non-expanding lung caused by fibrosis and thickening of the visceral pleura Causes are : Post TB pleurisy Post RA pleurisy Post empyema/post hemothorax Management is decortication 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 28

29. Others Constrictive pericarditis Peritoneal Dialysis Cerebrospinal Fluid Leakage into the Pleural Space Ventriculoperitoneal Shunts 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 29

30. Exudative effusions These effusions may develop as a result of inflammation, injury, or malignancy , which can involve the pleural surfaces, the adjacent lung, or more distant tissues , such as mediastinal or abdominal organs. 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 30

31. 1. Parapneumonic Effusions and Empyema Parapneumonic effusions - Any effusion due to an underlying pneumonia. Empyema - presence of purulent pleural fluid or a positive pleural fluid gram stain or culture. Occur in 20% to 57% of patients hospitalized for CAP. The incidence is increasing, especially in the elderly population 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 31

32. A complicated parapneumonic effusion has Glucose level lower than 40 mg/dl or PH less than 7.2 or Loculated on ultrasonography Mechanism of PPE formation : Migration of inflammatory cells to the pleural space from an adjacent zone of lung infection Release pro- and anti-inflammatory cytokines that alter pleural membrane permeability. Recruitment of additional inflammatory cells 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 32

33. Influx of protein-rich fluid , initially creating a sterile and free-flowing effusion. Invasion of bacteria into the space, leads to Neutrophilic pleocytosis , Increased LDH Increased platelet-activating factor, and Decreased fibrinolytic activity that favors fibrin deposition in the pleural space 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 33

34. Risk factors for PPEs include : Diabetes, Immunosuppression Alcoholism, Poor dental hygiene Cancer, extreme age Increased severity of the pneumonia index Clinical presentation : Are typically those of the underlying pneumonia. However in elderly patients, these symptoms are frequently absent, and Anemia, fatigue, and failure to thrive often predominate, making the clinical diagnosis more difficult 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 34

35. Early risk stratification The RAPID ( R enal function, A ge, P urulence, I nfection source, D ietary factors) scoring system Predicts mortality at 3 months . Classifies patients at presentation into : Low-3%, Medium-9%, High-risk- 31 % 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 35

36. Complications Fibrothorax , trapped lung vs lung entrapment P leural calcification. Rarely, Bronchopleural fistula formation and Empyema thoracic and Empyema necessitans ( rupture of the empyema through the chest wall) 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 36

37. Treatment D epends on the stage of the disease Site of acquisition of infection should be considered in antibiotic selection. If uncomplicated: antibiotics If complicated: antibiotics + drainage Duration of the Abx is depends on the stage of effusion Drainage involves- Chest tube, VATS Fibrinolytic agents (MIST trials) Open thoracotomy and decortication Nutrition 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 37

38. Tuberculous Pleurisy The 2 nd most common extra-pulmonary TB. In the developing world-30% to 80% of all pleural effusions. Roughly 1% in developed countries. Occurs in 30% of patients with PTB. Two mechanisms postulated : 1.T helper cell–mediated delayed hypersensitivity reaction. 2.A Paucibacillary infection of the pleural space. 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 38

39. Clinical presentation Is often acute or subacute Fever (75%), pleuritic chest pain (50%–75%), and a nonproductive cough (70%–75%). Other symptoms include night sweats (50%), dyspnea (50%), and weight loss. Typically unilateral and encompass less than 2/3 rd of the hemithorax 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 39

40. Diagnosis is made by PFA- ADA, PCR, IFN-r Imaging Pleural biopsy(82%-92%)- at least 6 biopsy . Treatment includes Anti-TB Surgery 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 40

41. PE 4 th leading etiology of pleural effusion in the united states. Occur in 35% to 47% of patients with PE. Most are unilateral. Typically occupying less than half the hemithorax . The pathogenesis unknown . Reabsorption of pleural fluid after initiation of anticoagulation typically occurs within : 7 to 10 days in patients without radiographic evidence of infarction. 14 to 21 days in those with this finding. 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 41

42. Hemothorax The pleural fluid hematocrit must be >50% of the simultaneous peripheral blood hematocrit. One can estimate the pleural fluid hematocrit by dividing the pleural fluid RBC count by 100,000. If the pleural fluid appears bloody and the hematocrit is <50% , it is considered a hemorrhagic effusion The majority of cases of hemothorax are related to Blunt or penetrating trauma Thoracic procedures and Surgery Malignancy Tube thoracostomy is the best first step to drain a hemothorax . 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 42

43. Systemic Lupus Erythematous PE in 34% to 60% of patients during their disease course. Approximately 80% of patients have other organ involvement. Pleuritic pain has been reported to be a poor prognostic indicator. Pleural fluid ANA is usually positive. Treatment NSAIDS are the initial treatment of choice. Corticosteroids reserved for refractory cases. 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 43

44. Rheumatoid Arthritis Pleural effusions occur in up to 20% of pts , with 80% occurring in men . Patients are most commonly asymptomatic from the effusion. But often have concurrent evidence of Active arthritis Rheumatoid lung lesions, or Subcutaneous nodules. Low pleural fluid glucose is due to impaired glucose transport through pleura. PFA : Tadpoll cells, RF positive, low Glucose Most effusions related to RA resolve spontaneously or with systemic disease-modifying medication 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 44

45. Pancreatitis and Pancreatic Fistulae Prevalence approaching 50% in some case series. The mechanism of pleural fluid formation Release of proinflammatory mediators from the pancreas into the circulation. Transdiaphragmatic transit of parapancreatic inflammatory exudates. Lipolysis of mediastinal fat, and Early formation of pancreaticopleural fistulae. Effusions are typically small, exudative, occasionally bloody. Exudative and often has a low PH and high amylase(as high as 30x serum of level). Majority are left-sided (68%). Mortality up to a 30%. 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 45

46. Chylothorax Occurs when chyle leaks into the pleural space as a result of disruption of the thoracic duct at any point along its course. Trauma accounts for approximately 50% of cases. Lymphoma, is the most frequent nontraumatic etiology. Are most commonly unilateral, but may be bilateral in 20% of cases. Classically has a characteristic milky appearance . A PF TG level of >110 mg/dl is considered diagnostic while a level <50 mg/dl excludes the diagnosis . And chylomicrons . 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 46

47. Pseudochylous Effusions Also called “ chyliform ” or “cholesterol pleural effusion” Results from a markedly elevated cholesterol content and does not contain chylomicrons. Is usually the result of an exudative effusion that remains in the pleural space for an extended period of time—often 5 years or longer . The most frequent causes are TB and Rheumatoid pleuritic . Mostly unilateral and accompanied by pleural thickening . PFA : high cholesterol(>200 mg/dl) and TG below 110 mg/dl. Treatment is treating the underlying cause. 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 47

48. Esophageal rupture It is rare cause of exudative effusion ( PEEVO ) It is caused by trauma, foreign body, malignancy, iatrogenic. It is presented with chest pain with subcutaneous emphysema Diagnosis is made by CXR, CT & PFA Treatment Manage as early as possible Endoscopic stenting or surgical repair with antibiotics Drain the pleural fluid 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 48

49. Management of recurrent and persistent effusions Repeat thoracentesis Pleurodesis : obliteration or ablation of the pleural cavity through induction of pleural inflammation and fibrosis. Indwelling pleural catheter 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 49

50. Malignant pleural effusion Accumulation of fluid in the presence of malignant cells or tumor tissue in the pleural space. Is a hallmark of advanced-stage disease. Denotes a poor overall prognosis 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 50

51. Pathophysiologic mechanisms: involve complex host–tumor cell interactions that produce vasoactive and inflammatory signaling, host cell recruitment and activation, vascular permeability, angiogenesis, and tumor progression that culminate in fluid formation 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 51

52. Causes of Paramalignant Pleural Effusion 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 52

53. Diagnostic approach Imaging CXR US CT/ MRI PET scan PF cytology, IHC, tumor markers Pleural biopsy Closed Medical thoracoscopy Surgical thoracoscopy 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 53

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55. Prognosis The prognosis is poor with median survival range 3-12months Survival is highly variable and depends on a number of factors including the primary tumor type, performance status, and pleural fluid markers . There are different validated scoring system that predict the survival of pt with MPE ( may assist in guiding decisions regarding management options): LENT score, PROMISE score 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 55

56. Pneumothorax Is the abnormal presence of air in the pleural cavity, separating the visceral from the parietal pleura. Spontaneous pneumothorax- without preceding trauma or injury. Since underlying anatomic lung abnormalities ( subpleural blebs) are often identified in PSP, it is now believed that the majority of PSPs occur in the setting of occult lung disease 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 56

57. PSP - occur in a background of clinically normal lungs. SSP- occurs in the setting of underlying lung disease 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 57

58. Primary spontaneous pneumothorax PSP refers to development of a pneumothorax in the absence of underlying lung disease. The age-adjusted annual incidence ranges from 7.4 to 18 cases per 100,000 population in males and 1.2 to 6 cases per 100,000 in females. PSP is more common in males than females (roughly three to six times higher). Peak incidence is in the third to fifth decade of life. Are usually due to rupture of apical pleural blebs , small cystic spaces that lie within or immediately under the visceral pleura . 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 58

59. The classic body shape for the patients with PSP is “ tall and thin .” more common in taller patients with low body mass index and in smokers. Family history(10%). The risk of recurrence is higher in taller patients, but only in men. Interestingly, risk of recurrence is not consistently increased in smokers compared to nonsmokers 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 59

60. Emphysema-like changes (ELCS) Are subpleural blebs and bullae which are seen on CXR or chest CT Scan. On CXR- only 20% can be seen. On CT & by surgical evaluation- 80% can be seen. A bleb is outpouching (or vesicle) of the visceral pleura caused by air in the interstitium and typically less than 1 cm in diameter. Bulla measures greater than 1 cm, which is sharply demarcated by a thin wall (≤1 mm in thickness). 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 60

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62. Secondary spontaneous pneumothorax 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 62

63. Tension pneumothorax Is a medical emergency. Occurs when air enters but cannot escape from pleural space. The increased pressure causes : Chest discomfort. Reduces venous return. Hypotension and hemodynamic compromise Require urgent decompression with a cannula placed anteriorly in the second intercostal space in the midclavicular line . 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 63

64. Clinical features The main symptoms are chest pain and dyspnea , which occur in 95% of patients. The pain is usually acute, localized to the side of the pneumothorax, and typically pleuritic. Cough, hemoptysis, orthopnea, and Horner syndrome. Spontaneous pneumothorax usually occurs at rest, and fewer than 10% occur during strenuous exercise. Symptoms are more severe in SSP than PSP . 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 64

65. RADIOGRAPHIC APPEARANCE CXR: Demonstrate separation of parietal pleura (and chest wall) from visceral pleura(lung) by a lucent space devoid of pulmonary vessels . Pleural effusions may occur coincident with pneumothorax in up to 20% to 25% of pts. Hemopneumothorax occurs in 2% to 3% of cases of spontaneous pneumothorax b 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 65

66. Bullae(concave) vs Pneumothorax(convex) 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 66

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68. Lung Ultrasound Sensitivities and specificities ranging from 66% to 100% and 91% to 100%, respectively. Absence of lung sliding & lung point Imagings 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 68

69. Imagings 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 69 Using M mode to scan normal lung tissue gives the appearance of the “ seashore sign .” Where the “ sea appearance” represents skin, muscle, and the pleural line and the “ shore ” is the image of lung artifact with lung motion. Similar view of the upper muscle and pleural line, however, the “ Barcode ” sign represents lack of lung motion present in pneumothorax 77

70. Computed tomography Is the best modality for determining the presence, size, and location of intrapleural gas Imagings 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 70

71. PSP Treatment to get ride of the air from the pleural space If stable with size<3cm needs observation and size >3cm needs needle aspiration If unstable, this kind of patients need chest tube drainage If there is recurrence/failed chest tube drainage we need to do VATS SSP Needs inpatient admission Needs chest tube insertion After lung expansion , we have to do pleurodesis /VATS to prevent recurrence 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 71

72. References Murray & Nadel’s Textbook of Respiratory Medicine, 7E Fishman’s Pulmonary Diseases and Disorders, 6E UpToDate Online BTS guideline for pleural Disease 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 72

73. Thank You 7/6/2024 Dr Getamesay A, Approach to Pleural Diseases 73