Pleural Diseases PDF

PLEURAL DISEASES BY: DR. AHMED MODHER KHALAF Pneumothorax Pneumothorax is the presence of air outside the lung, within the pleural space. It must be distinguished from bullae or air cysts within the lung. Bullae can be the cause of an air leak.from the lung and can therefore coexist with pneumot...

PLEURAL DISEASES BY: DR. AHMED MODHER KHALAF Pneumothorax Pneumothorax is the presence of air outside the lung, within the pleural space. It must be distinguished from bullae or air cysts within the lung. Bullae can be the cause of an air leak.from the lung and can therefore coexist with pneumothorax Spontaneous pneumothorax occurs when the visceral pleura.ruptures without an external traumatic or iatrogenic cause Primary spontaneous pneumothorax is a disease in its own-.right Secondary spontaneous pneumothorax occurs when the- visceral pleura leaks as part of an underlying lung disease; any disease that involves the pleura may cause pneumothorax, including tuberculosis, any degenerative or cavitating lung.disease and necrosing tumours Tension pneumothorax is when (independent of aetiology) there is a build-up of positive pressure within the hemithorax, to the extent that the lung is completely collapsed, the diaphragm is flattened and the mediastinum is distorted and, eventually, the venous return to the heart is compromised. Any pleural breach is inherently valve-like because air will find its way out through the alveoli but cannot be drawn back in because the lung tissue collapses around the hole in the pleura. Patients being.mechanically ventilated following trauma are at particular risk Surgical emphysema is the presence of air in the tissues. It requires a breach of an air-containing viscus in communication with soft tissues, and the generation of positive pressure to push the air along tissue planes. The most serious cause is a ruptured oesophagus. Mediastinal surgical emphysema can also occur with asthma or barotrauma from positive pressure ventilation. A poorly managed chest drain with intermittent build-up of pressure allows air to track into the chest wall through the point where.the drain breaches the parietal pleura Primary spontaneous pneumothorax This is a common disease characteristically seen in young people from their mid-teens to late-20s. About 75% of cases are in young men, who tend to be tall, and the condition runs in families. It is due to leaks from small blebs, vesicles or bullae, which may become pedunculated, typically at the apex of the upper lobe or on the upper border of the.lower or middle lobes Usually, pneumothorax presents with sharp pleuritic pain and breathlessness. The pleura is exquisitely sensitive and the movement of the lung on and off the parietal pleura causes severe discomfort. As a result it is mild cases that are more painful, whereas complete collapse is usually painless but causes more breathlessness. Bleeding.and tension pneumothorax can occur They are usually self-limiting; careful observation is wiser than too-ready resort to a chest drain. If the patient is not in respiratory distress or hypoxic there is no urgency. Tension pneumothorax should be immediately relieved by inserting a.cannula into the hemithorax in as safe a position as possible :The best estimates of recurrence rates are Of patients who experience a first event, only about ;one-third experience recurrence Of those who have a second episode, about one-half go on ;to experience a third episode Those who have had three episodes will probably go on to.have repeated recurrences Inserting and managing a chest drain An intercostal tube connected to an underwater seal is central to the management of chest disease; however, the management of the pleura and of chest drains can be troublesome, even in.experienced hands The safest site for insertion of a drain is in :the triangle that lies ;Anterior to the mid-axillary line ;Above the level of the nipple Below and lateral to the pectoralis major muscle.This.will ideally find the fifth space :The technique includes the following.Meticulous attention to sterility throughout.Adequate local anaesthesia to include the pleura.Sharp dissection only to cut the skin Blunt dissection with artery forceps down through the muscle layers; these should only be the serratus anterior and.the intercostals An oblique tract, so that the skin incision and the hole in the parietal pleura do not overlie each other and the drain is in a.short tunnel, which reduces the chance of entraining air A drain for pneumothorax and haemothorax should aim towards the apex of the lung. A drain for pleural effusion or empyema should be nearer the base. The drain should pass over the upper edge of the rib to avoid the neurovascular.bundle that lies beneath the rib The retaining stitch should be secure but not obliterate the.drain A vertical mattress suture is inserted for later wound.closure This is vital for pneumothorax management but should be omitted if the drain is for empyema (provided there is.adherence of the pleura) because that tract should lie open After completion, check that the drain has achieved its objective by taking a chest radiograph. It is preferable not to.apply suction to the drain or to clamp it The danger is that the clamp may be applied for transport and forgotten. Dangers of disconnection and siphoning are small or best averted in other ways apart from clamping. A bubbling drain should (almost) never be clamped. Remove the drain.when it no longer has a function Definitive management of pneumothorax Pleurectomy and pleurodesis Surgery for pneumothorax is best performed by video-assisted.thoracoscopic surgery (VATS) :The object of this scope is threefold ;To deal with any leaks from the lung -1 ;To search for and obliterate any blebs and bullae -2 To make the visceral pleura adherent to the parietal pleura- 3 so that any subsequent leaks are contained and the lung.cannot completely collapse Pleural adhesion is achieved in one of three :ways Pleurectomy. The conventional approach through -1 thoracotomy is to systematically strip the parietal pleura from the chest wall. However, the intercostal veins are at risk, the subclavian vein can be torn at the apex and the sympathetic.chain can be damaged, causing Horner’s syndrome Pleural abrasion. A scourer is used to scrape off the slick -2 surface of the parietal pleura. This has the same effect as.pleurectomy, although it may not be as reliable Chemical pleurodesis. Talc insufflation is the preferred -3.method. It carries much less risk and may well be as effective Pleural effusion Pleural effusions are divided into exudates and transudates, depending on protein content (more or less than 30 g l–1), and characterised further according to glucose content, pH and lactate dehydrogenase content. The following are the most common ways in which the pleural fluid balance is :disturbed Elevated pulmonary capillary pressure. If left atrial pressure rises, the pulmonary capillary pressure must rise with it, whether as a result of impaired cardiac performance or an.overloaded circulation Reduced intravascular oncotic pressure. If the plasma proteins fall because of renal or hepatic disease or.malnutrition, the absorption mechanism fails Accumulation of pleural protein due to obstruction of the mediastinal lymphatics secondary to lymphoma or cancers.that invade the lymphatic system Excessive permeability of the capillaries to fluid and protein as in inflammatory diseases, particularly the collagen vascular diseases. Of particular importance to the surgeon is the fluid associated with pneumonia, which may result in.empyema Malignant pleural effusion Pleural effusion is a common complication of cancer. :This may be due to ;Lung cancer Pleural involvement with primary or secondary ;malignancy.Mediastinal lymphatic involvement Lung cancer There may be direct involvement of the parietal and/or visceral pleura, collapse of the lung parenchyma and spread to the mediastinal lymphatics, or a combination of these, causing pleural fluid accumulation. It is usually regarded as a feature that puts lung cancer beyond.surgical cure Pleural malignancy The only primary malignancy of the pleura seen with any regularity is malignant mesothelioma. This is a consequence of asbestos exposure with few exceptions. Mesothelioma commonly presents with breathlessness because of pleural effusions, pain and systemic features of malignancy. Diffuse seeding of the parietal and visceral pleura is a common pattern of dissemination of cancers, particularly.adenocarcinoma of any origin Mediastinal lymphatic involvement In many instances, particularly in breast cancer, there is no evident disease in the pleura. The disease is in the mediastinal lymphatics, which are obstructed, and this upsets the balance of physiological.forces that control pleural fluid Surgery for patients with malignant pleural effusion :The surgeon has two roles ;To make the diagnosis.To achieve effective palliation by pleurodesis Diagnosis Pleural biopsy can be obtained by a range of techniques. An unequivocally positive biopsy is useful but a negative biopsy may.be a sampling error Thoracoscopy or video-assisted thoracoscopic surgery The direct-vision thoracoscope has been used for many years. The surgeon is able to manipulate instruments with both hands to perform an impressive variety of procedures. Pneumonectomy, lobectomy and empyema drainage are all possible, but thoracoscopic procedures for common, more minor problems is the area providing clear justification for this technique. Lung biopsy and the treatment of recurrent pneumothorax are the most frequent indications. The principal advantage is that a large incision is not required and therefore less postoperative pain and a more.rapid recovery should result Surgical management The principle of surgery is to remove all cancer (the primary and the regional lymph nodes) but to conserve as much lung.as possible Empyema Empyema is the end-stage of pleural infection from any cause; the pathological diagnosis requires the presence of thick pus with a thick cortex of fibrin and coagulum over the lung. It can occur as a complication of any thoracic operation. It is seen if a traumatic haemothorax becomes infected or in the course of management of pneumothorax or pleural effusions. It may.be associated with pus under the diaphragm When empyema presents de novo it usually follows pneumonia and :three phases are described In the exudative phase, there is protein-rich (> 30 g l–1) effusion. If -1 this becomes infected with the organisms from the lung (typically Streptococcus milleri and Haemophilus influenzae in children), the scene is set for empyema. At this stage antibiotics may be all that is.required. Aspiration or drainage to dryness in addition is preferred Over the next days, the fluid thickens to what is known as the -2.fibrinopurulent phase. Drainage at this stage is prudent The organising phase causes the lung to be trapped by a thick peel or -3.‘cortex’ for which surgical management may be required Conditions that predispose to empyema formation Pulmonary infection Unresolved pneumonia Bronchiectasis Tuberculosis Fungal infections Lung abscess Aspiration of pleural effusion Surgery Oesophageal perforation Extrapulmonary sources Subphrenic abscess Rib resection and video-assisted thoracoscopic ‫ﻟﻸطﻼع‬ surgical biopsy This method is used for open pleural biopsy and in the surgical treatment of empyema. To perform this procedure satisfactorily, a double-lumen tube (endotracheobronchial) is required. The patient is positioned with the diseased side uppermost. The presence of fluid at.the site to be operated on is confirmed by needle aspiration For malignant effusion, an approach via the fifth, sixth or seventh rib.laterally is preferred For empyema, a more posterior approach aiming for the lowest part of the empyema cavity as shown by ultrasound or computerised.tomography (CT) is preferred A 3-cm incision over the selected rib is made and using diathermy it is deepened through the latissimus dorsi to the periosteum. The intercostal muscle is stripped off the upper surface of the rib. Care is required to free the periosteum from the groove in the lower border of the rib so that the nerve, artery and vein of the intercostal bundle come away uninjured with the intercostal muscle. The rib is divided with a ring-shaped rib cutter (costotome) that divides the rib easily.without damage to other structures All fluid can be aspirated under direct vision or.videothoracoscopy In the case of malignant effusion, a substantial full-thickness.piece of parietal pleura is sent for histological examination In empyema, adequate specimens of pus, coagulum and.pleura are sent for microbiological examination In malignant effusion, talc is insufflated as a dry powder so.that it coats the moist pleural surfaces Drainage A drain is inserted, which must lie in the bottom of.the cavity It should lie obliquely in its course through the skin.and chest wall and into the pleura, or it will kink The drain must exit the skin anterior to the mid-axillary line otherwise the patient will have to lie.on it, causing pain and obstructing the tube Decortication If the lung is trapped, there is space left and drainage is insufficient, the.more radical operation of decortication is performed An illustrate for the insertion of chest tube (drain) Rigid and flexible bronchoscopes Good luck