بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. Anatomy And Phsiology • The pleura are the thin membranes which surround the lungs and line the inside of the chest wall. • There are two layers: • The visceral pleura • Which is attached to the lung

3. Pleural Disorder By Prof. Entesar Sayed Ahmed Professor Of Chest Diseases Faculty Of Medicine For GirlsAl-Azhar Universty2007

4. The parietal pleura which is attached to the chest wall. • Between these two layers is the 'pleural space', which normally contains a thin layer of fluid to lubricatethe movement of breathing.

7. Intrapleural pressure • This is sub-atmospheric pressure within pleural space, which isnegativerelative to atmospheric and intrapulmonary pressure. • The negative pressure will be lostif air, blood, pus or more than afew millilitres fluid accumulate in this space and the affected lung will be unable to expand fully.

8. Normally, 10 to 20 mL of pleural fluid similar in composition to plasma but lower in protein (< 1.5 g/dL) is spread thinly over visceral and parietal pleurae, facilitating movement between the lung and chest wall.

9. Selected Pleural Diseases • Pleurisy • pleural effusion • pneumothorax

10. Pleurisy • A "primary" pleurisy is an inflammation arising in the pleural tissues themselves, from a germ that attacked them directly, or perhaps from an injury or growth.

11. A "secondary" pleurisy is an added effect from some other chest disease - pneumonia, for instance in which the germs reach the pleura as well as the lungs themselves from tuberculosis, or lung abscess, or tumour of the lung.

12. Causes • Viral infection • Lung infections, such as: • Pneumoniaandtuberculosis

13. Systemic lupus • Cancer metastases • Asbestos • Pancreatitis

14. Rheumatiod arthritis • Cancer metastases • Liver and kidney disease • Heart failure • Pulmonary embolism • Chest injury

15. Symptoms • Pain in the chest that is aggravated by breathing • Shortness of breath • "Stabbing" sensation

16. Diagnosis • Physical examination: • May show abnormallungsounds: • A friction rub -- a rough scratchy sound that accompanies inspiration and expiration . • Ralesmay be present if there is an accompanyingpneumonia.

17. Decreasedbreathe sound may be present if there is a collection of fluid around the lung. • Rhonchi may be present with accompanyingpneumoniaor bronchitic process.

18. Tests • CBC may help differentiate bacterial versusviral infection. • X-ray of the chest • Ultrasoundof the chest • Thoracentesis a collection of fluid from the pleural cavity.

19. Treatment • Pain Management • Analgesics and inflammatory drugs • Treating the Source of Infection

20. Pleural Effusion • A pleural effusion is an accumulation of fluid between the layers of the membrane that lines the lungs and chest cavity .

21. Mechanisms of Pleural Fluid Accumulation • An excessive amount of pleural fluid probably results from a combination of fluid draining into the tissues from the blood vessels and the overproduction of fluid by the mesothelial cells.

22. Increased hydrostatic pressure, especially systemic venous pressure combined with capillary wedge pressure in CHF . • Decreased oncotic pressure - by itself not a huge problem because of lymphatic reserves.  • Decreased (more negative) pleural pressure - collapsed or trapped .

23. Increasedpermeability of microvasculature, inflammatory fluid formation • Impaired lymphatic drainage - blockage of channels with tumor, fibrosis, etc. 

24. Fluid from peritoneal space - ascites moves via diaphragmatic lymphatics or diaphragmatic defects (lessthan 1 cm. 

25. Types Of Fluid • Four types of fluids can accumulate in the pleural space: • Blood (hemothorax) • Pus(pyothorax or empyema) • Serous fluid(hydrothorax) • Chyle(chylothorax)

26. Types Of Effusion • Transudative pleural effusions. • Exudative pleural effusions.

27. Transudative Effusions • Caused by some combination of increasedhydrostatic pressure and decreasedoncotic pressure in the pulmonary or systemic circulation.

28. :Selected Causes Of Transudates • Congestive heart failure • Nephrotic syndrome • Cirrhosis • Hypoalbuminemia

29. Urinothorax • Peritoneal dialysis • Atelectasis)early)

30. Exudative Effusions • Caused by local processes leading to increased capillary permeability resulting in exudation of fluid, protein, cells, and other serum constituents.

31. Selected Causes of Exudates • Infection (Bacterial, viral fungal, tuberculosis, or parasitic) • Malignancy • Connective tissue disease

32. Chylothorax • Hemothorax • Pancreatitis

33. Postcardiotomy syndrome • Drug-induced (eg, by amiodarone • Esophageal rupture • Uremia • Pulmonary embolism

34. Subdiaphragmatic abscess • Asbestos exposure • Atelectasis (chronic)

35. Chylous Effusion • Is a milky white effusion high in triglycerides caused by traumatic or neoplastic (most often lymphomatous) damage to the thoracic duct.

36. Chyliform (cholesterol Or Pseudochylous • Effusionsresemble chylous effusions but are low in triglycerides and highin cholesterol. • Chyliform effusions are thought to be due to release of cholesterol from lysed RBCs and neutrophils in long-standing effusions when absorption is blocked by the thickened pleura.

37. Chyliform effusions are thought to be due to release of cholesterol from lysed RBCs and neutrophils in long-standing effusions when absorption is blocked by the thickened pleura.

38. Hemothorax • Bloody fluid (pleural fluid hematocrit < 50%peripheral hematocrit) in the pleural space due to trauma or, rarely • As a result of coagulopathy or after rupture of a major blood vessel, Such as the aorta or pulmonary artery.

39. Empyema • Pus in the pleural space. • It can occur as a complication of pneumonia, thoracotomy, abscesses (lung, hepatic, or subdiaphragmatic), or penetrating trauma.

40. Empyema necessitans is soft-tissue extension of empyema leading to chest wall infection and external drainage.

41. Malignant Pleural Effusion • Malignant pleural effusions are a common complication of malignancy, and malignancy is a common cause of pleural effusions in general.

42. Lung cancer, breast cancer, lymphoma, and leukemia account for approximately 75% of all malignancy-associated effusions.

43. Iatrogenic Effusions • Can be caused by migration or misplacementof a feeding tube or central venous catheter, leading to infusion of tube feedings or IV solution into the pleural space.

44. Diagnosis • Medical History • Physical Examination • Chest Imaging

45. Thoracentesis • Needle Biopsy Of Pleural Or Lung • Bronchscopy • Thoracothcopy

46. Symptoms • Shortness of breath • Chest pain usually a sharp pain that is worse with cough or deep breaths • Cough • Hiccups • Rapid breathing • Chest presure

47. Chest pressure usually does not occur until the effusion is in the moderate(500-1500 ml) to large (>1500 ml) .

48. Cough is usually related to the associated atelectasis.

49. Physical examination • Physical findings are variable and depend on the volume of the pleural effusion. • Generally, findings are: undetectablefor effusions smaller than 300 mL. • With an effusion larger than 300 mL, physical findings often may include the following:

50. Asymmetric expansion of thoracic cag • Pleural friction rub • Mediastinal shift • Seen only with massive effusions usually >1000 mL