Pleural dieseases

1. THE PLEURA
part2

2. PNEUMOTHORAX
• It is the presence of air in the pleural
cavity
• CAUSES
Lung pathology (Spontaneous)
Trauma
Deliberate introduction of air(Artificial)

4. • OPEN PNEUMOTHORAx
• If air can move freely in and out of pleral space
during respiration
• Closed pneumothorax
• If no movement of air occurs
• Valvular pneumothorax
• If air enters during inspiration but doesnot leave
on expiration,intrapleural pressure increases
leading to tension pneumothorax

5. • Aetiology
• Spontaneous most common occur in
young men due to rupture of congenital pleural
bleb.
• In older patients COPD is main cause ,rare are
rupture of subpleural tension cyst .
• Traumatic are due penetrating chest
wound,close chest tauma ,rib fracture
,procedures like bronchoscopy ,PPV,
• Artificial PX as treatment of TB is of historical
interest.

6. • Ultrasonographic Evaluation
for Pneumothorax
• The first step in the examination is to identify the nipple line. Below
this line, the ultrasound probe is used to check each lung in 2
places: (1) at the midclavicular line and (2) on the anterior axillary
line. Although there is no absolute standard, examination of 2 or 3
interspaces is generally recommended for a complete examination.
• The ribs are identified; these will appear hyperechoic, and their
acoustic shadows will appear as hypoechoic rays extending from
the ribs. The interspace between the 2 ribs is used as a fixed
anatomic landmark during the examination. Next, the pleural line is
identified; this is a hypoechoic line found at the inferior border of the
space between the 2 ribs.

7. For optimal pneumothorax
evaluation, patient is examined in
supine position

8. • Findings suggestive of pneumothorax
• The presence of a pneumothorax is
characterized by the absence of 2
findings: (1) the absence of pleural
(lung) sliding, and (2) the absence of
so-called comet-tail artifacts.[12] The
so-called lung point is a relatively recently
described sign that, although difficult to
identify, is pathognomonic for a
pneumothorax and can be used to
measure the size of the pneumothorax.

10. • The appearance of normal lung has been
described as the seashore sign (see the
first image below). This term refers to the
change in appearance between soft tissue
and lung, divided by the pleural line, a
change resembling that between sand and
sea waves. In the presence of a
pneumothorax, this demarcation is lost,
and the appearance on M-mode imaging
is described as the stratosphere sign

11. • Absence of comet tails
• Comet tails are artifacts that are thought to
be created when ultrasound waves
bounce off the interface between the
apposing visceral and parietal layers of
the pleura. They appear as hypoechoic
vertical raylike projections off the pleural
line and are parallel to the rib shadows
previously noted

12. M-mode ultrasonography showing
seashore sign, indicating normal
lungs. No pneumothorax exists.

13. M-mode ultrasonography showing
stratosphere sign, indicating
pneumothorax.

14. • Comet-tail artifact.

15. pneumo

19. rt pneumo

20. rt pnemo

23. • Tension Pneumothorax.
Radiograph of the chest shows a
large left-sided pneumothorax
(white arrows) which is under
tension as manifest as
displacement of the heart to the
right (black arrow) and depression
of the left hemidiaphragm (yellow
arrow). - See more at:
http://www.learningradiology.com/
archives2012/COW
%20511-/tensptxcorrect.html#stha
sh.Cu91IEub.dpuf

24. • Deep Sulcus Sign.
• Deep Sulcus Sign
(yellow arrow). Notice
also
pneumopericardium
(blue arrows) and
subcutaneous
emphysema (red
arrow).

25. • Tension pneumothorax on left
(blue arrow) is displacing the heart
and mediastinal structures to the
right (red arrow);
• this case also shows a deep
sulcus sign on the left (yellow
arrow). There is underlying hyaline
membrane disease. - See more at:
http://www.learningradiology.com/
archives2012/COW
%20511-/tensptxcorrect.html#stha
sh.Cu91IEub.dpuf

26. CT chest showing large right sided
hydro-pneumothorax from pleural
empyema. A air B fluid

27. • Radiograph of an older man who
was admitted to the intensive care
unit (ICU) postoperatively. Note
the right-sided pneumothorax
induced by the incorrectly
positioned small-bowel feeding
tube in the right-sided bronchial
tree. Marked depression of the
right hemidiaphragm is noted, and
mediastinal shift is to the left side,
suggestive of tension
pneumothorax. The endotracheal
tube is in a good position.

28. • chest radiograph of an elderly
male with chronic obstructive
pulmonary disease who presented
with a second left-sided
spontaneous pneumothorax in 2
months. Chest thoracostomy was
performed, the patient was
admitted, and talc pleurodesis was
performed the next day.

29. • Illustration depicting
multiple fractures of the
left upper chest wall. The
first rib is often fractured
posteriorly (black arrows).
If multiple rib fractures
occur along the midlateral
(red arrows) or anterior
chest wall (blue arrows),
a flail chest (dotted black
lines) may result, which
may result in
pneumothorax.

30. malignant mesothelioma

31. malignant meso

32. • Pleural effusion in a
70-year-old man with
a history of asbestos
exposure and known
left-sided MPM. Axial
contrast material-
enhanced CT scans
obtained at different
levels show unilateral
pleural effusion (P)
with extensive
calcified pleural
plaques (arrows).

33. • Pleural effusion in a
70-year-old man with
a history of asbestos
exposure and known
left-sided MPM. Axial
contrast material-
enhanced CT scans
obtained at different
levels show unilateral
pleural effusion (P)
with extensive
calcified pleural
plaques (arrows).

34. • Nodular pleural
thickening in a 55-
year-old man with
MPM. Axial
nonenhanced CT
scan shows nodular
pleural thickening in
the right hemithorax
(arrows).

35. • Pleural thickening in a
51-year-old man with
MPM. Axial contrast-
enhanced CT scan
shows circumferential
and nodular left-sided
pleural thickening
(arrows). The tumor
encases the
contracted left
hemithorax, having a
rindlike appearance.

36. • Pleural thickening in a
63-year-old man with
MPM who had undergone
an Eloesser flap
procedure for
mesothelioma. Axial
contrast-enhanced CT
scan shows
circumferential right-sided
pleural thickening
(arrowheads). Note also
the large chest wall
defect (arrow) from the
Eloesser flap procedure.

37. • Interlobar fissure
involvement in an 82-
year-old man with
MPM and a history of
pleurodesis. Axial
nonenhanced CT
scan shows right-
sided pleural
thickening and a
pleural mass that
extends into the right
major fissure (arrows)

38. • Calcified pleural mass in
a 55-year-old woman with
MPM. Axial nonenhanced
CT scans obtained at
different levels show
multiple calcified
subpleural and pleura-
based masses (arrow).
The masses represent
either plaques that have
been engulfed by the
primary tumor or calcified
MPM

39. • Calcified pleural mass in
a 55-year-old woman with
MPM. Axial nonenhanced
CT scans obtained at
different levels show
multiple calcified
subpleural and pleura-
based masses (arrow).
The masses represent
either plaques that have
been engulfed by the
primary tumor or calcified
MPM

40. meso
• Frontal radiograph of
the chest shows
circumferential,
lobulated pleural
thickening along the
left lung with volume
loss.

41. • Axial contrast-
enhanced CT scan
shows
circumferential,
lobulated pleural
thickening encasing
the left lung. Tumor
tissue is also seen
abutting the
mediastinum and
pericardium.

42. • coronal fused PET-
CT images show the
hypermetabolic tumor
encasing the left lung
and infiltrating into the
lung parenchyma and
along the fissure. The
tumor is also seen to
contact but not invade
the diaphragm and
pericardium.

43. bronchopleural fistula

44. Asbestosis Pleural Plaque

45. Pleural Plaque

46. Extensive bilateral pleural
calcifications are seen in this
patient

47. • The presence of bilateral calcified pleural plaques is
fairly specific for the diagnosis of asbestos exposure.
Patients with asbestos exposure are at a 5-fold greater
risk of developing lung cancer. There is a synergistic
effect between asbestos exposure and smoking with a
55-fold increase in risk for lung cancer. Mesotheliomas
are malignancies of the pleura that are associated with
condition and are rarely found in people without asbestos
exposure. Historically, occupations with high risk of
exposure to asbestos include shipyard workers, auto
mechanics, construction workers and other construction
trades.

49. • Pleural plaque in a
64-year-old man with
a history of asbestos
exposure. Axial high-
resolution CT scans
(mediastinal window)
show multiple areas
of pleural thickening
along the
posterolateral chest
wall (arrows in a) and
the dome of the
diaphragm