THE PLEURA part2

PNEUMOTHORAX

• It is the presence of air in the pleural cavity

• CAUSESLung pathology (Spontaneous)TraumaDeliberate introduction of air(Artificial)

• 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

• 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.

• 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.

For optimal pneumothorax evaluation, patient is examined in

supine position

• 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.

• 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

• 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

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

M-mode ultrasonography showing stratosphere sign, indicating

pneumothorax.

• Comet-tail artifact.

pneumo

rt pneumo

rt pnemo

• 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#sthash.Cu91IEub.dpuf

• Deep Sulcus Sign.• Deep Sulcus Sign

(yellow arrow). Notice also pneumopericardium (blue arrows) and subcutaneous emphysema (red arrow).

• 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#sthash.Cu91IEub.dpuf

CT chest showing large right sided hydro-pneumothorax from pleural

empyema. A air B fluid

• 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.

• 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.

• 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.

malignant mesothelioma

malignant meso

• 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).

• 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).

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

• 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.

• 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.

• 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)

• 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

• 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

meso

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

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

• 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.

bronchopleural fistula

Asbestosis Pleural Plaque

Pleural Plaque

Extensive bilateral pleural calcifications are seen in this

patient

• 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.

• 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