ABC of Pleural Diseases E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: ABC Series
- Sprache: Englisch
Pleural diseases are frequently managed in primary care, but specialist knowledge is required to understand the full variety of presentations and available treatments in this rapidly developing field. ABC of Pleural Diseases is a brand new addition to the ABC Series which takes a unique approach to these conditions by dealing with them as a related group as well as in their individual manifestations.
The book provides a unique and comprehensive overview of pleural disease, beginning with the anatomy and physiology of the pleura. It then covers a wide range of specific conditions in greater detail, including pneumothorax, pleural effusions, pleural infections, as well as chapters on radiology and pathology. Full coverage is given of mesothelioma, the most common pleural cancer.
Written by a team of specialists, this reference guide to pleural diseases is a practical guide for General Practitioners, Junior Doctors, Specialist Nurses, Radiologists and all Healthcare Professionals working within chest medicine.
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Seitenzahl: 188
Veröffentlichungsjahr: 2018
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Table of Contents
Cover
Title Page
Contributors
CHAPTER 1: Anatomy and Physiology of the Pleura
Embryology
Macroscopic anatomy
Microscopic anatomy
Innervation, blood supply and lymphatics
Physiology of the pleural space
Role of the pleural space
Further reading
CHAPTER 2: Radiology of Pleural Disease
Plain radiography
Ultrasound
CT scan
PET CT
MRI
Further reading
CHAPTER 3: Pneumothorax
Definition, epidemiology, risk factors and aetiology
Presentation
Investigations
Management
Recurrent pneumothorax
Further reading
CHAPTER 4: Investigation of Pleural Effusions
Clinical presentation
History taking
Examination
Initial imaging
Pleural fluid tests
Biomarkers and auto‐antibodies
Cross‐sectional imaging
Metabolic and dynamic imaging
Pleural biopsy
Diagnostic challenges
Further reading
CHAPTER 5: Pleural Pathology
Normal anatomy and histology of the pleura
Pathological processes involving the pleura
Neoplasia (other than diffuse malignant mesothelioma) – primary pleural neoplasms and tumour‐like proliferations
Inflammation
Further reading
CHAPTER 6: Unusual Causes of Pleural Disease
Urinothorax
Yellow nail syndrome
Ovarian hyperstimulation syndrome
Meigs syndrome
Dural‐pleural fistula
Central venous catheter migration
Chylothorax
Pseudochylothorax
Further reading
CHAPTER 7: Pleural Infection
Pathology
Bacteriology
Natural history
Symptoms and signs
Diagnosis
Medical management
Surgery
Trapped lung
Prognosis and long‐term outcomes
Conclusions
Further reading
CHAPTER 8: Management of Malignant Pleural Effusions
Pathophysiology
Symptoms
Management – general considerations
Simple pleural aspiration
Intercostal chest drainage and pleurodesis
Thoracoscopy and talc poudrage
Indwelling pleural catheters
Which procedure is best?
The future
Conclusions
Further reading
CHAPTER 9: Malignant Mesothelioma
Epidemiology and aetiology
Pathogenesis
Clinical presentation and investigation
Pathological features
Diagnosis
Treatment and prognosis
Further reading
CHAPTER 10: Pleural Interventions
Diagnostic thoracocentesis
Therapeutic thoracocentesis
Complications of diagnostic and therapeutic thoracocentesis
Further reading
Section B: Pleural Interventions
Chest drain insertion (Seldinger technique)
Drain insertion technique
Post drain insertion
Drain removal
Tips
Troubleshooting
Further reading
Section C: Insertion of an Indwelling Pleural Catheter
A step‐by‐step guide to IPC insertion
CHAPTER 11: Medical Thoracoscopy
Role of medical thoracoscopy
Who should undergo a thoracoscopy?
Types of medical thoracoscopy
A step‐by‐step guide to medical thoracoscopy
Diagnostic accuracy of medical thoracoscopy
Complications and adverse events with medical thoracoscopy
Conclusions
Further reading
Section B: Medical Thoracoscopy
Role of medical thoracoscopy
A step‐by‐step guide to semi‐rigid thoracoscopy
Advantages of the semi‐rigid thoracoscope
Disadvantages of the semi‐rigid thoracoscope
Diagnostic accuracy of semi‐rigid thoracoscopy
Diagnostic accuracy: rigid thoracoscopy versus semi‐rigid thoracoscopy
Complications and adverse events with semi‐rigid thoracoscopy
Conclusions
CHAPTER 12: Surgical Management of Pleural Disease
Historical developments
Thoracic anaesthetic
Thoracic surgery
Primary and secondary pneumothoraces
Malignant pleural effusions
Empyema
Pleural tumour
Trauma
Conclusions
Further reading
Index
End User License Agreement
List of Tables
Chapter 04
Table 4.1 Causes of pleural exudates and transudates.
Table 4.2 Biomarkers in the investigation of pleural effusions.
Chapter 05
Table 5.1 Classification of benign and malignant neoplasms of the pleura, including tumour‐like conditions.
Chapter 08
Table 8.1 Advantages and disadvantages of pleural procedures.
Chapter 09
Table 9.1 Causes of benign reactive mesothelial hyperplasia and organising pleuritis and histological features mimicking or indicating malignancy.
Chapter 10
Table 10.1 Recommended routine pleural fluid tests after diagnostic pleural aspiration.
Chapter 11
Table 11.1 A summary of the indications and contraindications for medical thoracoscopy.
List of Illustrations
Chapter 01
Figure 1.1 CT angiogram demonstrating the course and variability of the intercostal arteries posteriorly.
Chapter 02
Figure 2.1 Postero‐anterior (PA) chest radiograph (CXR) showing pneumothorax. The white arrow indicates the edge of the visceral pleural.
Figure 2.2 PA‐CXR showing pleural plaques in left midzone (white arrows).
Figure 2.3 Ultrasound appearance of the normal lung and pleura. Echogenic ‘stripe’ of the two opposing pleural layers (white arrow).
Figure 2.4 Ultrasound appearance of a pleural effusion (E) with diaphragm (white arrow) and spleen (S) visible.
Figure 2.5 Ultrasound image showing heavily septated pleural effusion.
Figure 2.6 Two cross‐sectional computed tomography (CT) images showing nodular thickening (asterisk) and mediastinal involvement (arrow) in the presence of pleural effusion (E).
Chapter 03
Figure 3.1 Tension pneumothorax with evidence of early tracheal shift.
Figure 3.2 Standard methodology for measurement of pneumothorax size.
Figure 3.3 Secondary pneumothorax with evidence of interstitial lung disease.
Figure 3.4 British Thoracic Society 2010 guideline algorithm for the management of pneumothorax.
Chapter 04
Figure 4.1 Algorithm for the investigation of a pleural effusion.
Figure 4.2 Chest X‐rays: (a) meniscus of left pleural effusion; (b) D‐shaped appearance of loculated pleural empyema; (c) asbestos‐related pleural plaques.
Figure 4.3 Thoracic ultrasound image of a complex septated pleural effusion.
Figure 4.4 Thoracic ultrasound demonstrating large anechoic pleural effusion (a) and nodularity and thickening of the diaphragmatic pleura (b).
Figure 4.5 Pleural phase contrast CT scan demonstrating the thick, nodular pleural thickening of pleural malignancy (a). Note extension over the mediastinal surface (b).
Figure 4.6 Integrated positron emission tomography with computed tomography (PET‐CT) scan of right malignant pleural mesothelioma demonstrating intense areas of pleural FDG avidity.
Chapter 05
Figure 5.1 Solitary fibrous tumour (SFT): variable cellularity and branching vasculature (a) with ‘patternless’ arrangement of bland cells with intervening ‘ropey’ collagen (b).
Figure 5.2 SFT: tumour exhibiting myxoid (a) and cellular, vaguely herringbone‐like areas (b).
Figure 5.3 Nodular pleural plaque: macroscopic appearance of solid, 10 × 20 mm yellowish nodule (a) mimicking an expansile tumour nodule, but histology (b) reveals dense, hyalinised, ‘basket‐weave’ collagen only.
Figure 5.4 Chest CT demonstarting pleural thymoma.
Figure 5.5 Histology of acute pleural empyema showing a thick layer of fibrinopurulent exudate overlying congested parietal pleura (a) and containing numerous neutrophils and necrotic inflammatory cells (b).
Figure 5.6 Organising fibrinous pleuritis demonstrating fibrosis, dense chronic inflammation and vertically oriented vessels (a) and an example of eosinophilic pleuritis associated with mesothelial hyperplasia (b).
Figure 5.7 Granulomatous pleuritis: a discrete aggregate of epithelioid histiocytes forming a granuloma.
Chapter 06
Figure 6.1 Dystrophic nail changes in a patient with typical yellow nail syndrome.
Figure 6.2 CT of the thorax demonstrating a bland‐looking effusion in a patient with nail changes.
Figure 6.3 Thoracentesis of fluid, demonstrating milky pleural fluid.
Figure 6.4 CT scan demonstrating a ventriculo‐peritoneal shunt.
Chapter 07
Figure 7.1 Thoracic ultrasound showing heavily septated complicated parapneumonic effusion.
Figure 7.2 Empyema at the time of video‐assisted thoracic surgery (VATS).
Chapter 08
Figure 8.1 Site of primary tumour (%) of 2040 patients with malignant pleural effusions.
Figure 8.2 CT scan showing a large left‐sided pleural effusion (arrow A), causing complete compression of the left lung. Two pleurally based soft tissue masses are seen on the left (arrow B) with associated pleural thickening.
Figure 8.3 A wide‐bore chest drain and drainage bottle.
Figure 8.4 A patient undergoing local anaesthetic thoracoscopy. The monitor screens show pleural biopsies being taken.
Figure 8.5 Talc poudrage seen via a thoracoscope. A fine film of talc is seen covering the parietal pleura in the top of the picture, with deflated lung visible inferiorly.
Figure 8.6 An indwelling pleural catheter immediately after insertion.
Figure 8.7 Chest X‐ray showing a right‐sided hydro‐pneumothorax (arrow A) secondary to trapped lung (arrow B), with an indwelling pleura catheter (IPC) in situ. Arrow C illustrates the IPC entering the pleural space and arrow D shows it coiled up externally against the skin.
Figure 8.8 An approach to the management of malignant pleural effusions. CXR, chest X‐ray; IPC, indwelling pleural catheter.
Chapter 09
Figure 9.1 Epithelioid malignant mesothelioma (EMM). (a,b) Tubulopapillary pattern: note the relatively bland, uniform appearance of the tumour cells. (c,d) Solid pattern: sheets of large, rounded cells with abundant cytoplasm (c) and nested arrangement (d). (e,f) Lattice‐like strands of bland epithelioid cells ‘floating’ within myxoid stroma (e) and lobular carcinoma‐like growth pattern associated with desmoplastic stroma (f).
Figure 9.2 EMM: clear cell change imparting signet ring‐like appearance (a) and cytokeratin immunostain (b) demonstrating tubules and cords of mesothelial cells within fibrous tissue beneath the pleural surface: early invasive mesothelioma or entrapped reactive mesothelium? (b) This case subsequently evolved into biphasic diffuse pleural malignant mesothelioma (re‐biopsied after 6 months).
Figure 9.3 Sarcomatoid malignant mesothelioma (SMM). (a) Cellular tumour with fairly bland spindle‐shaped cells arranged in haphazard intersecting fascicles; (b) an example demonstrating more pronounced nuclear pleomorphism; (c) desmoplastic variant demonstrating dense collagenous stroma and a storiform arrangement of hyperchromatic spindle cells; and (d) histiocytoid cells partly obscured by a dense lymphoid infiltrate.
Figure 9.4 Biphasic malignant mesothelioma (BMM). Sarcomatoid pattern in upper left field merging with rounded, epithelioid tumour cells on the lower right (a) and biphasic appearance emphasised by cytokeratin immunohistochemistry (b).
Chapter 10
Figure 10.1 Local anaesthetic insertion into subcutaneous tissue.
Figure 10.2 Local anaesthetic insertion into intercostal muscles and parietal pleura.
Figure 10.3 Pleural aspiration with 50 mL syringe.
Figure 10.4 Equipment for therapeutic aspiration with 6 Fr aspiration catheter.
Figure 10.5 Insertion of aspiration catheter.
Figure 10.6 Advancing aspiration catheter.
Figure 10.7 Fluid drainage bag collecting pleural fluid.
Chapter 10b
Figure 10.8 The patient is sitting up and leaning over a table. The red shaded area is the ‘no fly zone’ for chest drain insertion which should be avoided in most cases. A study showed that intercostal arteries are exposed within the intercostal space in the first 6 cm lateral to the spine.
Figure 10.9 Decubitus position; the safety triangle is shaded blue.
Figure 10.10 Equipment for insertion of a Seldinger chest drain.
Figure 10.11 Step‐by‐step guide to insertion of a Seldinger chest drain.
Chapter 10c
Figure 10.12 Infiltration of local anaesthetic at drain insertion site. A mark is visible inferiorly where the drain will exit the skin.
Figure 10.13 Aspiration of pleural fluid via the introducer needle.
Figure 10.14 Removal of the introducer needle with the guidewire left in situ.
Figure 10.15 Indwelling pleural catheter with plastic tunnelling device attached to the proximal end. A polyester cuff is visible halfway along the catheter.
Figure 10.16 Catheter tunnelled under the skin with the distal end visible externally (the proximal end is not visible).
Figure 10.17 Insertion of a blunt dilator and introducer into the pleural space. The proximal end of the catheter is seen exiting the skin at this point.
Figure 10.18 Removal of the guidewire and dilator, leaving the introducer in situ.
Figure 10.19 Peeling the introducer away from the catheter.
Figure 10.20 Advancing the catheter into the pleural space, as the peel‐away introducer is removed.
Figure 10.21 Indwelling pleural catheter running smoothly through the subcutaneous tunnel into the pleural space.
Chapter 11
Figure 11.1 Blunt dissection into the pleural cavity.
Figure 11.2 Trocar insertion.
Figure 11.3 Insertion of suction catheter and pleural fluid drainage.
Figure 11.4 Insertion of (a) semi‐rigid scope; (b) rigid scope.
Figure 11.5 Inspection of pleural surface using rigid scope: (a) normal pleura; (b) diffuse pleural nodularity seen in malignancy.
Figure 11.6 Taking pleural biopsies (rigid approach, single port).
Figure 11.7 Talc poudrage. Image from rigid scope approach, post poudrage.
Figure 11.8 Talc poudrage: (a) under direct vision using semi‐rigid approach; (b) image taken from rigid scope approach.
Figure 11.9 Chest drain insertion.
Figure 11.10 End of the procedure.
Chapter 11b
Figure 11.11 Blunt dissection into the pleural cavity.
Figure 11.12 Trocar insertion.
Figure 11.13 Inspection of pleural surface (pleural nodule and thickening seen).
Figure 11.14 Biopsy forceps.
Figure 11.15 Taking pleural biopsies.
Figure 11.16 Taking pleural biopsies under direct visualisation.
Figure 11.17 Talc poudrage kit.
Figure 11.18 Talc poudrage.
Figure 11.19 Talc poudrage.
Figure 11.20 Chest drain insertion.
Figure 11.21 End of the procedure.
Chapter 12
Figure 12.1 Theatre set up for a video‐assisted thoracic surgery (VATS) procedure.
Figure 12.2 Diaphragmatic fenestrations (whorles) in a young woman who has multiple episodes of pneumothoraxes.
Figure 12.3 VATS images of early empyema at fibrinopurulent stage.
Figure 12.4 Decortication of thickened visceral pleura in a chronic organising empyema.
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Pleural Diseases
EDITED BY
Najib M. Rahman
University of Oxford, Oxford, UK
Ian Hunt
St. George’s Hospital, London, UK
Fergus V. Gleeson
Churchill Hospital, Oxford, UK
Nick A. Maskell
Academic Respiratory Unit, University of Bristol, UK
This first published 2018 © 2018 by John Wiley & Sons Ltd
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Library of Congress Cataloging‐in‐Publication Data
Names: Rahman, Najib M., editor. | Hunt, Ian, M.D., editor. | Gleeson, Fergus V., editor. | Maskell, Nick A., editor.Title: ABC of pleural diseases / edited By Najib M. Rahman, Ian Hunt, Fergus V. Gleeson and Nick A. Maskell.Description: Hoboken, NJ : Wiley, 2017. | Series: ABC series | Includes bibliographical references and index. |Identifiers: LCCN 2017043481 (print) | LCCN 2017045215 (ebook) | ISBN 9781118527115 (pdf) | ISBN 9781118527108 (epub) | ISBN 9780470654743 (pbk.)Subjects: | MESH: Pleural DiseasesClassification: LCC RC751 (ebook) | LCC RC751 (print) | NLM WF 140 | DDC 616.2/5–dc23LC record available at https://lccn.loc.gov/2017043481
Cover Design: WileyCover Image: © stockdevil/Gettyimages
Contributors
Rahul BhatnagarAcademic Respiratory Unit, University of Bristol, UK
Anna C. BibbyAcademic Respiratory Unit, University of Bristol, UK
John P. CorcoranOxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
Matthew EvisonWythenshaw Hospital, Manchester, UK
Stephanie FraserThoracic Surgery, Guy’s Hospital, London, UK
David Feller‐KopmanJohns Hopkins Medical School, Baltimore, MD, USA
Fergus V. GleesonChurchill Hospital, Oxford, UK
Rob J. HallifaxOxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
John HarveyNorth Bristol NHS Trust, Bristol, UK
Clare E. HooperWorcestershire NHS Trust, UK
Ian HuntSt. George’s Hospital, London, UK
Y.C. Gary LeeUniversity of Western Australia, Perth, Australia
Nick A. MaskellAcademic Respiratory Unit, University of Bristol, UK
Andrew McDuffNew Cross Hospital, Wolverhampton, UK
Mohammed MunavvarRoyal Preston Hospital, Preston, UK
Najib M. RahmanOxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
Carol TanSt George’s Hospital, London, UK
Ambika TalwarChurchill Hospital, Oxford, UK
Brendan TinwellSt George’s Hospital, London, UK
Ahmed YousufGlenfield Hospital, Leicester, UK
CHAPTER 1Anatomy and Physiology of the Pleura
John P. Corcoran and Najib M. Rahman
Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
OVERVIEW
The pleural space is a real rather than potential space, containing a small amount (<20 mL) of pleural fluid.
Mesothelial cells line the visceral and parietal pleura, with size and shape varying according to position. They are metabolically active and can perform a variety of functions.
The parietal pleura is innervated whereas the visceral pleura has no nerve supply (and hence does not produce pain in pathological conditions).
The pleural space is normally under negative pressure.
Pleural fluid is secreted from the systemic vessels of the parietal pleura, and is drained through lymphatic channels in the parietal pleura. The normal drainage capacity is very large compared to the secretion capacity.
The pleural cavity is a real rather than potential space, containing a thin layer of fluid and lined with a double‐layered membrane covering the thoracic cavity (parietal pleura) and outer lung surface (visceral pleura) whose precise purpose and structure are incompletely understood. The gaps in our knowledge are best illustrated by the unexplained anatomical variations among different mammals. In humans, the left and right pleural cavities are separated by the mediastinum, but in species as diverse as the mouse and bison there is a single pleural cavity, allowing free communication of fluid and air between right and left. The elephant has evolved to have no cavity at all – instead having loose connective tissue between the two pleural membranes. In time, it may be that describing how and why these differences have evolved will help us to understand the role the pleural cavity has in humans. This chapter focuses on the key features of human pleural anatomy and physiology.
Embryology
The human body contains three mesothelium‐lined cavities – two large (pleural, peritoneal) and one small (pericardial) – derived from a continuous mesodermal structure called the intra‐embryonic coelom as it is partitioned at 4–7 weeks’ gestation. Arising from a medially placed foregut structure that will ultimately form the mediastinum, primordial lung buds grow out into the laterally placed pericardio‐peritoneal canals, taking a layer of lining mesothelium that will become the visceral pleura in the process. As the lungs rapidly enlarge, they enclose the heart and widen the pericardio‐peritoneal canals to form the pleural cavities. These are separated from the pericardial space by the pleuro‐pericardial membranes, whilst the septum transversum (an early partial diaphragm) joins the pleuro‐peritoneal membranes to partition each pleural cavity from the peritoneal space. The mesothelium lining the pericardio‐peritoneal canals as they become the pleural cavities goes on to form the parietal pleura.
Macroscopic anatomy
The pleura is a double‐layered serous membrane overlying the inner surface of the thoracic cage (diaphragm, mediastinum and rib cage) and outer surface of the lung, with an estimated total area of 2000 cm2 in the average adult male. Between lies the pleural cavity, a sealed space maintained 10–20 micrometres across and filled with a thin layer of fluid to maintain apposition and provide lubrication during respiratory movement. The left and right pleural cavities are completely separated by the mediastinum.
The visceral pleura is tightly adherent to the entire lung surface, not only where it is in contact with chest wall, mediastinum and diaphragm, but also into the interlobar fissures. The parietal pleura is subdivided into four sections according to the associated intrathoracic structures: costal (overlying ribs, intercostal muscles, costal cartilage and sternum); cervical (extending above the first rib over the medial end of the clavicle); mediastinal; and diaphragmatic. Inferiorly, the parietal pleura mirrors the lower border of the thoracic cage but may extend beyond the costal margin, notably at the right lower sternal edge and posterior costovertebral junctions.
