What Are Pleurisy and Other Disorders of the
Pleura?
Pleurisy (PLUR-is-see) is inflammation (swelling) of
the pleura. The pleura is a large, thin sheet of tissue (membrane) that wraps
around the outside of your lungs and lines the inside of your chest cavity.
Between the layer of the pleura that wraps around
your lungs and the layer that lines your chest cavity is a very thin space.
This is called the pleural space. Normally it's filled with a small amount of
fluid—about 4 teaspoons full. The fluid helps the two layers of the
pleura glide smoothly past each other as your lungs breathe air in and out.
Pleurisy occurs when the two layers of the pleura
become red and inflamed. Then they rub against each other every time your lungs
expand to breathe in air. This can cause sharp pain with breathing.
Infections like pneumonia are the most common cause
of swelling, or inflammation, of the pleura and pleurisy.
Other Disorders of the Pleura
Pleural Effusion
In some cases of pleurisy, excess fluid builds up in
the pleural space. This is called a pleural effusion. The buildup of fluid
usually forces the two layers of the pleura apart so they don't rub against
each other when you breathe. This can relieve your pain.
However, a large amount of extra fluid can push the
pleura against your lung until the lung, or a part of it, collapses. This can
make it hard for you to breathe.
In some cases of pleural effusion, the extra fluid
gets infected and turns into an abscess. This is called an empyema
(em-pi-E-ma).
You can develop a pleural effusion if you don't have
pleurisy. For example, pneumonia,
heart
failure, cancer, or a
pulmonary
embolism can lead to a pleural effusion.
Pneumothorax
Air or gas also can build up in the pleural space.
This is called a pneumothorax (noo-mo-THOR-aks). It can result from acute lung
injury or a lung disease like emphysema. Lung procedures, like surgery,
drainage of fluid with a needle, examination of the lung from the inside with a
light and a camera, or mechanical ventilation, also can cause it.
The most common symptom is sudden pain in one side
of the lung and shortness of breath. A pneumothorax also can put pressure on
the lung and cause it to collapse.
If the pneumothorax is small, it may go away on its
own. If it's large, you may need to have a tube placed through your skin and
chest wall into the pleural space to remove the air.
Hemothorax
Blood also can collect in the pleural space. This is
called hemothorax (he-mo-THOR-aks). The most common cause is injury to your
chest from blunt force or chest or heart surgery. Hemothorax also can occur in
people with lung or pleural cancer.
Hemothorax can put pressure on the lung and force it
to collapse. It also can cause shock, a state in which not enough blood and
oxygen reach important organs in the body.
Outlook
Pleurisy and other disorders of the pleura can be
serious, depending on what caused the inflammation in the pleura.
If the condition that caused the pleurisy or other
pleural disorders isn't too serious and is diagnosed and treated early, you
usually can expect a full recovery.
Other Names for Pleurisy and Other Disorders of the
Pleura
- Pleurisy—Pleuritis and pleuritic chest pain
- Pleural effusion—Fluid in the chest and
pleural fluid
- Pneumothorax—Air around the lung and air
outside the lung
What Causes Pleurisy and Other Disorders of the
Pleura?
Pleurisy
Many different conditions can cause pleurisy. Viral
infection is the most common cause. Other conditions that can cause pleurisy
are:
- Bacterial infections like pneumonia and
tuberculosis
- Autoimmune disorders like systemic lupus
erythematosus and rheumatoid arthritis
- Lung cancer, including lymphoma
- Other lung diseases like
sarcoidosis,
asbestosis,
lymphangioleiomyomatosis,
and mesothelioma
- Pulmonary
embolism, a blood clot in the blood vessels that go into the lungs
- Inflammatory bowel disease
- Familial Mediterranean fever, an inherited condition that
often causes fever and swelling in the abdomen or lung
- Infection from a fungus or parasite
- Heart surgery, especially
coronary
artery bypass grafting
Other causes of pleurisy include:
- Chest injuries
- Reactions to certain medicines that can cause a
condition similar to systemic lupus erythematosus. These medicines include
procainamide, hydralazine, and isoniazid.
In some cases, doctors can't find the cause of the
pleurisy.
Pleural Effusion
The most common cause of pleural effusion, or fluid
in the pleural space, is
congestive
heart failure. Lung cancer, pneumonia, tuberculosis, and other lung
infections also can cause swelling of the pleura and lead to a pleural
effusion. Asbestosis, sarcoidosis, and reactions to some medicines also can
lead to pleural swelling and pleural effusion.
Pneumothorax
A pneumothorax, or air in the pleural space, can be
caused by lung diseases like
chronic
obstructive pulmonary disease (COPD), tuberculosis, and acute lung injury.
Surgery or a wound or injury to the chest also may lead to a pneumothorax.
Hemothorax
The most common cause of hemothorax, or blood in the
pleural space, is an injury to the chest. Cancer of the lung or pleura and
chest or heart surgery also may lead to a hemothorax.
Hemothorax also can be a complication of
tuberculosis.
What Are the Signs and Symptoms of Pleurisy and
Other Disorders of the Pleura?
Pleurisy
The main symptom of pleurisy is a sharp or stabbing
pain in your chest that gets worse when you breathe in deeply or cough or
sneeze.
The pain may stay in one place or it may spread to
your shoulder or back. Sometimes it becomes a fairly constant dull ache.
Depending on what's causing the pleurisy, you may
have other symptoms, such as:
- Shortness of breath
- A cough
- Fever and chills
- Rapid, shallow breathing
- Unexplained weight loss
- A sore throat followed by pain and swelling in
your joints
Pleural Effusion
Pleural effusion often has no symptoms.
Pneumothorax
The symptoms of pneumothorax include:
- Sudden, sharp chest pain that gets worse when you
breathe in deeply or cough
- Shortness of breath
- Chest tightness
- Easy fatigue (tiredness)
- A rapid heart rate
- A bluish color of the skin caused by lack of
oxygen
Other symptoms of pneumothorax include flaring of
the nostrils; anxiety, stress, and tension; and
hypotension
(low blood pressure).
Hemothorax
The symptoms of hemothorax are often similar to
those of pneumothorax. They include:
- Chest pain
- Shortness of breath
- Respiratory failure
- A rapid heart rate
- Anxiety
- Restlessness
How Are Pleurisy and Other Disorders of the Pleura
Diagnosed?
Your doctor will find out if you have pleurisy or
another pleural disorder by taking a detailed medical history and doing a
physical exam and several tests. The purpose is to:
- Rule out other causes of your symptoms
- Find the cause of the pleurisy or other pleural
disorder so it can be treated
Medical History
Your doctor will ask you for a detailed medical
history. He or she is likely to ask you to describe the pain, especially:
- What it feels like
- Where it's located and whether you can feel it in
your arms, jaw, or shoulder
- When it started and how long you've had it
- What makes it better or worse
- Whether it goes away and then comes back
Your doctor will probably also want to know about
any other symptoms that you may have, like shortness of breath, cough, or
palpitations (a feeling that your heart has skipped a beat or is beating too
hard).
Other things your doctor is likely to ask about
include whether you've ever:
- Had heart disease
- Smoked
- Traveled to places where you may have been
exposed to tuberculosis
- Had a job that exposed you to asbestos
- Taken nitrofurantoin or amiodarone or a medicine
that can cause a condition that's similar to systemic lupus erythematosus (an
autoimmune disorder)
Physical Exam
Your doctor will listen to your breathing with a
stethoscope to find out whether your lungs are making any strange sounds.
When you have pleurisy, the inflamed layers of the
pleura make a rough, scratchy sound as they rub against each other when you
breathe. Doctors call this a pleural friction rub. If your doctor hears the
friction rub, he or she will know that you have pleurisy.
If you have a pleural effusion, fluid has built up
in the pleural space and pushed the two layers of the pleura apart so that they
don't produce a friction rub. But if you have a lot of fluid, your doctor may
hear a dull sound when he or she taps on your chest. Or the doctor may have
trouble hearing any breathing sounds.
Reduced breathing sounds also can be a sign of
pneumothorax.
Diagnostic Tests
Depending on the results of your physical exam, your
doctor may recommend other diagnostic tests.
Chest X Ray
A chest x ray takes a picture of your heart and
lungs. It may show air or fluid in the pleural space. It also may show what's
causing the condition—for example, pneumonia, a fractured rib, or a lung
tumor.
Sometimes an x ray is taken while you lie on the
side where the pain is. This may show fluid that didn't appear on the standard
x ray taken while you were standing.
Computerized Tomography (CT) Scan
This test provides a computer-generated picture of
your lungs that can show pockets of fluid. It also may show signs of pneumonia,
a lung abscess, or a tumor.
Ultrasound
This test uses sound waves to create pictures of
your lungs. It may show where fluid is located in your chest. It also can show
some tumors.
Magnetic Resonance (MR) Scan
This test also is called nuclear magnetic resonance
(NMR) scanning or magnetic resonance imaging (MRI). It uses powerful magnets
and radio waves to show pleural effusions and tumors.
Blood Tests
Blood tests can show whether you have a bacterial or
viral infection, pneumonia, rheumatic fever, a
pulmonary
embolism, or lupus.
Arterial Blood Gas Tests
In this test, a small amount of blood is taken from
an artery in your wrist. It's then checked for oxygen and carbon dioxide
levels. This test shows how well your lungs are taking in oxygen.
Thoracentesis
Once your doctor knows whether fluid has built up in
the pleural space and where it is, he or she can remove a sample for testing.
This test is called thoracentesis (THOR-a-sen-TE-sis). The doctor inserts a
small needle or a thin, hollow, plastic tube through the ribs in the back of
your chest into your chest wall and draws fluid out of your chest.
Thoracentesis usually doesn't take long. Most of the
time, it can be done in your doctor's office or at your hospital bed. Many
doctors use ultrasound to guide the needle to the fluid that's trapped in small
pockets around your lungs.
Thoracentesis usually doesn't cause serious
complications, but your doctor may do a chest x ray after the procedure to be
sure. Most of the complications are minor and will get better on their own, or
they're easily treated.
Possible complications of thoracentesis include:
- Pneumothorax, or buildup of air in the pleural
space, with a collapsed or partially collapsed lung. Sometimes air comes in
through the needle or the needle makes a hole in your lung. Usually, a hole
will seal itself. But sometimes air can build up around the lung and make it
collapse. The doctor may need to use a chest tube to remove the air and let the
lung expand again.
- Pain.
- Bleeding and bruising where the needle went in.
In rare cases, bleeding may occur in or around the lung. The doctor may need to
use a chest tube to drain the blood. In some cases, surgery may be needed.
- Infection where the needle went in.
- Liver or spleen injury. This is very rare.
Fluid Analysis
Doctors look at the fluid removed by thoracentesis
under a microscope. They look at the chemicals in it and its color, texture,
and clearness for signs of infection, cancer, or other conditions that may be
causing the buildup of fluid or blood in the pleural space.
Biopsy
If your doctor thinks that tuberculosis or cancer
may have caused the fluid buildup, he or she may want to look at a small piece
of the pleura under a microscope.
To take a tissue sample, the doctor may:
- Insert a needle through the skin on your chest to
remove a small sample of the outer layer of the pleura.
- Insert a small tube with a light on the end
(endoscope) into tiny cuts in your chest wall so that the doctor can see the
pleura. He or she can then snip out small pieces of tissue. This procedure must
be done in the hospital under general anesthesia.
- Snip out a sample of the pleura through a small
cut in your chest wall. This is called an open pleural biopsy. It's usually
done if the sample from the needle biopsy is too small for an accurate
diagnosis. This procedure must be done in the hospital under general
anesthesia.
How Are Pleurisy and Other Disorders of the Pleura
Treated?
Goals of Treatment
The goals of treatment are to:
- Remove the fluid, air, or blood from the pleural
space
- Relieve symptoms
- Treat the underlying condition
Remove Fluid, Air, or Blood From the Pleural
Space
If large amounts of fluid, air, or blood aren't
removed from the pleural space, they may put pressure on your lung and cause it
to collapse.
The procedures used to drain fluid, air, or blood
from the pleural space are similar.
- During thoracentesis, the doctor inserts a needle
or a thin, hollow, plastic tube through the ribs in the back of your chest into
your chest wall. A syringe is attached to draw fluid out of your chest. This
procedure can remove more than 6 cups of fluid at a time.
- When larger amounts of fluid must be removed, a
chest tube may be inserted through your chest wall. The doctor injects a local
painkiller into the area of your chest wall outside where the fluid is. He or
she will then insert a plastic tube into your chest between two ribs. The tube
is connected to a box that suctions the fluid out. A chest x ray is taken to
check the tube's position.
- A chest tube also is used to drain blood and air
from the pleural space. This can take several days. The tube is left in place,
and you usually stay in the hospital during this time.
- Sometimes the fluid contains pus that is very
thick or blood clots. Or it may have formed a hard skin or peel. This makes it
harder to drain the fluid. To help break up the pus or blood clots, the doctor
may use the chest tube to put certain medicines into the pleural space. These
medicines are called fibrinolytics. If the pus or blood clots still don't drain
out, you may need surgery.
Relieve Symptoms
For relief of pleurisy symptoms, your doctor may
recommend:
- Acetaminophen or anti-inflammatory agents, such
as ibuprofen, to control pain.
- Codeine-based cough syrups to control a
cough.
- Lying on the painful side. This may make you more
comfortable.
- Breathing deeply and coughing to clear mucus as
the pain eases. Otherwise, you may develop pneumonia.
- Getting plenty of rest.
Treating the Underlying Condition
Looking at the fluid under a microscope can often
tell the doctor what's causing the fluid buildup. Then treatment of the
underlying condition can begin.
If the fluid is infected, treatment involves
antibiotics and draining the fluid. If the infection is tuberculosis or from a
fungus, treatment involves long-term use of antibiotics or antifungal
medicines.
If the fluid is caused by tumors of the pleura, it
may build up again quickly after it's drained. Sometimes antitumor medicines
will prevent further fluid buildup. If they don't, the doctor may seal the
pleural space. This is called pleurodesis.
In pleurodesis, the doctor drains all the fluid out
of the chest through a chest tube. Then he or she pushes a substance through
the chest tube into the pleural space. This substance irritates the surface of
the pleura. This causes the two layers of the pleura to squeeze shut so there
is no room for more fluid to build up.
Chemotherapy or radiation treatment also may be used
to reduce the size of the tumors.
If
congestive
heart failure is causing the fluid buildup, treatment usually includes
diuretics and other medicines.
Key Points
- Pleurisy is inflammation (swelling) of the
pleura. The pleura is a large, thin sheet of tissue (membrane) that wraps
around the outside of your lungs and lines the inside of your chest cavity.
- Pleurisy occurs when the two layers of the pleura
become red and inflamed. Then they rub against each other every time your lungs
expand to breathe air in.
- Other disorders of the pleura include pleural
effusion (buildup of fluid in the pleural space), pneumothorax (buildup of air
or gas in the pleural space), and hemothorax (buildup of blood in the pleural
space).
- Many different conditions can cause pleurisy.
Viral infection is the most common cause. The most common cause of pleural
effusion is
congestive
heart failure. Lung diseases, like
chronic obstructive pulmonary disease (COPD), tuberculosis, and acute lung
injury, cause pneumothorax. Injury to the chest is the most common cause of
hemothorax.
- The main symptom of pleurisy is a sharp or
stabbing pain in your chest that gets worse when you breathe in deeply or cough
or sneeze. Pleural effusion often has no symptoms. Pneumothorax and hemothorax
have similar symptoms, including chest pain, shortness of breath, and a rapid
heart rate.
- Your doctor will find out if you have pleurisy or
another pleural disorder by taking a detailed medical history and doing a
physical exam and several tests.
- Treatment for pleurisy is designed to remove the
fluid, air, or blood from the pleural space, relieve symptoms, and treat the
underlying condition.
- If the condition that caused pleurisy isn't too
serious and is diagnosed and treated early, you can expect a full
recovery.
Links to Other Information About Pleurisy and Other
Disorders of the Pleura
NHLBI Resources
Non-NHLBI Resources
Clinical Trials
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