pleural disease - paccm @ pitt€¦ · pleural disease meghan fitzpatrick, md pleural disease: ......

PleuralDisease

MeghanFitzpatrick,MD

PleuralDisease:Objec:ves

•  Reviewtheanatomyandphysiologyofthepleuralspace

•  Reviewdiagnosisandmanagementofcommondisordersofthepleura– Pleuraleffusion– Pneumothorax– PleuralTumors

PleuralAnatomy

•  Visceralandparietalpleurasurroundthelungandlinethoraciccavity,respec:vely

•  Singlelayerofmesothelialcells,withunderlyinglayerofconnec:ve:ssuecontainingvasculature,lympha:cs,nerves

NeJerF.AtlasofHumanAnatomy,2ndedi:on.1997,Plate200.

PleuralAnatomy

•  Bothparietalandvisceralpleurainhumansaresuppliedbysystemiccircula:on

•  Lympha:csarepresentinbothvisceralandparietalpleura,butfluidfromthepleuralspaceisprimarilyabsorbedbytheparietalpleurallympha:cs

•  Painfibersarelocatedonparietalpleuraonly

PleuralPhysiology

•  Pleuralspacepressureinaspontaneouslybreathingpersonisanega:vepressurespace(withexcep:onofduringforcedexhala:on)

cmH

2O

Liters

-5

-8

FRC

LungVolume

Intrapleuralpressure

PleuralPhysiology:FluidTransfer•  2-20mLoffluidineachpleuralspace,con:nuouslyfiltered

viapleuralcapillaries•  Fluidflowforeverycapillarysystemcanbedescribedusing

theStarlingequa:onQf=Kf*[(PCAP-PPL)-σ(πCAP - πPL)]Qf:fluidflow(intopleuralspace)P:hydrosta:cpressures,π:onco:cpressuresKf:filtra:oncoefficient(capillarypermeability)σ:reflec:oncoefficient(abilityofthecapillarytoretainsolute)

Filtration:Qf=Kf*[(PCAP-PPL)-σ(πCAP - πPL)]

πPL:+5Kf

Kfσ

σ

πCAP : +34

PCAP:+26PPL:-5

PLEURALcapillariesNeteffectslightnetposi:vefiltra:onintopleuralspace

ParietalPleuralLympha6csAbsorbFluid,Solute,andCellsfromthePleuralSpace

πPL:+5Kf

Kfσ

σ

πCAP : +34

PCAP:+26PPL:-5

WhatLeadstoExcessPleuralFluidCollec:on?

•  Mul:pleMechanisms…


Kf

Kf

Kf

Kf

Kf

Kf

πCAP πPL

PCAP PPL

IncreasedPleuralCapillaryPermeability:•  PleuralInflamma:on•  Infec:on•  Connec:veTissueDisease•  Malignancy


Kf

Kf

Kf

Kf

Kf

Kf

êπCAP πPL

PCAP PPL

Decreasedcapillaryonco:cpressure:•  Hypoalbuminemia•  Nephro:csyndrome


Kf

Kf

Kf

Kf

Kf

Kf

πCAP éπPL

PCAP PPL

Increasedpleuralonco:cpressure:•  notusuallysignificant•  occasionallywithhemothorax


Kf

Kf

Kf

Kf

Kf

Kf

πCAP πPL

éPCAP PPL

IncreasedPleuralCapillaryHydrosta:cPressure:•  RightorLedLVFailure(CHF)•  VolumeOverload•  SuperiorVenaCavaSyndrome


Kf

Kf

Kf

Kf

Kf

Kf

πCAP πPL

PCAP êPPL

Decreasedpleuralhydrosta:cpressure:•  Lungatelectasis

Filtration:Qf=Kf*[(PCAP-PI)-σ(πCAP - πI)]

πI

PI

Kf

σ

πCAP

PCAP

PULMONARYcapillaries

inters::um

Increasedinters::alfluidoverwhelmingtheclearanceofthepulmonarylympha:cs•  Highpressureorhighpermeability

pulmonaryedema(CHF,pneumonia,ARDS,VolumeOverload,etc.

DecreasedLympha:cabsorp:on

•  Lympha:cobstruc:on– Malignancy–  Connec:veTissueDisease

–  Empyema

•  Markedlyelevatedsystemicvenouspressures

PleuralEffusionPathogenesis:Summary

Mul:pleMechanisms:1)  Increasedpulmonaryinters::alfluidfrom

alveolar/pulmonarycapillaryleak(pulmonarycircula:on)intointers::alspacesoflung,thenintothepleuralspace

2)  Pleuralcapillary(systemiccircula:on)Starlingchanges

3)  Obstruc:onofparietallympha:cdrainage4)  Breachofpleuralspacetoanotherfluid-filled

compartment

PleuralEffusionClinical:Background

•  Morethan1,000,000casesannuallyinU.S.

•  Physicalexamfindingsreflectfluidinterposedbetweenthechestwallandthelung:dullnesstopercussion,decreasedtac:lefremitus,diminishedbreathsounds

•  AppearsonCXRatavolumeof200mLinPAprojec:onand50mLonlateral–decubitusviews,ultrasound,orCTenhancedetec:on

Lpleuraleffusion:PA/lat

Lpleuraleffusion:PA,Ldecubitus

Case1:76yomalewithdyspnea

•  Progressivedyspneafollowingaor:cvalvesurgery

•  Peripheraledemanotedathip

•  Generalizedweakness,failuretothrive


•  Diagnos:cthoracentesisforfluidanalysis,withassociatedbloodwork

– Fluidprotein=1.6,FluidLDH=54– Serumprotein=6.1,SerumLDH=132

•  Howisthefluidcharacterized?A.  ExudateB.  Transudate

TransudatevExudate

•  Transudatesresultfromasystemicprocess(mostcommonlyCHF,hepa:cdisease,andrenaldisease)intheseongofnormalpleuraandrarelyrequirefurtherdiagnos:ctes:ngofthepleuralfluid

•  Exudatesdevelopinseongoflungand/orpleuralpathology

TransudateversusExudate

•  Importanttodifferen:ate– Narrowsdifferen:aldiagnosis– Exudateindicatesneedforfurtherdiagnos:ctes:ngofthepleuralfluid

•  Light’sCriteria(onlyneed1)1.  PleuralProtein:SerumProtein>0.52.  PleuralLDH:SerumLDH>0.63.  PleuralLDH>2/3ofUpperLimitNormalSerum


1.  PleuralProtein:SerumProtein>0.5•  1.6/6.1=0.26

2.  PleuralLDH:SerumLDH>0.6•  54/132=0.41

3.  PleuralLDH>2/3ofUpperLimitNormalSerum•  ULNserum=171;54not>2/3

MeetsnoneofLight’sCriteria;thusisaTRANSUDATEandrequiresnofurtherfluidtes:ng

Transudate:LimitedDifferen:alCommon•  Conges:veHeartFailure•  Cirrhosis•  Nephro:csyndrome•  Hypoalbuminemia

LessCommon•  PE(usuallyexudate)•  Associatedwithperitoneal

dialysis•  Urinothorax•  CSFLeak

•  Treatment:Treatunderlyingcause•  Mayrequiredrainageifverylarge,butlikelyto

recurifunderlyingcausenotaddressed.

Case1:34yomalewithunilateralexuda:veeffusion

MostCommonCausesofPleuralEffusionintheUnitedStates


•  2weeksofworseningdyspneaonexer:on

•  IntermiJentcoughproduc:veofbrownsputum,Rsidedchestpain

•  Fevers,chills,anorexia•  Recenthospitaliza:onforintoxica:on


•  Diagnos:cthoracentesisforfluidanalysis,withbloodwork

– Fluidprotein=3,FluidLDH=12,000– Serumprotein=7,SerumLDH=246

•  Howisthefluidcharacterized?A.  ExudateB.  Transudate


1.  PleuralProtein:SerumProtein>0.5•  3/7=0.43

2.  PleuralLDH:SerumLDH>0.6•  12,000/246=48

3.  PleuralLDH>2/3ofUpperLimitNormalSerum•  12,000>>>>171

Meets2of3ofLight’sCriteria(onlyneededone);thusisanEXUDATEandrequiresfurtherdiagnos:ctes:ng


•  Whatisthemostlikelycauseofhisexuda:veeffusion?

A.  PneumoniaB.  PulmonaryEmbolismC.  MalignancyD.  Conges:veHeartFailure


MostCommonCausesofPleuralEffusionintheUnitedStates

ParapneumonicEffusion•  Mostcommoncauseofexuda:veeffusioninUnitedStates

•  Complicates40-60%ofbacterialpneumonia•  Parapneumoniceffusion,especiallyempyema,associatedwithincreasedmortality

•  CommonOrganisms:–  CAP:Streptococcus,Staphylococcus,anaerobes(Fusobacterium,Bacteroides,Peptostrepococcus)

–  HCAP:Staph(MRSA),gram-nega:veaerobes(E.coli,Psuedomonas,Klebsiella)

•  Highermortalitywithgram-nega:ves,Staph,andhospital-acquired


•  Youobtainfurtherappropriatefluidstudiesinyourpa:ent,resul:ngwiththefollowing:– appearance:purulent– pH=7.0;glucose<10,WBC=unobtainable;gramstain:manyWBC,feworganisms

– cytology:nega:ve,AFB:nega:ve•  Whatistheclassifica:onofthiseffusion?

A.  UncomplicatedparapneumonicB.  ComplicatedparapneumonicC.  Empyema

Classifica:onofParapneumonicEffusion Uncomplicated Complicated Empyema

Imagingcharacteristics Free-7lowing Loculated,septated,orwithassociatedpleuralthickening.Mayalsobefree-7lowing;imagingcharacteristicsdonotruleoutcomplicatedeffusion

Anyofthecharacteristicsofcomplicated,ordense7luid/airloculessuggestiveofpus

Appearance Frankpus

Gramstain/Culture Negative Maybepositive +/-positivegramstain,culturemaybepositive

pH >7.2 <7.2 <7.0

Glucose >60 <60 <60

LDH <3XserumUNL >3XserumUNL >3XserumUNL(usuallyveryhigh)

•  Cannotdifferen:ateuncomplicatedfromcomplicatedeffusionwithoutsamplingthefluid.

•  Parapneumoniceffusionsofadequatesize(>10mmondecubitusfilm)mustbesampled,andcomplicatedparapneumoniceffusionsmustbedrained.

•  Don’tforgetANTIBIOTICS!

REQUIREDRAINAGE

Case2:34yomalewithempyema


•  Subacuteonsetofdyspneaonexer:on,nowatrest

•  Fa:guedandfrail•  HistoriesincludeRbreastcancer,CHF,andgallstonerequiringbiliarysurgery2monthspriortoadmission


•  Diagnos:cthoracentesisforfluidanalysis,withbloodwork

– Fluidprotein=5.5,FluidLDH=148– Serumprotein=7.1,SerumLDH=139

•  Exudate–nowwhat?

Undifferen:atedexudate:Rou:neStudies

Study IndicationAppearance Frankpus:empyema

Frankblood:possiblehemothorax(sendHct)Milky:chylothorax

CultureandGramStain EvalInfection.Sendinculturebottles

Cytology EvalMalignancy

CellCountandDifferential Seenextslide

GlucoseLevel <60indicatesinfection,malignancy,orrheumatoideffusion

pH <7.2indicatescomplicatedinfection,malignancy,rheumatoideffusion,esophagealleak

Exudate:CellCountGeneralCharacteristic PossibleDifferential

Macrophage-predominant(~75%) Normal

Neutrophil-predominant:Acutein7lammation

PneumoniaPulmonaryEmbolismSubdiaphragmaticAbscessAcuteTBConnectiveTissueDisease(Acute)

Lymphocyte-predominant:Chronicin7lammation

MalignancyConnectiveTissueDisease(Chronic)ChronicTB

Eosinophilia(>10%Eos):Non-speci7ic

Drug-inducedPneumothoraxMalignancyInfectionParasiticDisease

Undifferen:atedexudate:Rou:neStudies:Ourpa:ent

Study IndicationAppearance Orange-yellow,viscous

CultureandGramStain Negative

Cytology Pending

CellCountandDifferential Seenextslide

GlucoseLevel 79(<60indicatesinfection,malignancy,orrheumatoideffusion)

pH Notobtained(<7.2indicatescomplicatedinfection,malignancy,rheumatoideffusion,esophagealleak)

Exudate:CellCount–OurPa:ent

GeneralCharacteristic PossibleDifferential

Macrophage-predominant(~75%) Normal

Neutrophil-predominant:Acutein7lammation

PneumoniaPulmonaryEmbolismSubdiaphragmaticAbscessAcuteTBConnectiveTissueDisease(Acute)

Lymphocyte-predominant:Chronicin7lammation

MalignancyConnectiveTissueDisease(Chronic)ChronicTB

Eosinophilia(>10%Eos):Non-speci7ic

Drug-inducedPneumothoraxMalignancyInfectionParasiticDisease

WBCCount=400;76%L,14%M,8%N,1%E

Exudates:ExtensiveDifferen:alCommon•  Parapneumonic•  Malignancy•  PulmonaryEmbolism•  Post-cardiacinjury

LessCommon•  Tuberculosis•  CollagenVascularDisease•  Pancrea:cDisease

abdominalabscess,esophagealperfora:on

•  Chylothorax•  Hemothorax•  Drug-induced•  BenignAsbestosEffusion•  Andothers…


•  Whatfurtherstudieswouldyouobtain?A.  AmylaseB.  TotalbilirubinC.  RheumatoidfactorD.  AdenosinedeaminaseE.  CTangiogramF.  Allofthese?G.  Noneofthese,I’msavinghealthcaredollars

AncillaryPleuralFluidStudiesTest Indication

Adenosinedeaminase(ADA) Tuberculosis

Interferon-gamma Tuberculosis

Amylase Pancreaticdisease,esophagealrupture

Hematocrit >50%ofserumHct:hemothorax

RheumatoidFactor Rheumatoideffusion

TriglycerideLevel,Chylomicrons Trig>110&plueral:serumcholesterol<1.0:chylothoraxChylomicrons+ive:chylothorax

Creatinine Urinothorax(transudate)

β2-transferrin Cerebrospinal7luidleak;suspectifpatienthasaventriculoperitoneal(VP)shuntorrecentthoracicspinesurgery(transudate)

TotalBilirubin Biliary-pleural7istula

TreatmentofNon-Infec:ousExudate

•  Treatunderlyingcause•  Localtreatmentdependsonsymptoms;unlikecomplicatedparapneumoniceffusionorempyema,drainageisnotrequired

•  Simpledrainage,indwellingpleuralcathether,orpleurodesismaybeusedtotreatasymptoma:ceffusion,dependingonunderlyingcause

Pneumothorax

•  Airinthepleuralspace(entersviabreachofchestwallorlung)

•  Presen:ngfeatures:chestpain&dyspnea

•  Examfindings:nofremitus,diminishedbreathsounds,hyper-resonantpercussionnote

Pneumothorax•  Measurement:“Large”if:

–  >2cmchestwalltoptxathilum

–  >3cmapextocupola•  Classifica:on:

–  Primaryspontaneous:developsinpa:entwithnormallungs

–  Secondaryspontaneous:developsinpa:entwithlungdisease

–  Trauma:c:notspontaneous(penetra:ngtrauma,blunttrauma+/-ribfracture,posi:vepressureven:la:on)

3cm

2cm

Pneumothorax:PrimarySpontaneous

•  Spontaneousptxinpa:entwithnormallungs•  Riskfactors:– CigareJesmoking– Malesex– Tallthinhabitus– Gene:cpredisposi:on(Marfan’s,Ehlers-Danlos,A1AT)

Pneumothorax:PrimarySpontaneous

•  Pathogenesis:Possiblyruptureofsubpleuralblebs

•  Treatment:dependsonsizeandsymptoms– Observa:on(verysmallptx,minimalsx)– Supplementaloxygen– Simpleaspira:on+/-indwellingtubeplacement– Sclerotherapyorsurgicalmanagement

Pneumothorax:SecondarySpontaneous

•  Spontaneousptxinpa:entwithunderlyinglungdisease(COPD,lungcancer,fibrosis,bronchiectasis,etc)

•  Poorlytoleratedduetolackofreserveforgasexchange;associatedwith>10%mortality

•  Pathogenesis:abnormalparenchyma•  Treatment:–  Indwellingcatheterplacement– Surgicalmanagementorsclerotherapy,usuallyofferedwithini:aleventtopreventrecurrence

RecurrentPneumothorax

•  Recurrenceratesrangefrom30-55%andarehigherinsecondarypneumothorax

•  RiskFactors:Smoking,tall/thinhabitus•  Sclerotherapyorsurgicalmanagementusuallypursuedat:meoffirstsecondarypneumothoraxd/thighriskofrecurrence

•  Similarinterven:onspursuedforprimarypneumothoraxat:meoffirstrecurrence

IatrogenicPneumothorax:MechanicalVen:la:on

•  MVdeliversposi:vepressureven:la:ontotherespiratorysystem,usuallyinseongofunderlyingparenchymaldisease

•  Riskfactors:decreasedpulmonarycompliance,increasedpeakormeanairwaypressures(ex:ARDS)->leadingtoruptureofdistendedalveoli

DeepSulcusinSupineCXR

TensionPneumothorax

•  Life-threateningemergency

•  Riskfactors:posi:ve-pressureven:la:on•  Pathophysiology:“One-wayvalve”phenomenon:airenterspleuralspaceandcan’texit

TensionPneumothorax

•  Resultsinprogressivelyposi:vepleuralpressuremaintainedthroughouttherespiratorycycle

•  Posi:vepleuralpressurecompromisesvenousreturnanddecreasescardiacoutput;ul:matelyprogressestoobstruc:veshockandcardiacarrest

NeJermedicalillustra:onusedwithpermissionofElsevier.Allrightsreserved.

TensionPneumothorax•  Classicexamfindings:elevated

JVP,absentbreathsoundsonaffectedside,trachealshidawayfromaffectedside.Neednotallbepresent

•  Treatment:mustallowposi:vepleuralpressuretoescapetolowerpressureenvironment(atmosphericpressure)->“decompression”ofthepleuralspace–  needlethoracostomy–  tubethoracotomy

NeJermedicalillustra:onusedwithpermissionofElsevier.Allrightsreserved.

PleuralTumors

•  Metasta:corprimary•  Frequentlyassociatedwitheffusion

•  Metasta:cinvolvementmostcommonlyfrom3primaries:– LungCancer– BreastCancer– HematologicMalignancy(Lymphoma,Leukemia)

PrimaryPleuralTumors

•  Rare:Solitaryfibroustumorofthepleura(mesenchymalorigin),usuallybenign

•  Morecommon:MalignantPleuralMesothelioma

MalignantPleuralMesothelioma

•  Epidemiology:U.S.incidence~10permillion,with~2500U.S.deaths/year,decliningduetodecreaseinasbestosexposure

•  RiskFactors:Asbestosfiberexposure(carpentry,plumbing,ship-building,pipe-fiong,brakework,insula:on).Prolongedlatencyperiod–20-40yearsfrom:meofexposure.–  80%ofmesotheliomacasesarerelatedtoasbestos– Developsin~10%ofpersonswithexposurehistory


www.cdc.gov.MMWRWeeklyReports2009:58(15);393-396.AccessedOctober2015.f/cc:fibers/cubiccen:meter;averagedoveran8-hourshid,limitsperOSHA


•  Clinicalfindings:chestpain,dyspnea,pleuralthickeningonchestimaging,+/-pleuralplaques,frequentlyeffusion

•  Diagnosis:Requirespleuralbiopsy

•  Histology:Maybeepitheliod,sarcomatoid,ormixed hJp://radiopaedia.org/encyclopaedia/cases/all

Credit:DrAhmedAbdRabou

MalignantPleuralMesothelioma•  Staging:

–  T1:ipsilateralpleura(parietalonly:T1a;visceral:T1b)withoutdeepextension–  T2:involvesen:reipsilateralpleuraandextendstodiaphragmorlung–  T3:locallyadvanced(mayinvolvefascia,medias:nalfat,chestwall,par:al

pericardium)but“poten:allyresectable”–  T4:unresectable:contralateralpleura,transmuralpericardium,medias:nal

organs,peritoneum,diffuseextensionthroughchestwall

–  N0:Nonodes–  N1:ipsilateralhilar/bronchopulmonarynodes–  N2:subcarinal,ipsilateralmedias:nal,nodes–  N3:contralateralnodes

–  M0:nomets–  M1:mets


•  Treatment:Primaryfocusispallia:onofdyspneaandchestwallpain–  Pleurodesis–  Surgical(radicalpleurectomyanddecor:ca:on,extrapleuralpneumonectomy)–selectedcases,notconsideredstandardofcare

–  Chemotherapy(pemetrexedandcispla:n)–  +/-Radia:on

•  Prognosis:poor,mediansurvival8-12monthsfromdiagnosis.–  Worseprognos:cfactors:olderage,worseperformancestatus,non-epithelioidhistology,malegender,leukocytosis

•  Survivalbenefitsoftreatmentareunconvincinginmostpa:ents

pleural disease - paccm @ pitt€¦ · pleural disease meghan fitzpatrick, md pleural disease: ......

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