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Pleural Diseases

Pleural Diseases

1. PNEUMOTHORAX (PT)

  • Presence of air in the pleural space
  • Etiology 

Pathogenesis

  • Closed pneumothorax – communication between the airway and the pleural space seals off as the lung deflates and doesn’t re-open
    • Pleural pressure remains negative
    • Spontaneous reabsorption of air an re-expansion of lung occurs in days-weeks
  • Open pneumothorax – communication fails to seal, air continues to pass freely between bronchial tree and pleura
    • E.g. a bronchopleural fistula
      • Can facilitate transmission of infection from airways into the pleura and lead to empyema
    • MC after rupture of an tuberculous cavity or lung abscess into the pleura
  • Tension pneumothorax – communication between the airway and pleura acts as a one way valve
    • Allows air to enter the pleura during inspiration but not to escape during expiration
    • Large amount of trapped air accumulates – intrapleural pressure rises above atmospheric pressure
    • Can cause mediastinal displacement to the opposite side, with compression of the opposite normal lung

Clinical features

  • Sudden onset unilateral pleuritic chest pain
  • Breathlessness
  • Combination of absent breath sounds + resonant percussion is diagnostic of PT
  • Tension PT – rapidly progressive breathlessness, tachycardia, hypotension, cyanosis, mediastinal shift

Diagnosis

  • CXR – sharply defined edge of deflated lung; absent lung markings external to edge; mediastinal shift
  • CT – not routine; indications are underlying lung disease or uncertain diagnosis

Treatment

  • Primary PT in which the lung edge is <2cm away from chest wall – resolves without intervention
  • Percutaneous needle aspiration of air
  • Intercostal tube drainage – for patients with significant underlying lung disease

Tension PT

  • Needle decompression – temporary measure before chest drain can be placed
    • In 2nd intercostal space, mid clavicular line
  • Chest drain – with distal end connected to an underwater seal
    • 4th/5th intercostal space in the mid axillary line

2. EMPYEMA

  • Collection of pus in pleural cavity – large amount of neutrophils are present

Etiology

  • Empyema is most commonly due to bacterial pneumonia or TB
  • Other causes
    • Infection of haemothorax following trauma/surgery
    • Oesophageal rupture
    • Rupture of subphrenic abscess

Pathogenesis

  • Pleural spaces are covered with a thick inflammatory exudates
  • Due to ↑pressure, the pus can rupture into a bronchus – causing bronchopleural fistula

Clinical features

Diagnosis

  • CXR – can be indistinguishable from pleural effusion
  • CT
  • USS

Treatment

  • Chest tube drainage
  • Antibiotics

3. MESOTHELIOMA

  • Malignant pleural tumour
  • Etiology – past asbestos exposure
  • Clinical features – increasing breathlessness due to pleural effusion; chest pain
  • As tumour progresses it can invade the lung parenchyma, mediastinum and pericardium
  • Poor prognosis – therapy is mostly palliative
    • Chemotherapy
    • Radiotherapy
    • Pleurodesis – to manage pleural effusions, obliteration of pleural cavity.

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