Pleural Dysfunction & Management

• The Pleurae: 

  • Pleura (singular)  
  • Pleurae (plural)  
  • A thin double layered serous membrane 
  • Parietal pleura which lines the thoracic wall and the superior diaphragm (innervated by the phrenic nerve) 
  • Visceral pleura which lines the surface of the lungs and fissures (divisions between different lobes) 
  • This double layer creates a potential space (the pleural cavity) 
• The Pleural Cavity: 

  • Thin layer of pleural fluid in the pleural cavity   
  • Separation of pleurae strongly resisted by surface tension of pleural fluid (locked together)   
  • Lubricates - allows pleurae to glide over each other   
  • Parietal pleura is innervated by intercostal and phrenic nerves – has pain fibres 
• Inflammation of the Pleurae: 

  • Inflammation of the parietal pleura results in pain (pleurisy)   
  • Inflammation of the pleurae may result in an increase in pleural fluid (pleural effusion)  
  • Inflammation of the pleurae may result in a pleural rub on auscultation - frictions 
• Pleural Effusion: 

  • Pleural effusion is excess fluid that accumulates in the pleural cavity   
  • Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during respiration   
  • Pleural effusion can occur secondary to bacterial or viral infection (e.g. pneumonia or TB), primary cancer (mesothelioma – mainly caused by asbestos), metastatic cancer (Ca breast), heart failure or pulmonary embolus 
•  Management of Pleural Effusion:  

  • Treatment aims to remove fluid from lung   
  • Doctor may place a pigtail or intercostal chest drain (ICD) to drain the fluid  
  • A surgeon may need to perform a surgical procedure as treatment of a malignant effusion (Thoracic surgery lecture)  

  – Stick parietal and visceral pleura together (pleurodesis – chemical or surgical)  

  – Strip off parietal pleura from chest wall (pleurectomy) 
• Empyema: 

  • Empyema is a collection of pus in pleural space  
  • Empyema is caused by infection that spreads from the lung 

  – Bacterial pneumonia  

  – Lung abscess  

  – Thoracic surgery  

  – Trauma or injury to the chest 
• Empyema – clinical features: 

  • Chest pain, which worsens on deep inspiration   
  • Dry cough  
  • Excessive sweating, especially night sweats  
  • Fever and chills  
  • General discomfort, uneasiness, or ill feeling (malaise)   
  • Shortness of breath  
  • Unintentional weight loss 
• Management of Empyema: 

  • Treatment aim is to cure infection and remove collection of pus from the lung 
  • Antibiotics prescribed to control infection  
  • Doctor may place a pigtail or intercostal chest drain (ICD) to drain the pus  
  • A surgeon may need to perform a procedure to peel away the lining of the lung (decortication) if the lung does not expand properly  
• Pneumothorax:  

  • Pneumothorax is the presence of air in the intrapleural space  
  • An abnormal communication between either  

    - The alveoli and the pleural space e.g. emphysema (spontaneous) or  

    - The atmosphere and the pleural space e.g. stab wound (traumatic)  

  • Loss of negative intrapleural pressure results in lung collapse 
• Pneumothorax – Clinical Features: 

  • Pain – disruption to the parietal pleura 
  • Breathlessness – lungs collapsed so reduced surface area for gaseous exchange 
  • Reduced breath sounds on auscultation  
  • Reduced oxygen levels in the blood (hypoxaemia) – reduced surface area for gaseous exchange 
  • Chest x-ray (CXR))changes 
• Tension Pneumothorax:  

  Mediastinal shift AWAY from the side of the pneumothorax 

  Life threatening because of the effect on the heart, due to it being pushed causing compression meaning that it cant beat or pump  the blood around effectively  

  Rapid build up of air in the pleura space 
• Management of a Pneumothorax:  

  • Intercostal drain (ICD) inserted to restore negative intrapleural pressure   
  • Excess air will flow out of the pleural space into the chest drain bottle (bubbling) 
  • Lung will reinflate  
  • If pleura has healed then ICD can be removed  
  • Surgery may be required if there is a persistent air leak 
• Physiotherapy Intervention: 

  • Ensure adequate analgesia  
  • Gentle shoulder ROM exercises don’t push through pain 
  • Thoracic postural advice   
  • Main aim of treatment is to increase lung volume  
  • Increase lung volume with positioning, deep breathing exercises and physical exercise e.g. walking or exercise bike 
  • Standing increases the lung volume the best 
• Intercostal drains: 

  • Underwater seal to ensure drainage away from patient (keep drainage bottle upright)  
  • Keep the drainage bottle below the level of the patient’s chest  
  • Clamp the tubing (as briefly as possible) if you have to lift the bottle above the patient’s chest  
  • ICD may be bubbling, swinging or static  
  • Never clamp a bubbling ICD – the air leak will build up again which may result in the lung collapsing again 
  • Always assess the ICD before and after treatment to check not been dislodged or kinked  
  • If ICD falls out – cover with glove and then sterile gauze as quickly as possible