Pleura

• Pneumothorax

  Presence of air in pleural space
• Spontaneous pneumothorax (SP)

  • Occurs when visceral pleura ruptures without external traumatic or iatrogenic cause
  • Can be classified into primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP)
• Primary spontaneous pneumothorax (PSP)

  • No underlying cause
  • Commonly occur in young people 15-30 years
  • 75% are tall men & the condition runs in families
  • Caused by leaking bleb, bullae or vesicles
  • These lesions are typically in apex of upper lobes or upper border of middle & lower lobes
  • Bleeding & tension pneumothorax can occur
• Clinical features of pneumothorax

  • Sharp pleural pain
  • Breathlessness
• Management of pneumothorax

  1. Careful observation better than rapid chest drain (patient should not be hypoxic or in respiratory distress)

  2. Intercostal chest tube connected to underwater seal

  3. The drain should pass over the upper edge of rib to avoid neurovascular bundle injury & directed to apex
• Recurrence rate of pneumothorax

  • Of those occur 1st time 30% experience recurrence
  • Of those with 2nd episode 50% experience recurrence
  • Of those with 3 times go to repeated recurrence
• Definitive treatment of pneumothorax

  Video-assisted thoracoscopic surgery (VATS) to close the air leak, obliterate bleb or bullae, and create adhesion between parietal & visceral pleura
• Pleurodesis

  A procedure by which we create adhesion between lung and chest wall so that pleural space artificially obliterated
• Tension pneumothorax

  • Regardless etiology, there is a build up positive pressure within the pleura, like patient on mechanical ventilation
  • Lung is completely collapse
  • Diaphragm is flattened
  • Shifting of mediastinum to other side
  • Decrease venous return to the heart
• Pleural effusion

  Presence of fluid in pleural cavity
• Exudate

  Pleural fluid with protein content >30 gm /L
• Transudate

  Pleural fluid with protein content < 30 gm /L
• Causes of pleural effusion

  • Increase pulmonary capillary pressure due to increase left atrial pressure due to heart failure or overload circulation
  • Decrease intravascular oncotic pressure due to renal failure & malnutrition
  • Obstruction to mediastinal lymphatic channels secondary to lymphoma or lung cancer
  • Inflammatory disease leads to increase permeability of the capillaries to fluid & protein
• Malignant pleural effusion

  • Caused by lung cancer, pleural malignancy, or mediastinal lymphatic involvement

  
• Malignant mesothelioma

  • Common cause is asbestos exposure
  • Presents with breathlessness due to pleural effusion, pain & systemic feature of malignancy
• Surgical intervention in malignant pleural effusion

  1. Aim: For diagnosis and palliative treatment by pleurodesis

  2. Pleural biopsy: Positive biopsy is useful, negative biopsy does not exclude malignancy

  3. VATS: Previously used for biopsy while now used for pneunectomy, lobectomy & empyema drainage. Most frequent indication are lung biopsy & treatment of recurrent pnumothorax. Advantages: small incision, less PO pain, more rapid recovery

  
• Empyema

  Accumulation of thick pus in pleural cavity
• Causes of empyema

  • Complication of any thoracic operation
  • Traumatic hemothorax become infected
  • Improper treatment of pleural effusion or pneumothorax
• Stages of empyema

  • Exudative phase: high protein effusion infected with organism like strept.melleri & H.Infuenza. In this stage antibiotic is enough.
  • Fibroupurulent phase: In this stage the fluid become thick and treated by chest tube.
  • Organising phase: Lung is trapped by thick peel & here surgery may be required.
• Treatment of empyema

  1. Rib resection & drainage

  2. Decortication
• Decortication

  Excision of the thick fibrinous peel from the pleural surface, thereby permitting the expansion of the underlying lung parenchyma. Patients with long-standing empyema, pleural thickening, hemothorax, and pleural tumors are candidates for decortication.