PLEURAL EFFUSION AND MALIGNANT MESOTHELIOMA

 

MAIN TOPIC

RESPIRATORY DISEASES

SUB TOPIC : PLEURAL EFFUSION

DEFINITION

 An abnormal accumulation of serous fluid in the pleural space is called pleural effusion.

 Pathophysiological process of formation of pleural effusion

A. Increased production of fluid in the setting of normal capillaries due to increased hydrostatic or decreased oncotic ( osmotic) pressure. Eg.

• Congestive cardiac failure

• Cirrhosis of liver

• Nephrotic syndrome

• Hypoproteinemia

B. Increased production of fluids due to:

Decreased lymphatic clearance of obstruction of lymphatic channels and abnormal capillaries permeability:

- Pneumonia

- Tuberculosis malignancies

- Trauma

- Other inflammatory conditions

TYPES OF EFFUSION

On the basis of biochemical nature of fluids.

A. Transudative effusion:

i. Congestive cardiac failure

ii. Cirrhosis of liver

iii. Nephrotic syndrome

iv. Pericardial disease.( Constructive pericarditis)

v. Hypoproteinemia

vi. Myxoedema

B. Exudative effusion

i. Pneumonia

ii. Malignancy of lung and pleural

iii. Pulmonary embolism

iv. Tuberculosis

v. Collagen vascular disease ( RA, SLE)

vi. Pancreatitis

vii. Meig’s syndrome

On the basis of unilateral or bilateral

A. Unilateral effusion

i. Pneumonia

ii. Pulmonary tuberculosis

iii. Malignancies

iv. Meig’s syndrome

v. Pulmonary embolism

vi. Pancreatitis

B. Bilateral effusion

i. Congestive cardiac failure

ii. Cirrhosis of liver

iii. Nephrotic syndrome

iv. Pericardial diseases

v. Hyponatremia

vi. Collagen vascular diseases

vii. Bilateral tuberculosis

viii. Bilateral pneumonia

CLINICAL FEATURES

• Symptoms

• Breathlessness : depends on the rate and size of effusion

• Chest pain before effusion develops

• Dry cough

• History of other features

• Generalized weakness

- Fever

- Anorexia

- Weight loss

- Haemoptysis

• Features of other underlying diseases: CCF, Nephrotic syndrome, Cirrhosis of liver.

• Signs on Examination

- Patient dyspnoeic

- Use of accessory muscles

- Look for cyanosis

- Look for clubbing

- Look for lymphadenopathy and features of superior- venacava obstruction.

 Chest examination

 Inspection:

• Reduced chest wall movement on affected side

• Fullness of intercostal space on affected side

 Palpitation : 

• In massive unilateral effusion mediastinal shifting towards opposite site

• Diminished chest expansion on affected side

• Diminished or absent vocal Fremitus

 Percussion :

• Stony dull on percussion on affected side

 Auscultation

• Diminished or absent breath sound on affected area

• Diminished or absent vocal resonance

INVESTIGATIONS

- Blood TC, DC, ESR, Hb%

High ESR, decreased Hb% in pulmonary tuberculosis.

Leucocytosis with neutrophilia in para pneumonic effusion

- Mantoux test positive

- Sputum for Gram stain, culture and AFB and malignant cells

- Chest x-Ray

- Pleural fluid analysis

- Appearance

- Cells normal and abnormal ( malignant cells)

- Gram staining, AFB and culture

- Biochemical analysis

• Glucose

• LDH

• Adenosine deaminase (ADA) for TB

• Protein

• Amylase

- Pleural biopsy

- CT scan of chest

- Others

• Ultrasonography of chest

• Bronchoscopy and biopsy

• Scalene lymph node biopsy

- To find out other causes of pleural effusion i.e non pulmonary causes.

LIGHT CRITERIA

1. Pleural fluid protein : serum protein>0.5

2. Pleural fluid : Serum LDH - >0.6

3. Pleural fluid LDH more than 2/3rd of serum level.

If among three present only one is known as exudate (infection).

RISK FACTORS OF PLEURAL EFFUSION

1. Heart failure.

2. Bacterial pneumonia.

3. Lung cancer and other tumours with lung metastases.

4. Pulmonary embolism.

5. Radiation therapy to the chest.

6. Nephrotic syndrome.

7. Hypothyroidism.

8. Ovarian tumours.

TREATMENT

• General measures

• Bed rest

• Propped up position

• O2 inhalation if indicated

• Symptomatic support

• Thoracocentesis : Removal of fluids from pleural space

- Percutaneous aspiration

- Chest tube drainage for empyema

• Specific Treatment

I. Treatment of tuberculosis with anti tubercular drugs and prednisolone for few weeks. ( 20 mg/ day for 4- 6 week)

II. Malignant effusion:

• Intercostal tube drainage followed by obliteration of pleural space by chemical and surgical procedure

• Chemotherapy for underlying malignancy.

III. Para- pneumonic pleural effusion

• Aspiration or thoracostomy tube followed by antibiotics.

IV. Treatment of other conditions:

• Congestive cardiac failure

• Nephrotic syndrome

• Pneumonia, etc.

COMPLICATION OF PLEURAL EFFUSION

1) Empyema

2) Pneumothorax

3) Re- expansion pulmonary Oedema

4) Cardio-respiratory distress.

5) Haemothorax

6) Renal failure.

SUB TOPIC :

MALIGNANT MESOTHELIOMA

DEFINITION

Malignant Mesothelioma is a rare Cancer that occurs in the thin layer of tissue that covers the majority of internal organs (mesothelium).

Mesothelioma is an aggressive and deadly form of Cancer. Mesothelioma treatments are available, but for many people with Mesothelioma, a cure is not possible.

CAUSES

In general, Cancer begins when a series of genetic mutations occur within a cell, causing the cell to grow and multiply out of control. It isn’t clear what causes the initial genetic mutations that lead to Mesothelioma, though researchers have identified factors that may increase the risk.

RISK FACTORS

The main risk factor for pleural mesothelioma is exposure to asbestos. In fact, most cases of pleural mesothelioma have been linked to high levels of asbestos exposure, usually in the workplace. Asbestos is a group of minerals that occur naturally as bundles of tiny fibers.

CLINICAL FEATURES

- Chest pain

- Fingers clubbing

- Weight loss

- Dyspnoea

- Recurrent pleural effusion

INVESTIGATIONS

• Chest x-Ray:

- Pleural thickening/ pleural effusion

- Bloody pleural effusion

• Pleural Biopsy

 Fine-needle aspiration

 Thoracoscopy

 Laparoscopy

 Thoracotomy

 Laparotomy

COMPLICATION

• Difficulty breathing

• Chest pain

• Difficulty swallowing

• Swelling of the neck and face caused by pressure on the large vein that leads from upper body to heart (superior vena cava syndrome)

• Pain caused by pressure on the nerves and spinal cord

• Accumulation of Fluid in the chest (pleural effusion), which can compress the lung nearby and make breathing difficult.

TREATMENT

- Symptomatic Treatment

- No curative treatment

- Surgery

SOME IMPORTANT QUESTIONS

1. Is mesothelioma a painful death?

Ans; Mesothelioma is a strange cancer, it is the second most painful to endure, the first being bone cancer.

2. Why is mesothelioma so painful?

  Ans; Mesothelioma pain can be due to tumors pressing on nerves and vital organs. As the disease progresses, fluid buildup, particularly in the chest and abdominal cavities, can lead to pain with activity, breathing, coughing and eating.

3. Is smoking a risk factor for mesothelioma?

Ans; By itself, smoking does not increase the risk of mesothelioma, but the combination of smoking and asbestos exposure can increase the risk of certain types of cancer in the lungs.

Thank you for reading hope you gain some knowledge regarding pleural effusion and malignant Mesothelioma. If you loved it follow us for more and also if you have some questions regarding this contact us in our Facebook👇 Handel's or email

@CTEVT TECHnical NEPAL

Email :- ctevtechnical@gmail.com