retrospective study of pleural diseases

www.wjpr.net Vol 7, Issue 9, 2018.

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Deshpande et al. World Journal of Pharmaceutical Research

RETROSPECTIVE STUDY OF PLEURAL DISEASES

Roma Raykar*1, Mansi Deshpande

2, Joanna Baptist

3 and Tushar J Palekar

4

1,3

Assistant Professor, Dr. D.Y. Patil College of Physiotherapy, Pune.

2Final Year BPT, Dr. D.Y. Patil College of Physiotherapy, Pune.

4Principal and Professor, Dr. D.Y. Patil College of Physiotherapy, Pune.

ABSTRACT

Background: The extent of pleural disease has substantially increased

in the past decade because of rise in incidence of pleural space

infection and pleural malignancies. The aetiology of pleural disease is

broadly multifactorial; viral and bacterial infection, pneumonia and

lung diseases. Common pleural diseases are Pleural Effusion,

Pneumothorax, Hydro pneumothorax, Pleurisy and Empyema.

Objective: The study was carried out to find out the extent of pleural

disease based on demographic data of age and gender, incidence of

cough, extent of dyspnoea, incidence of addition and to rule to

common form of pleural disease in Indian Population. The study would

help in preventing the disease and taking early intervention in patients who fall under the

population at risk. Materials and Methods: A retrospective study comprising of a sample

size of 114 patients was collected in the past three years, the data collected was analysed

using graphs and tables and presented in a tabular format. Results and Conclusion: Results

reviewed that 47% of patients were between 41-60 years of age group to have pleural disease.

61% male patients were affected with pleural disease. Presence of cough was found in 59%

of patients, while dyspnoea was found in 72% of patients. Incidence of addiction was 62%

associated with pleural disease. Pleural effusion was the commonest pleural disease. The

study would be helpful to determine aetiological hazards and identify individuals at high risk

of infection.

KEYWORDS: Pleural disease, retrospective study, infections, addictions.

INTRODUCTION

Pleural diseases affect the pleura and the pleural space of the lung.[1]

World Journal of Pharmaceutical Research SJIF Impact Factor 8.074

Volume 7, Issue 9, 1433-1446. Research Article ISSN 2277– 7105

Article Received on

19 March 2018,

Revised on 09 April 2018,

Accepted on 30 April 2018

DOI: 10.20959/wjpr20189-11988

*Corresponding Author

Mansi Deshpande

Final Year BPT, Dr. D.Y.

Patil College of

Physiotherapy, Pune.


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Pleura is a thin tissue covered by a layer of cells that surround lungs and inside of chest wall,

while pleural space is the space between lungs and the chest wall. It allows normal to and fro

motion of lungs during breathing. The outer pleura are the visceral pleura and the

corresponding inner layer is the parietal pleura.[1]

The pleural cavity contains a small amount of fluid – 10 ml on each side. Pleural fluid

volume is maintained by a balance between fluid production and removal and changes in the

rates of either can result in presence of excess fluid.[2]

Pleural diseases are high in region of high pollution and poor hygiene, as these individuals

are more prone to parenchymal diseases like pneumonia, tuberculosis, etc which later

predisposes to involve pleural region.[2]

Pleural diseases are caused due to viral, bacterial infections, pulmonary embolism, chest

trauma, pneumonia, lung diseases or any heart surgery.[3]

Common symptoms shown by patients of pleural diseases are dyspnoea, cough, sputum,

chest pain, fever, etc. Cough is caused by accumulation of fluid in the pleura. Dry cough is

common in pleural disease.[2]

Dyspnoea is a marked symptom in early stage of pleural disease. Dyspnoea which is more on

exertion initially, increases as the disease deteriorates.

Pleural diseases affect adults and older age group because of increased risk of infections and

other lung conditions3.

Males have higher predominance due to increased risk of infection,

smoking, etc. Smoking and tobacco chewing fuels mutagenesis, initiation and proliferation of

mesothelioma cells, this lead to inflammation of the pleura and surrounding leading to

pleurisy and empyema.[4]

Physical examination reveals diminished or absent breath sounds with severe chest pain and

breathlessness.[3]

Investigations that can be carried out are chest radiography, ultra sound, pleural fluid

examination, pleural biopsy and thoracoscopy.

Risk factors of pleural diseases are congestive heart failure, pneumonia, malignancy,

myocardial infarction, chronic smoking, drug induced infection.[4]


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Complications include lung scarring, lobar collapse, re-expansion pulmonary oedema,

trapped lung, etc.[4]

Surgical management includes pleurodesis, thoracentesis, tube thoracotomy, pleurectomy.[4]

Physiotherapy marks a very important role in betterment of patients with pleural diseases.

Physiotherapy management includes thoracic breathing exercises to increase lung volume and

aid normal breathing. Spirometer techniques are used to increase the lung capacity and lung

function.[3]

Chest physiotherapy includes percussion, vibration and shaking for the removal of cough

secretions, while dyspnoea relieving positions are taught to reduce shortness of breath.[3]

The common pleural diseases are:

1. Pleural effusion

2. Pneumothorax

3. Hydro pneumothorax

4. Pleurisy

5. Empyema

1. Pleural effusion

Any abnormal amount of pleural fluid in the pleural space is called pleural effusion. Pleural

fluid enters the pleural space across both the visceral and parietal pleura, when the interstitial

pressure within either the lung or chest wall is increased. Abnormalities of increased pleural

fluid production or blockade of drainage can cause pleural fluid to accumulate.[3]

Accumulation may occur by transudation from the circulation or by exudation and

inflammation. Causes of exudates include malignant disease, pneumonia, tuberculosis, SLE,

etc. Causes of transudates include CHF, nephrotic disease and cirrhosis.[4]

Clinical signs include chest pain, difficulty in breathing, dry cough. There is also diminished

movement on the affected side with dullness to percussion and reduced tactile vocal fremitus

over the fluid. Males are affected more. Complications include lung scarring, empyema, and

sepsis.[4]


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Investigations such as chest radiography show fluid as whitish areas on the lung base.

Thoracentesis is an invasive procedure to remove fluid from the pleural space for diagnostic

as well as therapeutic purposes. There is evidence of homogenous opacity with obliteration of

the costophrenic angle.[4]

Small pleural effusions require no treatment, while larger ones require drainage of pleural

fluid. Pleurodesis is a process of fusing the parietal and visceral pleura with a fibrotic reaction

that prevents further pleural fluid formation or seals the pleural space.[5]

Thoracentesis is a

procedure of inserting a needle into the pleural space and removing the fluid.

Physiotherapy treatment includes postural drainage, percussion, vibration and coughing

techniques for secretion clearance. Diaphragmatic breathing to maintain and retain

respiratory function. Localised expansion exercises to control breath volume are useful[4]

.

Fig 1: Pleural effusion.[1]

2. Pneumothorax

Pneumothorax is the presence of air in the pleural space, sometimes associated with collapse

of the lung. This may result from penetrating injuries of the chest wall but more commonly

from spontaneous rupture of the visceral pleura with leak of air from the lung.[3]

Primary pneumothorax occurs in patients with no history of lung disease. Secondary

pneumothorax affects patients with pre-existing lung disease. Where the communication

between the airway and pleural space seals of as the lung deflates and does not re-open the

pneumothorax is referred to as ‘closed pneumothorax’.[6]

A larger pneumothorax results in

absent or decreased breathe sounds. Intension pneumothorax there is progressive


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breathlessness associated with tachycardia, hypotension, cyanosis and tracheal displacement

away from the side.[6]

The sharp pleuritic pain may refer to shoulder tip. Chest movements

will be diminished and there will be resonance to percussion.[3]

Investigations such as chest radiography will show a collapsed lung with peripheral

radiolucency and the lung edge is visible.[3]

X-rays may also show the extent of any

mediastinal displacement and reveal any pleural fluid or underlying pulmonary disease.[3]

Primary pneumothorax usually resolves without interventions. In young patients with

moderate or secondary pneumothorax, percutaneous needle aspiration of air is a simple

method. With a large pneumothorax, treatment by intercostal drainage with a valve is

indicated.[5]

Physiotherapy includes manual assistance like percussion, vibration and shaking for removal

of secretions. Diaphragmatic and relaxation breathing exercises for breathing technique

retraining. Illness progression and effect of allergen factors should be advised.[3]

Fig 2: Pneumothorax.[13]

3. Hydropneumothorax

It is the accumulation of both air and fluid in the pleural cavity due to introduction of air

during pleural fluid aspiration presence of gas forming organism, thoracic trauma. There is

usually fluid at the bottom and air at the top.[4]

Clinical signs are straight line dullness, splash, sound of coin and fullness of chest.[7]


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Investigations include chest radiography which shows a sharp pleural line with increased

opacity.[8]

Chest x-ray also shows upright air fluid level in the thoracic cavity. There is

marked straight horizontal fluid demarcation.[7]

Surgical interventions include simple aspiration, chest tube placement for removal of air.

Surgery options also include thoracoscopy, open thoracotomy, resection of blebs or pleura.[4]

Physiotherapy management includes chest physiotherapy for airway clearance of excessive

secretions. Postural drainage in anti-gravity positions is also useful.[4]

Fig 3: Hydropneumothorax.[8]

4. Pleurisy

It is the inflammation of the pleura lining and the inner chest wall. It is also known as

pleuritis. It can be caused due to infections, TB, CHF, pulmonary embolism. Inflammation

can lead to sharp chest pain (pleuritic pain) that worsens during breathing. Due to

inflammation, two layers of pleural membrane rub against each other producing pain when

you inhale and exhale.[1]

Signs and symptoms include chest pain that worsens when you breathe, cough or sneeze,

shortness of breath, cough and fever only in some cases.[8]

Investigations such as chest x-ray include show inflated lungs. It also includes rubbing of two

inflamed layers of pleura with each breath, the noise generated is pleural friction rub.

Thoracentesis, thoracoscopy or pleuroscopy includes removal of fluid and tissue for testing.[7]


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Treatment includes thoracentesis in which a hollow, plastic tube is inserted to draw fluid out.

External splinting of the chest wall and pain medications reduces pain of pleurisy.[9]

Fig 4: Pleurisy.[14]

5. Empyema

Empyema is a condition in which pus gathers in the area between pleural cavities. Empyema

can develop after pneumonia, which can cause due to streptococcus pneumonia and

staphylococcus auras. It can also result from bronchiectasis, COPD, RA. It is also known as

pylothorax, purulent pleuritis or lung empyema.[10]

The infection causes the fluid to build up faster that it is absorbed. The infected fluid

thickens, it causes lining of lung and chest cavity to stick together and form pockets called

empyema.[10]

Simple empyema occurs in early stage of illness, includes dyspnoea, dry cough, fever,

stabbing chest pain, etc. complex empyema results in sever inflammation and if infection gets

worse, it can lead to formation of a thick peel, called pleural peel. Symptoms include

dyspnoea, decreased breath sounds, chest pain, and weight loss.[9]

Investigations include chest radiographs that show the fluid and pus in the pleural space.

Ultrasound shows exact amount and location of fluid. While blood tests help to identify the

causative microorganism, thoracentesis is used by inserting a needle through the back of

ribcage to take a sample of fluid.[9]

Treatment is aimed at removing the pus and treating infection. In simple empyema,

percutaneous thoracentesis is performed by inserting a needle in pleural space to drain the


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fluid. In complex stages, drainage tubes are must use under anaesthesia; thoracotomy is one

example of that.[11]

Physiotherapy includes good postural drainage to drain out the pus, followed by breathing

exercise to increase lung volume.[12]

Fig. 5 Empyema[5]

MATERIALS AND METHODOLOGY

Study commenced after necessary approvals from the college authorities. Case records of

patients of surgery ward of D.r. D.Y Patil medical college and hospital for pleural diseases

from 1st January 2015 to 31

st December 2017 are collected. In this study, inclusion criteria

were patients with pleural diseases and their corresponding symptoms. While, exclusion

criteria were patients with Obstructive pulmonary diseases.

Data was collected based on demographic data of age and gender, presence or absence of

cough, extent of dyspnoea, incidence of addiction and to find out the common pleural

disease.

The data collected was analysed using graphs and tables and presented in a tabular format.

DATA RECORDING CHART

Sr.

no Name Age Gender

Cough

(present/absent)

Dyspnoea

(present/absent)

Addiction

(present/absent) Diagnosis

RESULTS: The data obtained was analysed and presented in tables and graphs.


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Graph- I : Demographic Data.

Table I(a) Age.

AGE GROUP NO. OF PATIENTS

20-40 29

41-60 53

61-80 32

Interpretation: Graph I(a) and Table I(a) shows that 41-60 years of age group is affected the

most (47%), 61-80 (28%) and 20-40 (25%)

Graph I(b): GENDER

Table I(b).

GENDER RATIO NO. OF PATIENTS

MALES 70

FEMALES 44

TOTAL 114

Interpretation: Graph I(b) and Table I(b) shows that 61% were males and 39% were females.


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Graph II: Presence and absence of cough

Table II.

Cough No. of patients

Present 67

Absent 37

Total 114

Interpretation: Graph II shows that 59% patients show presence of cough while 41% show

absence of cough.

Graph III: Presence and absence of dyspnoea.

Table III.

Dyspnoea No. of patients

Present 82

Absent 32

Total 114

Interpretation: Graph III and Table III showed that out of 114, 82 patients showed symptoms

of dyspnoea.


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Graph IV: Incidence of addiction.

Table IV.

Addiction No. Of patients

Present 71

Absent 43

Total 114

Interpretation: Graph IV and Table IV showed that 71 out of 114 patients had history of

addiction.

Graph V : Commonest form of pleural disease.

Table V.

Diagnosis No. Of Patients

Pleural effusion 66

Pneumothorax 32

Hydropneumothorax 5

Pleurisy 4

Empyema 7

Total 114

Interpretation: Graph V and table V shows that Pleural effusion is the commonest form of

pleural disease.


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DISCUSSION

Diseases of the pleura and their extent have increased by a decade due to increasing pollution,

increased risk of infections, addiction among young adults, etc.

A retrospective study was conducted among 114 individuals aged between 20-80, those

having pleural disease.

Graph I based on the demographic data of age and gender was reviwed, and the study showed

the common age group to have pleural disease was 41-60 years. Lung capacity and muscle

function on a cellular level decreases as age increases. Clearance of particles from the lung

through the mucociliary elevator is decreased and associated with ciliary dysfunction.[15]

Many complex changes in immunity with aging contribute to increased susceptibility to

infections producing a low immune response. Considering all of these age- related changes to

lungs and pleura, pleural diseases are common in older age groups.[15]

As with gender, male population is affected more as compared to female, the ratio being 2:1.

This is because of the primary risk for mesothelioma remains occupational with certain drugs

like asbestos, which is common in male dominated population. Also the incidence and

evidence of smoking and tobacco chewing is common among males, which leads to further

inflammation of the pleura leading to evident pleural diseases.[15]

Graph II shows that pleural diseases showed a common symptom of cough among more than

half of the individuals.

The pleura creates too much fluid when its inflamed or irritated. The fluid accumulates in the

chest cavity outside the lung, resulting in disturbance in normal respiration.[16]

In pleural disease like pneumothorax, there is inflation of the lung, which leads to cough. In

empyema, there are filled pockets of exudate fluids, which lead to faulty breathing

mechanisms, which results in disturbance in normal respiration resulting in cough. Dry cough

is more common in patients of pleural disease.[16]

Graph III showed that dyspnoea is found to be another major symptom in pleural disease.

Gas exchange worsens with pleural effusions leading to faulty lung and respiratory

mechanisms. Also the sense of respiratory effort, chemoreceptor stimulation, and mechanical


1445


stimuli arising in lung and chest wall receptors, and neuro ventilatory dissociation may all

contribute to dyspnoea.[16]

Airway inflammation and perturbation in the ventilator response due to weakness in the

respiratory muscles causes difficulty in breathing. This leads to altered respiratory muscle

function and breathlessness.[16]

Graph IV showed that addiction was found to be a risk factor among maximum patients of

pleural diseases.

Smoking leads to infections which affect the alveoli and airways, smoke moves more deeply

into the respiratory tract, more soluble gases are absorbed and particles are deposited in the

airways and alveoli.[17]

The substantial doses of carcinogens and toxins delivered to the pleura and lungs place

smokers at risk for malignant para pneumonic effusions and other non-malignant pleural

diseases.

Chronic smoking causes sustained injurious stimulus which damages the lung tissue and

decreases the lung defence healing property. This further leads to diffuse changes in the

lining of airways of lung and epithelium, years later leading to diseases affecting the pleura.17

Graph V concluded that pleural effusion was found to be the commonest pleural disease,

because of common viral and bacterial function.

Pleural effusion affects all age groups and incidences of other diseases are secondary to

pleural effusion. Pneumothorax, hydropenumothorax, pleurisy and empyema are secondary to

pleural effusion in most of the cases.[18]

CONCLUSION

From the 114 subjects taken into consideration for the study of pleural diseases the following

are the conclusions:-

The most common affected age group is 41-60 years (47%)

Males are more affected than females (61%)

Majority of patients showed the addiction associated with pleural disease (62%)


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Dyspnoea (72%) and cough (59%) are found to be the common symptoms among patients

of pleural disease.

Pleural effusion was found to be the commonest pleural disease (58%)

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retrospective study of pleural diseases

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