Pleural Diseases and Disorders

The pleura is the specialized protective membrane covering the lungs. This thin, two-layered tissue envelops the lungs and lines the inner chest cavity, creating a space between them called the pleural space. Normally, this space contains a small amount of lubricating pleural fluid, allowing the layers of the pleura to glide smoothly past each other as the lungs expand and contract during breathing.

When this delicate system is disrupted, it can lead to a range of conditions collectively known as pleural diseases or pleural disorders. These conditions can significantly impact respiratory function and overall well-being.

What Are Pleural Disorders?

Pleural disorders encompass any medical condition that affects the pleura, the pleural space or the pleural fluid. These conditions can range in severity from mild inflammation to life-threatening accumulations of fluid, air or blood in the chest cavity. The primary role of the pleura is to protect the lungs and ensure effortless breathing. When this protective barrier is compromised, it can lead to various respiratory symptoms and complications.

Common Types of Pleural Disorders

Several distinct conditions fall under the umbrella of pleural disorders. Each has its unique characteristics, though many share common symptoms.

Pleural Effusion

One of the most common pleural diseases is pleural effusion, a condition characterized by the excessive accumulation of fluid in the pleural space. While a small amount of fluid is normal, an abnormal buildup can compress the lung, making breathing difficult.

Pleural effusions can be broadly categorized into two types:

• Transudative Effusions: These occur when fluid leaks into the pleural space due to increased pressure in the blood vessels or low protein levels in the blood. A common cause of transudative pleural effusion is congestive heart failure, a condition where the heart struggles to pump blood effectively, leading to fluid backup. Other causes include kidney failure or liver cirrhosis.
• Exudative Effusions: These are more complex and result from inflammation or injury to the pleura itself, or from problems with fluid and protein leakage. Causes can include lung cancer, pneumonia, pulmonary embolism or infection.

Pleurisy (Pleuritis)

Pleurisy, also known as pleuritis, is an inflammation of the pleura. This inflammation causes the two layers of the pleura to rub against each other, leading to sharp chest pain, especially during breathing, coughing or sneezing. Viral infection is a common cause of pleurisy, though it can also result from bacterial infections, autoimmune diseases or underlying lung conditions.

Pneumothorax

A pneumothorax occurs when air or gas accumulates in the pleural space, causing the lung to collapse partially or completely. This can happen due to a blunt or penetrating chest injury, certain medical procedures or spontaneously without any apparent cause (spontaneous pneumothorax). Symptoms often include sudden chest pain and shortness of breath.

Hemothorax

Hemothorax is the accumulation of blood in the pleural space. This condition is most often caused by trauma to the chest, such as a car accident or a penetrating injury. It can also occur as a complication of surgery or certain medical conditions. Hemothorax requires prompt medical attention to drain the blood and address the underlying cause.

Empyema

Empyema is a serious condition where pus collects in the pleural space. It is typically a complication of bacterial pneumonia or lung abscess, where the infection spreads to the pleura. Symptoms often include fever, chills and significant chest pain. Empyema requires aggressive treatment, often involving drainage of the pus and antibiotics.

Pleural Tumors

While less common, tumors can also affect the pleura. These can be benign (non-cancerous) or malignant (cancerous). Malignant pleural mesothelioma is a rare but aggressive form of cancer that develops in the pleura, often linked to asbestos exposure. Lung cancer can also spread to the pleura, leading to malignant pleural effusion.

Pleural Fibrosis and Pleural Thickening

Pleural fibrosis refers to the scarring and thickening of the pleura. This can result from chronic inflammation, infection (like tuberculosis), asbestos exposure or previous pleural effusions. While pleural thickening itself is not curable, managing the underlying cause and addressing symptoms is important. The life expectancy for someone with pleural fibrosis varies greatly depending on the extent of the fibrosis, the underlying cause and overall health. It is not generally considered a life-threatening condition on its own, but it can be a sign of a more serious underlying issue.

Symptoms of Pleural Disorders

The symptoms of pleural disorders can vary depending on the specific condition and its severity. However, several common symptoms often indicate a problem with the pleura.

• Chest pain: This is often a sharp, stabbing pain that worsens with deep breaths, coughing or sneezing (pleuritic chest pain). It may be localized to one side of the chest or spread to the shoulder or back.
• Shortness of breath (dyspnea): Accumulation of fluid or air in the pleural space can compress the lung, making it difficult to expand fully and leading to breathlessness.
• Cough: A dry cough may accompany pleural disorders, particularly if there is irritation or inflammation of the pleura.
• Fever and chills: These symptoms often indicate an infection, such as pneumonia leading to empyema or a viral infection causing pleurisy.
• Fatigue: General weakness and tiredness can accompany many chronic or acute illnesses, including pleural disorders. If you experience persistent chest pain, difficulty breathing or any of these symptoms, it is important to seek medical attention promptly.

Causes of Pleural Disorders

The causes of pleural disorders are diverse and can range from infections to chronic diseases. Some of the most common causes include:

• Infections: Viral infections are a common cause of pleurisy. Bacterial infections, especially pneumonia, can lead to empyema. Tuberculosis can also affect the pleura.
• Congestive heart failure: As mentioned, this is a very common cause of transudative pleural effusion.
• Cancer: Lung cancer, lymphoma and metastatic cancers from other parts of the body can spread to the pleura, causing malignant pleural effusion or pleural tumors.
• Pulmonary embolism: A blood clot in the lung's arteries can cause pleural inflammation and effusion.
• Trauma: Injuries to the chest wall can lead to pneumothorax or hemothorax.
• Autoimmune diseases: Conditions like lupus or rheumatoid arthritis can sometimes cause inflammation of the pleura.
• Kidney or liver disease: These conditions can lead to fluid imbalances in the body, contributing to transudative pleural effusions.
• Asbestos exposure: Long-term exposure to asbestos fibers is a known cause of pleural thickening and malignant pleural mesothelioma.

Preventing Pleural Disorders

While not all pleural disorders are entirely preventable, several important measures can significantly reduce the risk of developing these conditions.

• Avoiding exposure to toxic substances such as asbestos is crucial, as asbestos fibers are strongly linked to the development of pleural thickening and malignant pleural mesothelioma.
• Prompt treatment of respiratory infections and immunizations against pneumonia and influenza can help prevent complications like empyema and pleurisy.
• Maintaining good management of chronic diseases — such as heart, liver or kidney conditions — also plays a key role in reducing the likelihood of fluid accumulation in the pleural space.
• Use proper protective equipment in occupational settings.
• Refrain from smoking and vaping.

Diagnosis of Pleural Diseases

Diagnosing a pleural disorder typically involves a combination of a thorough medical history, physical examination and imaging tests.

• Medical history and physical exam: Your doctor will ask about your symptoms, medical history and any potential exposures. During the physical exam, they will listen to your lungs and chest for abnormal sounds, such as diminished breath sounds or friction rubs.
• Chest X-ray: This is often the first imaging test performed. A chest X-ray can reveal the presence of fluid (pleural effusion), air (pneumothorax) or thickening of the pleura.
• CT scan: A computed tomography (CT) scan provides more detailed images of the lungs and pleura, helping to identify the exact location and extent of the problem and sometimes revealing the underlying cause like a tumor or infection.
• Ultrasound: Ultrasound can be used to guide fluid drainage procedures and assess the amount of fluid.
• Thoracentesis: If there is a significant pleural effusion, a procedure called thoracentesis may be performed. A small needle is inserted into the pleural space to remove a sample of pleural fluid. This fluid is then analyzed in a laboratory to determine its composition (transudative vs. exudative) and to check for infection, cancer cells or other indicators that can help identify the underlying cause.
• Pleural biopsy: In some cases, a small tissue sample from the pleura may be taken (pleural biopsy) for microscopic examination, especially if cancer or tuberculosis is suspected. This can be done via needle biopsy or during a surgical procedure like thoracoscopy.
• Thoracoscopy: This minimally invasive surgical procedure involves inserting a thin, lighted tube with a camera (thoracoscope) into the chest cavity through a small incision. This allows the doctor to visualize the pleura directly, take biopsies and sometimes perform therapeutic procedures. Also known as video-assisted thoracoscopic surgery (VATS).

Treatment Options for Pleural Disease

Treatment for pleural disease is highly dependent on the specific disorder, its underlying cause and the severity of symptoms. The primary goals of treatment are to relieve symptoms, remove any accumulated fluid or air and address the root cause of the problem.

Addressing the Underlying Cause

Since many pleural disorders are symptoms of other medical conditions, treating the underlying cause is paramount.

• Medications: For infections, antibiotics (for bacterial infections) or antiviral medications may be prescribed. Anti-inflammatory drugs can help manage pain and inflammation associated with pleurisy. Diuretics may be used for effusions related to congestive heart failure.
• Cancer treatment: If cancer is the cause, treatment may involve chemotherapy, radiation therapy or surgery.

If there is a pleural effusion from heart, kidney or liver disease, we will work with your heart, kidney or liver doctors to manage those diseases with medications, surgeries or procedures.

Draining Fluid or Air

For conditions like pleural effusion, pneumothorax or hemothorax, removing the accumulated fluid or air is often necessary to relieve pressure on the lung and improve breathing.

• Thoracentesis: This procedure uses a needle to drain fluid from the pleura. It can be used for diagnostic purposes and also as a therapeutic measure to relieve symptoms from large effusions. Done under local anesthesia and guided by ultrasound, a catheter (empty plastic tube similar to an IV) is inserted between the ribs, usually in the back, to drain the fluid. It takes about 15 minutes. The fluid removed can be sent for lab studies to help determine the underlying cause (looking at the types of cells present in the fluid, evaluating for markers of inflammation, and for infection). Thoracentesis can also help patients breathe better. A simple bandage is applied after the procedure, and it is usually tolerated well with minimal pain.
• Chest tube insertion: For larger accumulations of fluid, air or blood, a chest tube may be inserted into the pleural space. This tube remains in place for a period, allowing continuous drainage and re-expansion of the lung.
• Indwelling pleural catheter (e.g., PleurX): For recurrent malignant pleural effusions, an indwelling pleural catheter can be surgically implanted. This allows patients or caregivers to drain fluid at home, improving comfort and reducing hospital visits.

Other Procedures

• Pleurodesis: For recurrent pleural effusions, especially those due to cancer, pleurodesis may be performed. This procedure involves introducing a substance (like talc or doxycycline) into the pleural space, causing the two layers of the pleura to stick together. This obliterates the pleural space, preventing further fluid accumulation.
• Decortication: In cases of severe pleural thickening or empyema with significant scarring, a surgical procedure called decortication may be necessary. This involves removing the thick, fibrous peel from the lung's surface, allowing it to re-expand.
• Thoracotomy: In more complex cases, open chest surgery (thoracotomy) may be required.

The pleural clinic team arranges post-consult care to review test results, arrange any other testing or procedures or provide referrals to specialists. If there is a concern the fluid could come back, a follow up appointment will be made for another ultrasound. If other procedures are needed that can’t be done in clinic, such as a chest tube or a pleuroscopy, we will help with those arrangement as well.

Living with Pleural Disorders

The life expectancy of a person with pleural effusions depends entirely on the underlying cause. If the effusion is due to a treatable condition like infection or congestive heart failure, the prognosis is often good with proper management. However, if it is caused by advanced lung cancer or other severe, untreatable conditions, the prognosis may be significantly shorter. Similarly, the survival rate for pleural effusion is not a fixed number but is tied directly to the primary disease causing it.

While pleural disorders can be serious, advancements in diagnosis and treatment offer hope and improved outcomes for many individuals. Early detection and appropriate management of underlying conditions are key to preventing complications and maintaining lung health. If you or a loved one are experiencing symptoms related to pleural disorders, consulting with a health care professional for an accurate diagnosis and personalized treatment plan is the most important step.

Expert Care for Pleural Diseases

One of the most important jobs for our team is to make sure you and your loved ones make educated and personalized decisions about procedures and further testing. We want to ensure you understand the disease itself: why it’s happening, how it contributes to current symptoms and what the future may bring.

You deserve to hear all the options for both evaluation and treatment. Like much of medicine, there is no “one size fits all” approach, and detailed discussions with your care teams helps you understand your disease and the options, and make the best decision. We also believe in a true team approach and will work and communicate with other health care team members (for example, oncologists, surgeons, cardiologists, nephrologists and primary care doctors and clinicians) to provide unified care.