Pleural Diseases - Standard Treatment Guidelines

There are 4 types of pleural diseases: pleurisy, pleural effusion, pneumothorax and pleural mesothelioma. Pleural mesothelioma is a malignant condition of pleura related to asbestos exposure occurring rather infrequently in our country compared to other lung cancers and is beyond the purview of this review.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Pleural Diseases. Following are the major recommendations :

Case definition:

For both situations of care:

1. Pleurisy is defined as an acute inflammation of the pleura. The inflammation can be primary or secondary due to spread from an adjacent structure.

1. Primarily, viral infections of the pleura result in pleurisy. Secondarily, the pleura may be involved due to pneumonia or pulmonary infarction. The present review is restricted to ‘primary’ pleurisy.

2. Pleural effusion is defined as an excessive accumulation of fluid in the lungs. There are mainly two types of pleural effusions: transudative and exudative pleural effusion.

1. Fundamentally, transudative pleural effusions reflect a systemic pathology and exudative pleural effusions reflect a local pleural pathology. Generally, transudative effusions are usually bilateral, whereas exudative effusions are usually unilateral.


2. The common causes of transudative pleural effusions are congestive heart failure and hypoalbuminemic states (cirrhosis, nephrotic syndrome).


3. The common causes of exudative pleural effusions are tuberculosis, malignancy and traumatic hemothorax. Uncommon causes include pancreatitis, connective tissue diseases, non-traumatic hemothorax (embolism, malignancy) and chylothorax (tumors, filariasis)

3. Pneumothorax is defined as air in the pleural cavity resulting in collapse of the whole lung or some part of the lung. It may be traumatic or spontaneous.

1. Traumatic pneumothorax can result in a life-threatening condition due to tension pneumothorax.


2. Spontaneous pneumothorax may occur without any associated underlying lung pathology (primary) or may be associated with underlying lung pathology (secondary).

1. The common secondary causes include tuberculosis and chronic obstructive airway disease. Smoking and marfanoid habitus are important risk factors. Secondary pneumothorax is a more critical condition as the underlying lung is already compromised.

Incidence of The Condition In Our Country

No systematic robust epidemiological studies are available from India

Differential Diagnosis

1. Pleurisy

• Cardiac: post-myocardial injury syndrome (Dressler syndrome)


• Renal: chronic renal failure

2. Pleural effusion

• Amebic liver abscess


• Lower lobe collapse


• Mass lesion

3. Pneumothorax

• Pulmonary embolism


• Acute coronary syndrome


• Large bulla

Prevention And Counseling

Optimal treatment of primary systemic illness. Abstinence from smoking, alcohol and other substance abuse.

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

*Situation 1: At Secondary Hospital: Optimal Standards of Treatment in Situations where technology and resources are limited

Clinical Diagnosis

Symptoms

1. Pleurisy: sharp pain in the lateral hemithorax characteristically increasing on inspiration and coughing.

2. Pleural effusion: may be asymptomatic or associated with dull aching pain on the affected site. Dyspnea, dry cough may also be present. Symptoms of underlying systemic pathology may be associated.

3. Pneumothorax: sudden onset excruciating pain associated with dyspnea especially in a smoker.

Signs

1. Pleurisy: acute history of fever, pleural rub.

2. Pleural effusion: findings of primary systemic disease, local examination reveals decreased tactile fremitus, stony dull note on percussion and absent breath sounds on auscultation.

3. Pneumothorax: marfanoid habitus, local examination reveals decreased tactile fremitus, tympanitic note on percussion and absent breath sounds on auscultation.

Investigations

1. Pleurisy: No specific investigation per se. Patients with pleurisy normally improve in 7-10 days.

2. Pleural effusion:

1. Chest X-ray (PA and lateral views of chest radiographs): 50 ml fluid can be appreciated on lateral chest radiograph as a meniscus in the posterior costophrenic angle. Lateral decubitus film helps in differentiating a loculated effusion from a free fluid effusion.


2. Ultrasound: USG helps in confirming a pleural effusion as compared to pleural thickening, which many times cannot be appreciated on a chest radiograph. It is also useful in diagnosing loculated effusions, subpulmonic and subdiaphragmtic pathology like an amebic liver abscess.


3. Pleural fluid (PF) evaluation

• Diagnostic thoracocentesis performed with/without US guidance is the investigation of choice to differentiate between a transudative and exudative pleural effusion. This differentiation is the sheet anchor of further management.


• Colour

1. Pale yellow: transudative


2. Turbid : exudative


3. Frank pus : empyema


4. Blood-like : traumatic tap, hemothorax


5. Milky : chylothorax

• Biochemistry {Protein and lactate dehydrogenase (LDH)} Light’s criteria have a high (> 98%) sensitivity and specificity to classify PF. There are 3 criteria as follows:

1. PF protein/serum protein> 0.5


2. PF LDH/ serum LDH> 0.6


3. PF LDH> 2/3 upper limit serum LDH

Exudative PF: any one of 3 criteria present

Transudative: even if one of the 3 criteria are absent

• pH: normal PF pH is 7.64.


• Cell cytology for polymorphonuclear or lymphocytic predominance


• Malignant cytology (if available at secondary level)


• Bacteriology: Gram stain and culture sensitivity in addition to pH are very important investigations to decide regarding the management in cases of parapneumonic effusion vis-à-vis empyema.


• Adenosine deaminase (ADA) levels (if available at the secondary level) Higher ADA levels with lymphocytosis point to a diagnosis of tubercular pleural effusion


• Hematocrit (Hct): PF hct > 50% blood Hct signifies hemothorax differentiating from a traumatic thoracocentesis

3. Pneumothorax

1. Chest radiograph: collapsed lung at the hilum with absence of lung markings in the periphery.


2. Important to evaluate the contralateral lung radiographically-normal or abnormal for management.

Treatment:

not applicable

Standard Operating Procedure

In Patient

1. Pleurisy: symptomatic treatment with non-steroidal inflammatory drugs. If symptoms persist, evaluate for pleural effusion.

2. Pleural effusion

1. Therapeutic thoracocentesis - symptomatic relief of dyspnea (Caveat: not more than 1 litre of pleural fluid should be removed to prevent post thoracocentesis shock and re-expansion pulmonary edema in one sitting)


2. In a transudate, the primary cause has to be managed.


3. Exudative effusions

1. Tuberculosis: as per Revised National Tuberculosis Control Program (RNTCP) guidelines


2. It needs to be remembered that in cases of suspected empyema, establishing the diagnosis as early as possible after admission is the key. A delay in the institution of ICD even by a few more hours results in more fibrosis and loculations, which further complicate the long term management.


3. At admission, the following criteria help in deciding the plan in these patients

3. Pneumothorax

• Primary spontaneous:

1. Small pneumothorax requires observation.


2. Large pneumothorax requires simple aspiration. If lung does not expand then tube thoracostomy.

• Secondary spontaneous

1. Tube thoracostomy

• Traumatic

1. Depends on size- simple observation to thoracostomy

• Tension

1. Medical emergency


2. Large bore needle in second intercostal space. If air gushes out, tube thoracostomy

Out Patient

Treatment of primary systemic illness

Referral criteria:

1. Diagnosis not clear

2. Response to therapy not optimal

3. Recurrent pneumothorax

4. Persistent air leak

5. Unexpanded lung after 3 days of tube thoracostomy

*Situation 2: At Tertiary hospital where higher-end technology is available

Clinical Diagnosis

Symptoms

1. Pleurisy: sharp pain in the lateral hemithorax characteristically increasing on inspiration and coughing.

2. Pleural effusion: may be asymptomatic or associated with dull aching pain on the affected site. Dyspnea, dry cough may also be present. Symptoms of underlying systemic pathology may be associated.

3. Pneumothorax: sudden onset excruciating pain associated with dyspnea especially in a smoker.

Signs

1. Pleurisy: acute history of fever, pleural rub.

2. Pleural effusion: findings of primary systemic disease, local examination reveals decreased tactile fremitus, stony dull note on percussion and absent breath sounds on auscultation.

3. Pneumothorax: marfanoid habitus, local examination reveals decreased tactile fremitus, tympanitic note on percussion and absent breath sounds on auscultation.

Investigations

1.Pleurisy: As in situation V.1b) above

2. Pleural effusion: As in situation V.1b)2. above PLUS

• CT scan to accurately define the anatomy of lung parenchyma (lung abscess) and pleura (empyema by the split pleura sign, loculated effusion, pleural masses)


• Special investigations

1. PF triglyceride > 110 mg/dl for chylothorax


2. PF antinuclear factor for systemic lupus erythematosus (SLE) [specific but not very sensitive]


3. PF Rheumatoid factor and anti-citrullinated protein antibody (anti-CCP)


4. PF amylase for pancreatitis

• Pleural biopsy


• Medical thoracoscopy and video-assisted thoracoscopy (also has therapeutic potential)

3. Pneumothorax: as in situation V.1b)3. PLUS

1. Computed tomography to assess for blebs and associated pulmonary disease

Treatment:

not applicable

Standard Operating procedure

In Patient

1. Pleurisy: As in situation V.1c)a.1 above

2. Pleural effusion: As in situation V.1c)a.2 above PLUS

1. Pleurodesis with doxycycline – recurrent malignant pleural effusion


2. Chest tube instilled fibrinolytic therapy (streptokinase) - parapneumonic effusions


3. VATS (thoracotomy, if VATS not available)- non-resolving empyema


4. Pneumothorax as in V.1c)a.3 above PLUS

1. VATS with pleurodesis/bleb resection

Out Patient

Treatment of primary systemic illness

WHO DOES WHAT? and TIMELINES

Doctor:

Diagnosis and Management including counseling

Nurse:

Implementation of orders, monitoring of patients and counseling

Technician:

Investigations

Resources Required For One Patient

Guidelines by The Ministry of Health and Family Welfare :

Dr S.K. SHARMA AIIMS