What do you know about Pleuritis?
Pleurisy/Pleuritis
The result of any disease process involving the pleura (inflammation of pleura) and giving rise to pleuritic pain or evidence of pleural friction. Common in infection and infraction.
Such pain is localized, sharp, and fleeting; it is made worse by coughing, sneezing, deep breathing, or movement.
When the central portion of the diaphragmatic parietal pleura is irritated, pain may be referred to the ipsilateral shoulder.
On examination rib movement is restricted and a pleural rub may be present, may only be heard in deep inspiration or near the pericardium (pleuro-pericardial rub).
Loss of the pleural rub and diminution in the chest pain may indicate recovery or sign of the development of a pleural effusion.
A preceding history of cough, purulent sputum and pyrexia is presumptive evidence of a pulmonary infection which may not have been severe enough to produce a radiographic abnormality or which may have resolved before the chest X-ray was taken. So no advantage of Chest X-ray.
Treatment-treat the underlying disease.
Analgesics and anti-inflammatory drugs like paracetamol 500mg PO TDS or (eg, indomethacin, 25 mg orally two or three times daily).
Codeine (30–60 mg orally every 8 hours) may be used to control cough associated with pleuritic chest pain.
Opoid analgesic is also given if the pain is severe.
Pleural effusion
The accumulation of serous fluid within the pleural space is termed pleural effusion.
Accumulations of frank pus (empyema) or blood (haemothorax) represent separate conditions.
Normal homeostasis leaves 5–15 mL of fluid in the normal pleural space.
Five pathophysiologic processes account for most pleural effusions:
Increased production of fluid in the setting of normal capillaries due to increased hydrostatic or decreased oncotic pressures (transudates);
Increased production of fluid due to abnormal capillary permeability (exudates);
Decreased lymphatic clearance of fluid from the pleural space (exudates);
Infection in the pleural space (empyema); and bleeding into the pleural space (hemothorax).
Causes of pleural effusion
Common causes
Pneumonia ('para-pneumonic effusion')
Tuberculosis
Pulmonary infarction
Malignant disease
Cardiac failure
Subdiaphragmatic disorders (subphrenic abscess, pancreatitis etc.)
Uncommon causes
Hypoproteinaemia (nephrotic syndrome, liver failure, malnutrition)
Connective tissue diseases (particularly systemic lupus erythematosus and rheumatoid arthritis)
Acute rheumatic fever
Post-myocardial infarction syndrome (Dressler’s syndrome)
Exudative and transudative causes
Transudates
Congestive heart failure (> 90% of cases)
Cirrhosis with ascites
Nephrotic syndrome (hypoprotenemia)
Peritoneal dialysis
Hypothyroidism (Myxedema)
Ovarian tumours producing right-sided pleural effusion - Meigs' syndrome.
Constrictive pericarditis
Exudative
bacterial pneumonia (common)
carcinoma of the bronchus and pulmonary infarction - fluid may be blood-stained (common)
tuberculosis
connective-tissue disease
post-myocardial infarction syndrome (rare)
acute pancreatitis (high amylase content) (rare)
mesothelioma (rare)
sarcoidosis (very rare)
yellow-nail syndrome (effusion due to lymphoedema) (very rare)
Light’s criteria for distinguishing pleural transudate from exudate
Pleural fluid is an exudate if one or more of the following criteria are met:
Pleural fluid protein: serum protein ratio >0.5
Pleural LDH: serum LDH >0.6
Pleural LDH > 2/3rd of the upper limit of normal serum LDH
Clinical features
Symptoms
Pleurisy often precede the development of an effusion, especially in patients with underlying pneumonia, pulmonary infarction or connective tissue disease.
Patients with pleural effusions most often report dyspnea, cough, or chest pain.
Signs
Small pleural effusions are less likely to be symptomatic than larger effusions. Physical findings are usually absent in small effusions.
Inspection- asymmetrical expansion,
Palpation- decreased expansion on the affected side, trachea and apex beat may be shifted (massive effusion),
Percussion- stoney dull
Auscultation – absent breath sounds, increased vocal resonance, crackles above effusion.
Investigations
Radiology-
Chest X-ray: pleural fluid on the erect PA chest film.
Ultrasonography- more accurate, helps in safe needle aspiration and guides pleural biopsy.
Pleural aspiration and biopsy:
Appearance- will suggest empyema or chylothorax. Presence of blood: consistent with pulmonary infraction or malignancy but may represent traumatic tap.
Biochemical analysis: pleural fluid protein, pleural fluid LDH and pleural fluid amylase.
Gram stain and AFB stain: parapneumonic effusion, AFB 20% isolation
Pleural fluid cytology: malignancy, inflamatory cells.
Pleural biopsy: 80% positive in TB, 40% positive in malignancy.
Management
Therapeutic aspiration- to palliate breathlessness but removing more than 1.5 litres in one episode is inadvisable as there is a small risk of re-expansion pulmonary oedema.
Treatment of the underlying cause-for example, heart failure, pneumonia, pulmonary embolism or subphrenic abscess-will often be followed by resolution of the effusion.
Essentials of Diagnosis
May be asymptomatic; chest pain frequently seen in the setting of pleuritis, trauma, or infection; dyspnea is common with large effusions.
Dullness to percussion and decreased breath sounds over the effusion.
Radiographic evidence of pleural effusion.
Diagnostic findings on thoracentesis.
Empyema
Presence of pus in the pleural space. Always secondary to infection.
This usually arises from bacterial spread from a severe pneumonia, TB or after the rupture of a lung abscess into the pleural space.
Other causes are infection of hemothorax and rupture of subphrenic abscess through the diaphragm.
An empyema cavity becomes infected with anaerobic organisms and the patient is severely ill with a high fever and a neutrophil granulocytosis.
May involve the whole pleural space or only part of it (‘loculated or encysted’) and is almost invariably unilateral.
Pathology
If not treated it may rupture in to the bronchus causing bronchopleural fistula and pyopneumothorax,
May lead to grossly thickened and rigid pleura.
There may form subcutaneous abscess or sinus in the chest wall as well.
Clinical features
Systemic features
Pyrexia, usually high and remittent
Rigors, sweating, malaise and weight loss
Polymorphonuclear leucocytosis, high CRP
Local features
Pleural pain; breathlessness; cough and sputum usually because of underlying lung disease; copious purulent sputum if empyema ruptures into a bronchus (bronchopleural fistula)
Clinical signs of fluid in the pleural space
Investigations
Radiology:
Chest X-ray like pleural effusion, except with loculated empyema.
USG- position of the fluid, extent of pleural thickening and whether uniloculated or multiloculated.
CT scan- for assessing lung paranchyma and patency of major bronchi.
Aspiration of pus- confirms empyema, culture and sensitivity, tuberculous and non-tuberculous disease can be difficult and often requires pleural histology and culture.
Management
Treatment of non-tuberculous empyema-
When the pus is thin: intercostal tube (chest tube) connected to water seal drain system.
If initial aspirate reveals turbid fluid or frank pus or if loculations are seen on USG- chest tube on suction (5-10cm H2O) and flushed regularly with 20ml NS.
Antibiotics directed against organism for 2-4 weeks.
Surgical decortication of the lung- in gross thickening of the visceral pleura.
Treatment of tuberculous empyema
Antituberculosis chemotherapy must be started immediately
Aspiration of pus through a wide bore needle until it ceases to reaccumulate
Intercostal tube drain
Surgery- rarely required for residual empyema.
Spontaneous pneumothorax
Presence of air in the pleural space, can occur spontaneously or result from iatrogenic injury or trauma to the lung or chest wall.
Affects male aged 15-30 yrs, smoking, tall stature and presence of apical subpleural blebs.
Secondary in patients with preexisting lung disease, most common is older patients.
Clinical features
Sudden-onset unilateral pleuritic chest pain or breathlessness.
A larger pneumothorax (> 15% of the hemithorax) results in decreased or absent breath sounds,
The combination of absent breath sounds and resonant percussion note is diagnostic of pneumothorax.
Mediastinal displacement towards the opposite side, with compression of the opposite normal lung and impairment of systemic venous return, causing cardiovascular compromise.
Rapidly progressive breathlessness associated with a marked tachycardia, hypotension, cyanosis and tracheal displacement away from the side of the silent hemithorax.
Investigations
Chest X-ray: the sharply defined edge of the deflated lung with complete translucency (no lung markings) between this and the chest wall.
CT scan- differentiate from bullae from pleural air.
Early tension pneumothorax. The right lung is collapsed, and no vessels can be seen traversing the right hemithorax. The mediastinum is shifted slightly to the left. These are features of a large pneumothorax, with some tension component causing a shift of the mediastinum.
Management
