World Journal of Pharmaceutical Research SJIF Impact Factor 8.074

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1 SJIF Impact Factor Volume 7, Issue 9, Research Article ISSN 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. 2 Final Year BPT, Dr. D.Y. Patil College of Physiotherapy, Pune. 4 Principal and Professor, Dr. D.Y. Patil College of Physiotherapy, Pune. Article Received on 19 March 2018, Revised on 09 April 2018, Accepted on 30 April 2018 DOI: /wjpr *Corresponding Author Mansi Deshpande Final Year BPT, 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 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] Vol 7, Issue 9,

2 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 conditions 3. 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] Vol 7, Issue 9,

3 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] Vol 7, Issue 9,

4 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 Vol 7, Issue 9,

5 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] Vol 7, Issue 9,

6 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] Vol 7, Issue 9,

7 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 Vol 7, Issue 9,

8 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 1 st 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. Vol 7, Issue 9,

9 Graph- I : Demographic Data. Table I(a) Age. AGE GROUP NO. OF PATIENTS Interpretation: Graph I(a) and Table I(a) shows that years of age group is affected the most (47%), (28%) and (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. Vol 7, Issue 9,

10 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. Vol 7, Issue 9,

11 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. Vol 7, Issue 9,

12 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 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 Vol 7, Issue 9,

13 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 years (47%) Males are more affected than females (61%) Majority of patients showed the addiction associated with pleural disease (62%) Vol 7, Issue 9,

14 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%) REFERENCES 1. Murray and Nadel s textbook of respiratory medicine, 5 th edition, November 6, Robert M kacmarek, Egan s fundamentals of respiratory medicine, 10 th edition. 3. Patricia. A. downie. FCSP, Cash textbook of chest, heart and vascular disorders for physiotherapy, 4 th edition. 4. Musani Al. Treatment options for malignant pleural effusions. 5. Brain R Walter, Davidson s principles and practice of medicine 22 nd edition, copyright Clarke Christopher 2017, chest x-ray for medical students. 7. Chen PH Lin XZ, hydropneumothorax, medicine 2010, 8. Kliegman RH et.al. pleurisy, pleural effusion and empyema; Nelson textbook of respiratory disease 20 th edition, Moshe sehein, john C marshall, 2013, A guide to management of surgical infections. 10. Rosenstengal. A and Lee. Y 2012, April, pleural infection- current diagnosis and management, journal of thoracic disease. 11. Stuart potter, Tidy s physiotherapy, Seow A, Kazerooni E A, Pernicano P G et.al. comparison of upright inspiratory and expiratory chest radiographs for detecting pneumothoraces. 13. Staton G W Jr IX, Disorders of the pleura, hila and mediastinum. In: ACP medicine:14 Respiratory medicine, Hanna JW, Reed JC, Pleural infections: a clinical- radiological review, J thoracic imaging, Sharma G, Goodwin J. Effects of aging on respiratory system physiology and immunology, Bauman HR, the pleura rev respiratory disease, Kalpan JD, Calandino FS, Effect of smoking on pulmonary vascular permeability: a positron study, American review of respiratory disease, Clare Hoper, British Thoracic society pleural disease guidelines. Vol 7, Issue 9,