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the subject of this lecture is pleural
disease by which we mean pure effusions
which can be transient eighths or
exudates or infective in origin in
addition we'll talk about pneumothorax
which is air in the pleural space and
pleural thickening mesothelioma which is
a primary cancer of the pleura is that
actually discussed in the lung oncology
lecture there are a couple of important
basic concepts about pleural disease the
first is that there are no divisions in
the normal through space and that means
that when you have a pneumothorax of air
in the pleural space it will rise to the
top whereas if you have pleural fluid
then it will sink to the bottom and
pleural fusions are best detected at the
base of the lungs however if you get an
infection in the pleural space or a
hemothorax that is blood in the pleural
space or a surgeon has done some pleural
surgery then you get a diva's forming
between the visceral and the parietal
pleura and that can cause LOC ulation x'
of the pleural space divisions and that
will make the x-ray appearances of
pleural fluid or a pneumothorax quite
different the other basic concept is
that purl spaces under negative pressure
and this keeps the lungs inflated and
that means that when you get a
pneumothorax the lung will collapse
pleural disease is actually readily
detectable normally by clinical
examination the stethoscope will quite
easily pick up a difference when
somebody has a pneumothorax or a pleural
fusion between the affected site and the
normal site and percussion note will
readily pick up somebody with a large
profusion the best test isn't actually a
pleural ultrasound and that is the the
most efficient way of assessing for
pleural fluid and for divisions in the
pleural space and where there's only and
it's also effective at identifying
whether there's any masses or abner the
pleural surface itself so pleural
effusions fluid in the pleural space
this is an x-ray on the right hand side
of somebody with a left pleural effusion
that should be readily detectable
clinically and you can see it quite
easily on the chest x-ray these are very
common and they occur in multiple
different specialties because of the
causes are very large range will be seen
by mortal
from Medical Specialties the
presentation is over as an asymptomatic
finding on a chest x-ray or as the
effusion gets bigger the patient becomes
more and more breathless so that causes
progressive dystiny over days or weeks
sometimes with the more inflammatory
types of pleural fluid those which were
caused by infection or perhaps a bony
embolus then puristic chest pain is
actually a very prominent symptom and
polluted chest pain is very specific and
very easily characterized it's an a pain
that occurs on inspiration and it's
localized to where the inflammation is
occurring normally on one side of the
chest and you may hear a pleural rub
over that area so when you examine
somebody with pleural fluid what you'll
find is at the trachea for larger
fusions may be deviated away from the
ACEF of the effected side expansion of
the site of the lung with the pleural
fluid around it will be reduced and when
you pick us it will be very dull over
the pleural fluid because the air has
been replaced by liquid and that's
described as Stoney dog because it's
very dull indeed you won't be able hear
any breath sounds and vocal resonance
will also be reduced over the area of
the effusion sometimes at the top of the
fusion you may hear in an area patch of
bronchial breathing and of course you
may hear pleural rubber there's
inflammation of the pleura but that will
be heard where the visceral and the
parietal pleura are actually allowed to
to reach to oppose each other and
therefore won't be heard over the areas
of larger fusions but areas where the
effusion is much smaller there may be
also signs of what the cause that the
rural fusion is so for example there may
be powerful lymph nodes somebody's got a
cancer or an enlarged liver if somebody
has a cancer with liver metastases there
might be sides are quite liver disease
heart failure or rheumatoid arthritis
all of which are associated with poor
effusions and some patients
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