Pleura and chest wall

What are these?

The lungs are covered by two thin layers called the pleura, with a narrow space between them. Diseases of this space and of the chest wall take several forms.

Pleural fluid (pleural effusion). MedlinePlus describes it as a build-up of fluid between the layers of the membrane that covers the lung and chest. The body always makes a small amount of this fluid; the problem starts when there is too much. Common causes are heart failure, infection, inflammation, lung injury and tumours. Symptoms include chest pain (often worse with coughing or deep breaths), cough, fever and chills, and breathlessness. MedlinePlus stresses that sometimes there are no symptoms.

Pneumothorax (collapsed lung). MedlinePlus describes it as a leak of air from the lung into the space between the lung and the chest wall; the air presses on the lung and stops it expanding fully. Causes include chest injury, a broken rib, rupture of small air blisters (blebs) and some lung diseases. Tall, thin people and smokers are more at risk, and sometimes it happens for no reason. The symptom is sharp pain in the chest or shoulder that is worse with a deep breath or cough, along with breathlessness.

Empyema. MedlinePlus describes it as a collection of pus in the pleural space. It usually comes from an infection that has spread from the lung, such as bacterial pneumonia or tuberculosis, and sometimes occurs after chest surgery or chest injury. Signs are chest pain on deep breathing, fever and chills, night sweats, cough, tiredness, breathlessness and unexplained weight loss.

Rib injury. The NHS writes that a rib is usually injured by a fall, a blow or severe coughing, and the main pain is worse when breathing or coughing. Most broken or bruised ribs heal by themselves in two to six weeks, because a rib cannot be bandaged like other bones.

Who comes to a surgeon?

Most of these patients are first seen by a GP, an internist, a lung doctor or in the emergency department. A chest surgeon usually becomes involved when:

• fluid or air does not clear, or returns, with simple drainage;
• a chest tube is needed (MedlinePlus names it for fluid caused by cancer or infection and for a large pneumothorax);
• infection and pus remain and breathing is impaired;
• a pneumothorax comes back, which MedlinePlus says is more likely in some people (for example tall, thin people, or those who keep smoking);
• a blow to the chest has caused other injuries.

How is it investigated?

• Examination: listening to the lungs with a stethoscope and tapping on the chest (MedlinePlus).
• Imaging: chest X-ray, chest ultrasound or CT. In pneumothorax, a chest X-ray, sometimes a blood gas test, and CT if another injury is suspected.
• Thoracentesis: a needle is passed between the ribs and a sample of fluid is drawn out. The sample is checked for infection, cancer cells and protein (MedlinePlus).
• Blood tests and, if needed, other tests, such as an echocardiogram, a lung biopsy or bronchoscopy.

How is it treated in general?

According to MedlinePlus, the aim of treating pleural fluid is to remove the fluid, stop it coming back and treat its cause. MedlinePlus names these options:

• Drainage with thoracentesis, which lets the lung expand and makes breathing easier.
• Treating the underlying condition, such as heart failure medicines or antibiotics for infection.
• A chest tube, often used for fluid caused by cancer or infection.
• In some cases, a medicine placed in the chest to stop the fluid collecting again, a small tube that stays longer, or surgery.

For pneumothorax, MedlinePlus says a small one may get better by itself; sometimes air is drawn out with a needle; for a large pneumothorax a tube is placed between the ribs and may stay for several days; and if needed, lung surgery or pleurodesis may be considered to repair a leak or stop it coming back. For empyema, treatment is draining the pus with a tube and antibiotics, and, if breathing stays impaired, sometimes surgery.

Which way suits you is for your treating doctor and surgeon, and depends on the cause and the state of your lung.

What can you do?

• Write down your symptoms: when they started, whether they get worse with breathing or coughing, and whether you have a fever.
• Bring images, reports and the result of any fluid test.
• Carry your medicine list and do not stop any medicine yourself.
• If you smoke, ask your doctor for help to stop. MedlinePlus names continued smoking among the factors in a pneumothorax coming back.
• If you have a tube, do not kink it and keep the drainage container below chest level as the nurse instructs (MedlinePlus). Deep-breathing and coughing exercises help the lung expand.
• After a blow to the chest, the NHS advises taking slow, deep breaths regularly, pressing a pillow to your chest when you cough, and walking so the lung stays clear.

When to get urgent help

• Sudden or severe breathlessness, sharp chest pain that has just started, blue lips or skin, dizziness or a feeling of fainting. Call 115, Iran’s emergency number.
• Breathlessness or difficulty breathing right after thoracentesis. MedlinePlus says to contact your doctor or go to the emergency department; do not delay, and if you cannot reach a doctor, go to the emergency department.
• Coughing up more than a few streaks of blood. Call 115, Iran’s emergency number (NHS).
• After a rib injury: if it came from a serious accident such as a car crash, breathlessness or chest pain is getting worse, you have stomach or shoulder pain, or you cough up even a little blood. Call 115, Iran’s emergency number (NHS).
• The chest tube has come out, moved or come apart at its connection, or breathing is getting harder and pain is increasing. Cover the site with a clean gauze pad and tell the surgeon or emergency department at that moment (MedlinePlus).

Do not drive yourself. See the full list in the guide When should I call urgently?