DISORDER OF PLEURAL SPACE

Non Malignant Pleural Effusion

Malignant Pleural Effusion
Pneumothorax
Malignant Mesothelioma and Other Primary Pleural Tumors

PLEURAL EFFUSION
A pleural effusion is present when there is an excess quantity of
fluid in the pleural space.
Bilateral pleural effusions
Heart failure or ascites. Occasionally, they are due to collagen
vascular disease or metastatic tumor.
Unilateral pleural effusions
Tuberculosis, pneumonia, pulmonary infarction, metastatic tumor,
primary pleural tumor, lymphoma, collagen vascular disease, chest
trauma, ascites, and intra-abdominal inflammatory processes, such
as subphrenic abscess or pancreatitis
Etiology
Pleural fluid accumulates when pleural fluid formation exceeds
pleural fluid absorption. Normally, fluid enters the pleural space
from the capillaries in the parietal pleura and is removed via the
lymphatics situated in the parietal pleura.
Fluid can also enter the pleural space from the interstitial spaces of
the lung via the visceral pleura or from the peritoneal cavity via
small holes in the diaphragm.
The lymphatics have the capacity to absorb 20 times more fluid
than is normally formed. Accordingly, a pleural effusion may
develop when there is excess pleural fluid formation (from the
interstitial spaces of the lung, the parietal pleura, or the peritoneal
cavity) or when there is decreased fluid removal by the lymphatics.

Diagnostic Approach
Transudative pleural effusion occurs when systemic factors that influence the formation and absorption of pleural fluid are altered.
Causes left ventricular failure and cirrhosis.
Exudative pleural effusion occurs when local factors that influence the formation and absorption of pleural fluid are altered.
Causes bacterial pneumonia, malignancy, viral infection, and pulmonary embolism.
If one or more of the exudative criteria are met and the patient is clinically thought to have a condition producing a transudative
effusion, the difference between the protein levels in the serum and the pleural fluid should be measured. If this gradient is greater
than 31 g/L (3.1 g/dL), the exudative categorization can be
ignored because almost all such patients have a transudative
pleural effusion.
Diagnosis
Thoracentesis and pleural biopsy may be necessary to establish
the nature of a pleural effusion that has been recognized
radiographically. CT and MRI are usually not useful in determining
the exact cause of a pleural effusion.
Differential Diagnosis




Fishmans Pulmonary Disease 4
th
edition
Harrison Internal Medicine 18
th
edition
MALIGNANT PLEURAL EFFUSION
Malignancies Associated with Pleural Effusion
Most common malignancy to invade the pleura and produce effusion is Carcinoma of the lung
2
nd
cause is by Breast cancer
Metastatic carcinoma of lymphoma (10%), Ovarian and gastric cancer (5%). Less common is primary tumor of the pleura,
malignant mesothelioma.
Clinical Presentation
Pleural effusion (effusions is greater than 500 mL), cough and dyspnea on exertion (depends on size of effusion and patient
underlying pulmonary function). Thoracentesis results in relief of dyspnea in most patients
Chest pain may be present because of involvement of the parietal pleura, ribs, or chest wall
Weight loss and appear chronically ill
Cachexia and lymphadenopathy
25% patient with metastatic carcinoma is asymptomatic
About 20 percent of patients with lymphoma have no respiratory symptoms when the malignant pleural effusion is diagnosed.
Malignant mesothelioma usually related to asbestos exposure, patient with mesothelioma present with chest pain and shortness of
breath. The chest radiograph reveals a pleural effusion, generalized pleural thickening, and a shrunken hemithorax (thoracostomy is
needed for diagnosis)
Chest Radiographic
Pleural effusion ipsilateral to the primary lesion is the rule in carcinoma of the lung
Interstitial infiltrates with effusions (lymphangitic carcinomatosis) and multiple nodules with effusions also suggest malignant
disease.
Mesothelioma may show a moderate to large pleural effusion (early) or a nodular, thickened pleura with extension to the apex
of the hemithorax (late).
Pleural fluid
may be serous, serosanguinous, or grossly bloody
an exudate with a protein concentration of about 4 g/dl. However, protein concentrations have been reported in the range of
1.5 to 8.0 g/dl.
The number of nucleated cells in the pleura fluid is modest (1500 to 4000/l) and consists of lymphocytes macrophages, and
mesothelial cells.
In about one-half of malignant pleural effusions, lymphocytes predominate (5 to 70 percent of nucleated cells).
Malignant cells in pleural fluid are rare in some patients
Polymorphonuclear leukocytes usually represent less than 25 percent of the cell population
pleural fluid pH is low (less than 7.30), ranging from 6.95 to 7.29
glucose concentration is also low (less than 60 mg/dL, or the ratio of pleural fluid to serum glucose is below 0.5,
lactate concentration is high,
the PcO2 is high, and the PO2 is low
Diagnosis:
Detecting exfoliated malignant cells in pleural fluid or in pleural tissue obtained by percutaneous pleural biopsy, thoracoscopy,
or thoracotomy, or at autopsy
immunohistochemistry in the diagnosis of malignant pleural effusions secondary to adenocarcinoma, mesothelioma, and
lymphoma has been established.
Flow cytometry, a technique used to quantitate nuclear DNA levels, is useful in the evaluation of lymphocytic pleural effusions
in which lymphoma is a possible diagnosis
Treatment
*Radiation of the hemithorax is
contraindicated in malignant pleural
effusions from lung cancer, since the
adverse effects from radiation
pneumonitis outweigh possible
benefits of therapy.


Prognosis
The diagnosis of a malignant pleural effusion signals a poor prognosis. Patients with carcinoma of the lung, stomach, and ovary tend
to have a survival time of only a few months from the time that the malignant effusion is diagnosed; patients with breast cancer may
survive longer, several months to years, depending on the response to chemotherapy.
pH and glucose concentrations in the malignant pleural effusion are low (below 7.30 and 60 mg/dl, respectively), the survival time is
less (average 2 months) than in those with a normal pH and glucose (average 10 months).

NON MALIGNANT PLEURAL EFFUSION
PLEURAL EFFUSION SECONDARY TO PULMONARY EMBOLIZATION
Dyspnea is the most common symptom. The pleural fluid is
almost always an exudate. The diagnosis is established by spiral
CT scan or pulmonary arteriography. Treatment is the same as
for any patient with pulmonary emboli. If the pleural effusion
increases in size after anticoagulation, the patient probably has
recurrent emboli or another complication such as a hemothorax
or a pleural infection.
TUBERCULOUS PLEURITIS
Usually associated with primary TB and are thought to be due
primarily to a hypersensitivity reaction to tuberculous protein in
the pleural space.
S&S: fever, weight loss, dyspnea, and/or pleuritic chest pain.
The pleural fluid is an exudate with predominantly small
lymphocytes.
Diagnosis: high levels of TB markers in the pleural fluid
(adenosine deaminase > 40 IU/L, interferon > 140 pg/mL, or
positive polymerase chain reaction (PCR) for tuberculous DNA).
Alternatively, by culture of the pleural fluid, needle biopsy of the
pleura, or thoracoscopy.
Treatment: identical with TB
PARAPNEUMONIC EFFUSION
Associated with bacterial pneumonia, lung abscess, or
bronchiectasis and are probably the most common cause of
exudative pleural effusion in the United States. Empyema refers
to a grossly purulent effusion
aerobic bacterial pneumonia acute febrile illness consisting of
chest pain, sputum production, and leukocytosis.
anaerobic infections a subacute illness with weight loss, a
brisk leukocytosis, mild anemia, and a history of some factor
that predisposes them to aspiration.

PLEURAL EFFUSION DUE TO HEART FAILURE
The most common cause of pleural effusion is left ventricular
failure. The effusion occurs because the increased amounts of
fluid in the lung interstitial spaces exit in part across the visceral
pleura. This overwhelms the capacity of the lymphatics in the
parietal pleura to remove fluid
Thoracentesis should be performed if the effusions are not
bilateral and comparable in size, if the patient is febrile, or if
the patient has pleuritic chest pain,
Best treated with diuretics. If the effusion persists despite
diuretic therapy, a diagnostic thoracentesis should be
performed. A pleural fluid N-terminal probrain natriuretic
peptide (NT-proBNP) >1500 pg/mL is virtually diagnostic of an
effusion secondary to congestive heart failure.
VIRAL PLEURAL EFFUSION
Viral infections are probably responsible for a sizable percentage
of undiagnosed exudative pleural effusions.
In many series, no diagnosis is established for ~20% of exudative
effusions, and these effusions resolve spontaneously with no
long-term residua. Pleural fluid cell count usually reveals a
predominance of mononuclear cells.
AIDS
Uncommon. The most common cause is Kaposis sarcoma,
followed by parapneumonic effusion. Other common causes are
TB, cryptococcosis, and primary effusion lymphoma. Pleural
effusions are very uncommon with Pneumocystis carinii
infection.
CHYLOTHORAX
A chylothorax occurs when the thoracic duct is disrupted and
chyle accumulates in the pleural space.
Cause : Trauma, tumors in the mediastinum.
S&S : Dyspnea, and a large pleural effusion is present on
the chest radiograph.
Thoracentesis reveals milky fluid, and biochemical
analysis reveals a triglyceride level that exceeds 1.2
mmol/L (110 mg/dL).
Patients with chylothorax and no obvious trauma should have a
lymphangiogram and a mediastinal CT scan to assess the
mediastinum for lymph nodes.
Treatment:
Insertion of a chest tube plus the administration of octreotide. If
fail, a pleuroperitoneal shunt should be placed unless the
patient has chylous ascites.
Should not undergo prolonged tube thoracostomy with chest
tube drainage because this will lead to malnutrition and
immunologic incompetence.
HEMOTHORAX
Diagnosis: If there is bloody pleural fluid, a hematocrit should
be obtained on the pleural fluid.
If the haematocrit is more than half of that in the peripheral
blood, the patient is considered to have a hemothorax.
Cause: of trauma; other causes include rupture of a blood vessel
or tumor.
Treatment: tube thoracostomy
MISCELLANEOUS CAUSES OF PLEURAL EFFUSION