Presentation on Pleural Cavity | Jindal Chest Clinic

Overview on Pleural Cavity, including causes of pleural effusion, , symptoms of pleural cavity, causes of asymptomatic pleural effusion, causes of chylothorax, pulmonary care, pulmonologist, pulmonology, signs and symptoms of pleural cavity, diagnostics, and Treatment strategies. For more information, please contact us: 9779030507.

1. Pleural Cavity

2. Mechanism of fluid formation

3. Pleural Diseases Pleuritis – Dry pleurisy Pleural effusion – Hydrothorax Hemothorax Pyothorax – empyema Chylothorax Pneumothorax Hydro-pneumothorax Pyo -pneumothorax Fibrothorax – Pleural thickening

4. Pleural Effusion: Causes Exudative effusion Tuberculosis Bacterial – Synpneumonic P ost pneumonic Malignant Connective tissue disorders Pulmonary thromboembolism Transudative : CHF, constrictive pericarditis , Nephrotic syndrome, hypoproteinemia , cirrhosis

5. Symptoms and signs Chest pain or heaviness Breathlessness and cough General – weakness, fatigue, night-sweats, fever Signs: Tracheal and mediastinal shift Bulging of hemithorax Movements – diminished P. note – impaired / dull/ stony dull Br. Sounds – Decreased / absent Pl. rub, E gophony , etc. Symptoms & signs of underlying disease

6. Diagnosis Physical examination Chest radiology CXR : Opacity, rising level, or massive CT chest to see the underlying lungs, mediastinal LN etc. Sputum, if available Tuberculin skin test Pleural fluid aspiration ( Pleurocentesis ) pleural biopsy / thoracoscopy

7. Examination of pleural fluid Pleural fluid chemistry: pH , Fluid LDH level Fluid total protein and corresponding serum protein Fluid glucose and corresponding serum glucose Special chemistry: Fluid Amylase, Triglycerides, Cholesterol Total and differential cell count Cytological examination: Special stains for malignancy, fungal infections Immunological studies: Fluid ANA, Rheumatoid factor, Adenosine deaminae Special immuno -Cytology Flow Cytometry for diagnosis of lymphoma Tumor markers for diagnosis of malignant pl effusion

8. Pleural Biopsy Pleural biopsy Closed bx with Abram’s needle Thoracoscopic (Biopsy exam. May reveal granulomas or other histopath . Depending upon the cause ) Thoracoscopy – “Gold standard procedure” – examination and biopsy

9. Pleural fluid appearance in unique effusions Appearance Underlying Disease Pale yellow Most transudates Turbid Inflammatory exudates Pus Empyema Hemothorax Trauma, malignancy, Pulmonary embolism, Thoracic endometriosis Milky fluid Chylothorax Brown Amebic liver abscess Black Fungal infection ( aspergillus niger ) Yellow to green Rheumatoid pleurisy

10. Causes of pleural effusion Common causes of Transudative Pleural Effusion Heart failure (left and bi-ventricular failure) Cirrhosis of liver, Nephrotic syndrome Hypoalbuminemia , Constrictive pericarditis Peritoneal dialysis Subclavian vein thrombosis Common causes of Exudative Pleural Effusion Tuberculosis Non-tubercular infections (Bacterial, Fungal) Malignancies (Lung, pleura, metastases) Connective tissue diseases (RA, SLE) Pulmonary thromboembolism

11. Causes for asymptomatic pleural effusion Atlectasis Benign asbestos pleural effusion Hypoalbuminemia Nephrotic syndrome Peritoneal dialysis Rheumatoid effusion Trapped lung Urinothorax Yellow Nail syndrome

12. Causes of amylase rich pleural effusion Pancreatic Type Amylase Salivary Type Amylase Acute pancreatitis Adenocarcinoma of lung Squamous cell lung cancer Chronic pancreatitis Undifferentiated lung cancer Ovarian Cancer Pancreatic pleural fistula Multiple myeloma Lymphoma Lymphatic leukemia Pneumonia Tuberculosis

13. Causes of chylothorax Traumatic Non-traumatic Mediastinal , lung and cardiac surgery Benign Lyphangioieiomyomatosis Neck surgery especially on left side Tuberous sclerosis Central line placement aspecially on left side Filariasis Amylodosis Benign mediastinal tumors Endoscopic sclerotherapy Malignant Penetrating surgery to neck and thorax Lymphoma Mediastinal metastasis Post delivery Primary lung cancer Kaposi’s Sarcoma

14. Treatment Fluid aspiration – therapeutic Chest-tube drainage (empyema, pneumothorax, hemothorax ) Treatment of underlying disease: - Tuberculosis - Bacterial / fungal infections - Malignancy etc. ( Tmt of transudative effusion mostly consists of tmt of the cause of effusion)

15. Complications Depend upon the underlying etiology Increase in fluid causes breathlessness and respiratory distress Broncho -pleural fistula formation Hydropneumothorax may occur Empyema and pyo -pneumothorax Pleural fibrosis, thickening, chest deformity Chest movement restriction – long term May lead to chronic cor pulmonale

16. Empyema Pus in the pleural cavity Commonly occurs as a complication of pneumonia Sometimes , iatrogenic following aspiration, trauma Symptoms & Signs: Fever, rigors, sweating, malaise Tender hemithorax , Signs of bulging (Acute) or retraction (chronic empyema) Diagnosis: History, Chest X Ray, CT Chest, TLC , DLC, CRP, ESR etc Pl fluid/ pus examination – Gram’s stain, culture

17. Bacterial parapneumonic effusion Staphylococcus aureus , MRSA, S. epidermidis Streptococcus intermedius , St pneumoniae , St pyogenes , Streptococcus milleria Anaerobes: Fusobacterium , Bacteriods Peptosteptococcus , Prevotella spp., Clostridium spp. Klebsiella pneumoniae Pseudomonas aeruginosa Escherichia coli Enterobacter supp. Mycobacterium tuberculosis Actinomyces spp.

18. Treatment of empyema Drainage – ICTD Antibiotics – change according to causative organism and sensitivity reports Surgical intervention: Adhesiolysis Decortication Lung resection

19. Pleurodesis Therapeutic closure of pleural cavity through adhesion of pleural membranes Done in case of recurrent effusion Total drainage of fluid with ICTD following by administration of pleurodesic agent such as: - Tetracycline , doxycyclkine , mepacrine - Talc powder or slurry - Betadine - Cytotoxic agents: Bleomycin

20. Pneumothorax

21. Spontaneous Pneumothorax Primary: Cause unidentified Secondary : Identifiable cause Obstructive airway disease/ Bullous emphysema, Asthma Infections: Tuberculosis Pneumonias – Staphylococcal Fungal infections Lung cancer Connective tissue diseases Interstitial lung disease Miscellaneous: Lymphangioleimyomatosis Histiocytosis , Morfan’s Syndrome

22. Clinical Features Acute: Sudden onset chest pain, breathlessness Chronic/ Loculated : Heaviness, pain, breathlessness Symptoms of underlying illness Signs: - Bulge of hemithorax - Shift of mediastinum to opposite side - Movements diminished - Percussion note – hyper-resonant - Breath sounds – diminished - Bronchial breathing/ egophony

23. Types of Pneumothorax Clinical features also depend upon the type of pneumothorax Communicating (Open): Pt may be comfortable at rest, breathless on exertion. Sign of BP Fistula may be present Non-communicating (Closed): Subacute or chronic. May be loculated . Tension pneumothorax (Expanding): Acute with respiratoy distress.

24. Diagnosis History & physical examination Chest X-Ray, CT scanning Investigations for cause of pneumothorax Thoracoscopic examination

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26. Pleural line

27. Complications Tension pneumothorax Respiratory distress, shock Leakage of air to mediastinum and pericardial cavity ( pneumomediastinum ), subcutaneous tissues (subcutaneous emphysema), peritoneal cavity ( pneumoperitoneum ) etc. Cardiac compression – cardiac temponade Infection in the pleural cavity, hydro and pyo-pneumothorax , fistula etc.

28. Treatment 1. Drainage with a pig-tail catheter/ chest-tube under water-seal Acute and tension pneumothorax : Immediate drainage is required. 2. Supportive tmt : Oxygenation Treatment of underlying etiology 3. Surgery depending upon the cause ( Bullectomy , lobar or lung resection etc) 4. Recurrent pneumothorax: Pleurodesis

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