Pleural Disorders

Also known as Empyema, Hemothorax, Pleurisy, Pleural Effusion, Pneumothorax
Pleural disorders are conditions that affect the tissue that covers the outside of the lungs and lines the inside of your chest cavity. The tissue is called the pleura, and the thin space between its two layers is called the pleural space. A small amount of fluid fills the pleural space, and when you breathe in and out, this fluid helps the pleural layers glide smoothly against each other.

There are three types of pleural disorders—pleurisy, pleural effusion, and pneumothorax—and they have varying causes. Pleurisy is inflammation of the pleura. Pleural effusion and pneumothorax occur when an infection, medical condition, or chest injury causes fluid, pus, blood, air, or other gases to build up in the pleural space.

Chest pain, shortness of breath, and coughing are common symptoms of all types of pleural disorders, but treatment for pleural disorders varies depending on what type you have and how serious it is.

Explore this Health Topic to learn more about pleural disorders, our role in research and clinical trials to improve health, and where to find more information.

Types - Pleural Disorders

The types of pleural disorders are pleural effusion, pleurisy, and pneumothorax.

Pleural effusion
- Pleural Disorders

Pleural effusion is a buildup of fluid in the pleural space. The cause of the buildup determines the type of pleural effusion.

  • Exudative effusion is caused by a buildup of fluid from inflammation, tumors, infection, or lung injury. The types of exudative effusion vary by the fluid buildup in the pleural space. For example, an empyema is a buildup of infection or pus, a hemothorax happens when blood builds up, and a chylothorax results from a buildup of chyle, a substance formed in the small intestine.
  • Transudative pleural effusion is caused by pressure in the blood vessels, most often because of a medical condition such as heart, kidney, or liver failure. The pressure pushes excess fluid into the pleural cavity.
Fluid in the pleural space
Fluid in the pleural space. This image shows pleural effusion. Fluid is shown in the pleural space on the left lung. Medical Illustration Copyright © 2019 Nucleus Medical Media, All rights reserved.

 

Pleurisy
- Pleural Disorders

Pleurisy is inflammation of the pleura. It is also called pleuritis.

Pneumothorax
- Pleural Disorders

Pneumothorax occurs when air or other gas builds up in the pleural space and may cause part or all of the lung to collapse.

There are different types of pneumothorax.

  • Spontaneous pneumothorax may be caused by another medical condition that affects the lungs, such as chronic obstructive pulmonary disease (COPD), but people who have no signs of lung disease can also have a spontaneous pneumothorax.
  • Tension pneumothorax is a very large pneumothorax that may result in failure of the heart and the lungs. This can interfere with blood flow through your chest and cause your blood pressure to drop.
  • Traumatic pneumothorax is caused by a chest injury.
Cross-section of normal lungs and lungs with pleurisy and pneumothorax
Cross-section of normal lungs and lungs with pleurisy and pneumothorax. Figure A shows the location of the lungs, airways, pleura, and diaphragm. The inset image on the left shows a closer view of the two layers of the pleura and the pleural space. Figure B shows lungs with pleurisy and a pneumothorax. The inset image on the right shows a closer view of an infected lung with thickened and inflamed pleural layers.

 

Causes - Pleural Disorders

Pleural disorders may be caused by inflammation, injury, or an imbalance of fluids in the pleural space.

Inflammation
- Pleural Disorders

Pleurisy is caused by inflammation in the pleura. The inflammation may happen because of an infection, tumor, or another medical condition.

The inflammation affects the two thin layers of the pleura. This can cause the surface of the layers to become rough and the fluid in between the layers to become sticky. When this happens, the two layers may rub together every time you breathe in instead of gliding past each other.

Injury
- Pleural Disorders

A chest injury, even an injury that does not break the skin but causes internal damage, can allow air, fluid, or blood to leak into the pleural space. This can cause a pneumothorax or pleural effusion.

Air or blood can also leak into the pleural space as a result of a medical procedure, such as a chest biopsy, mechanical ventilation, or thoracentesis.

Imbalance of fluid
- Pleural Disorders

Pleural effusions develop when fluid enters the pleural space faster or at a higher amount than the body can reabsorb. This imbalance of fluids can be caused by heart, kidney, or liver failure, or other medical conditions.

Look for
- Pleural Disorders

  • Treatment will discuss medicines or procedures that your doctor may recommend if you are diagnosed with a pleural disorder.

Risk Factors - Pleural Disorders

You may have an increased risk for a pleural disorder because of your age, your family history and genetics, your lifestyle habits, medicines you take, other medical conditions, and your sex.

Age
- Pleural Disorders

Pleural disorders can happen at any age, but pneumothorax is most common in people 15 to 34 years old and people over age 55.

Family history and genetics
- Pleural Disorders

Having a family history of spontaneous pneumothorax increases your risk.

Lifestyle habits
- Pleural Disorders

Smoking tobacco or marijuana increases your risk of spontaneous pneumothorax.

Medicines
- Pleural Disorders

Taking certain medicines can increase your risk of some pleural disorders.

  • Anticoagulants, or blood thinners, such as heparin or warfarin, may increase the risk of hemothorax.
  • Cancer medicines, such as dasatinib and interleukin-2, may increase the risk of pleural effusion.
  • Medicines that can cause drug-induced lupus may increase the risk for pleural effusion. These medicines include hydralazine, used to treat high blood pressure, and procainamide, used to treat arrhythmia.
  • Nitrofurantoin, an antibiotic used to treat urinary tract infections, may increase the risk of pleural effusion.

Other medical conditions
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Pleural disorders are often complications of other diseases, either in the lungs or elsewhere in the body.

Sex
- Pleural Disorders

Men, especially those who are taller than average, are more likely than women to have a spontaneous pneumothorax, often without underlying lung disease.

Screening and Prevention - Pleural Disorders

There are no methods to screen for pleural disorders. If you have risk factors for pleural disorders, your doctor may recommend preventive strategies.

Prevention strategies
- Pleural Disorders

Learn about the preventive strategies your doctor may recommend.

  • Treating conditions that increase the risk of pleural disorders
  • Quitting smoking. Visit Smoking and Your Heart and the National Heart, Lung, and Blood Institute’s Your Guide to a Healthy Heart. For free help quitting smoking, you may call the National Cancer Institute’s Smoking Quitline at 1-877-44U-QUIT (1-877-448-7848).
  • Quitting or avoiding illegal drugs, such as marijuana

Look for
- Pleural Disorders

  • Diagnosis will explain tests and procedures that your doctor may use to diagnose pleural disorders.
  • Life After will discuss what your doctor may recommend to prevent your pleural disorder from recurring, getting worse, or causing complications.
  • Research for Your Health will explain how we are using current research and advancing research to prevent pleural disorders.
  • Participate in NHLBI Clinical Trials will discuss our open and enrolling clinical studies that are investigating prevention strategies for pleural disorders.

Signs, Symptoms, and Complications - Pleural Disorders

Pleural disorders may occur with no symptoms, or they may have obvious symptoms. Signs, symptoms, and complications vary depending on the pleural disorder and how severe it is.

Signs and symptoms
- Pleural Disorders

The signs and symptoms for pleural disorders may include:

  • Chest pain that is sharp or stabbing and gets worse when you breathe in deeply or cough or sneeze
  • Cough
  • Shortness of breath
  • Low weight or slow rate of weight gain in children. Usually the weight is well below the child’s ideal weight or the average weight of other children of the same age
  • Fever
  • Fatigue
  • Bluish skin caused by not getting enough oxygen
  • Anxiety
  • Rapid heart rate

Complications
- Pleural Disorders

Complications for pleural disorders can be life threatening. Some of the possible complications include:

  • Atelectasis, which can be a complication of pneumothorax.
  • Empyema, which is pus in the pleural space.
  • Sepsis
  • Shock, which is a life-threatening complication of hemothorax or tension pneumothorax. This can happen when blood pressure drops dangerously low.
  • Unexpandable (trapped or entrapped) lung, which can be a complication of pleural effusion that is caused by cancer, hemothorax, or pleurisy.

Look for
- Pleural Disorders

  • Diagnosis will discuss tests and procedures used to detect signs of pleural disorders and help rule out other conditions that may mimic a disorder.
  • Treatment will explain treatment-related complications or side effects.

Diagnosis - Pleural Disorders

Your doctor may diagnose a pleural disorder based on your medical history, a physical exam, and diagnostic tests and procedures. Before diagnosing you with a pleural disorder, your doctor will rule out other medical reasons or conditions that may be causing your signs and symptoms.

Medical history
- Pleural Disorders

Your doctor will want to learn about your signs and symptoms, risk factors, personal health history, and family health history to determine whether you have a pleural disorder and, if so, what kind.

To help diagnose a pleural disorder, your doctor may ask you to describe any chest pain, including details such as the following:

  • What it feels like
  • Where it is located and whether you can feel it in your arms, jaw, or shoulders
  • When it started and whether it goes away and then comes back
  • What makes it better or worse

This information about the chest pain you have experienced can help your doctor determine whether it is caused by problems with your heart, chest muscles, lungs, or digestive system.

Physical exam
- Pleural Disorders

As part of a physical examination, your doctor will measure your blood pressure and heart rate, feel your chest and belly, take your temperature, listen to your heart and lungs, and feel your pulse. Your doctor may also check the level of oxygen in your blood with a probe on your finger or forehead.

Your doctor will listen to your breathing to find out whether your lungs are making any abnormal sounds.

  • If you have pleurisy, the inflamed layers of the pleura may make a rough, scratchy sound as they rub against each other when you breathe. Doctors call this a pleural friction rub.
  • If you have a pleural effusion, fluid buildup in the pleural space may prevent 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.
  • If you have a pneumothorax, your doctor may hear more echo than usual when he or she taps on your chest.

Diagnostic tests and procedures
- Pleural Disorders

Your doctor may order a combination of the following tests to help diagnose a pleural disorder.

  • Biopsy to retrieve a sample of the pleura. The sample is checked for signs of disease.
  • Blood tests to show whether you have an illness that increases your risk of pleurisy or another pleural disorder
  • Chest CT scan to find pockets of fluid or air and signs of pneumonia, a lung abscess, tumors, blood clots, or other possible causes of pleural disorders
  • Chest MRI to look for possible causes of pleural disorders or confirm results of other imaging tests, such as a chest CT scan
  • Chest X-ray to look for air or fluid in the pleural space, problems with the lung or pleura, or an underlying cause of a pleural disorder, such as pneumonia, a fractured rib, or a lung tumor
  • Endoscopy to look for signs of disease, guide the doctor while performing a biopsy, or remove pleural fluid
  • Thoracentesis to remove a sample of pleural fluid for testing. The fluid removed during thoracentesis is tested and examined under a microscope for signs of infection, cancer, or other conditions that can cause fluid or blood to build up in the pleural space.
  • Ultrasound to look for fluid, air, or other abnormal findings in your chest

Tests for other medical conditions
- Pleural Disorders

Your doctor may order the following tests to help rule out other medical conditions that can cause chest pain.

  • Blood tests to rule out other medical conditions affecting the heart, liver, kidneys, or other chronic inflammatory diseases that can cause pleural disorders
  • Chest X-ray to look for signs of pneumonia or other serious problems
  • CT angiography to take pictures of your blood vessels and look for blood clots in the lungs. This can help rule out pulmonary embolism, a type of venous thromboembolism.
  • Electrocardiogram to measure your heartbeat and rule out a heart problem such as heart attack or pericarditis, a type of heart inflammation
  • Echocardiography to look for an aortic aneurysm or signs of damage to your heart

Reminders
- Pleural Disorders

  • Return to Risk Factors to review family history, lifestyle, or other medical conditions that increase your risk of developing pleural disorders.
  • Return to Signs, Symptoms, and Complications to review common signs and symptoms of pleural disorders.

Treatment - Pleural Disorders

How your pleural disorder is treated depends on what type of pleural disorder you have and how severe it is. Some pleural disorders go away without treatment. Others will require a procedure to remove air, fluid, or other material from the pleural space. The goal of treatment is to relieve symptoms and treat the underlying condition.

Medicines
- Pleural Disorders

Your doctor may recommend medicine to treat symptoms or causes of your pleural disorder, including:

  • Antibiotics, antifungals, or antiparasitic medicines to treat an infection in the pleural space or in the lung
  • Corticosteroids to reduce inflammation. Corticosteroids can have serious side effects with long-term use.
  • Morphine in low doses to treat chronic shortness of breath. This medicine has a risk of addiction.
  • Nonsteroidal anti-inflammatory drugs such as ibuprofen to reduce pain and inflammation

Procedures and other treatments
- Pleural Disorders

Your doctor may perform one or more procedures to treat a pleural disorder. Many of these procedures are performed using ultrasound.

  • Chest tube to drain fluid, blood, or air from the pleural space. This process can take several days. You may stay in the hospital while the tube is in place.
  • Heimlich valve to prevent fluid and air from getting into your chest when you breathe in. Your doctor may attach this one-way valve to a chest tube or indwelling pleural catheter (IPC), which allows you to move around more and may allow you to go home to wait for your lung to re-expand.
  • IPC, or indwelling pleural catheter, to drain pleural fluid. An IPC is a semi-permanent thin tube that is left in place so patients or caregivers can drain the fluid, usually a few times a week.
  • Injection of medicines into the pleural space to break up material that cannot be removed with a needle or drained through a chest tube
  • One-way endobronchial valve implanted in one of your bronchial tubes to allow air to exit the pleural space but not reenter
  • Oxygen therapy for pneumothorax
  • Pleurodesis to close up the pleural space by helping the two sides of the pleura stick together. For this procedure, your doctor will drain all of the fluid out of your chest through a chest tube. Then he or she will push a substance through the chest tube into the pleural space. The substance will irritate the surface of the pleura and cause the two layers of the pleura to stick together, preventing more fluid from building up.
  • Surgery to remove fluid, pus, or blood clots that cannot be removed with a chest tube; to remove part of the pleura; to remove one or more ribs; or to close up the pleural space with a pleurodesis procedure
  • Thoracentesis to remove air, blood, or other fluid from the pleural space with a needle. Possible complications include pneumothorax, pain, hemothorax and other bleeding, infection, and pulmonary edema. Complications are less likely if ultrasound is used to guide the procedure.

Look for
- Pleural Disorders

  • Research for Your Health will discuss how we are using current research and advancing research to treat people with pleural disorders.
  • Life After will discuss what your doctor may recommend, including lifelong lifestyle changes and medical care, to prevent your condition from recurring, getting worse, or causing complications.

Life After - Pleural Disorders

As you recover from your treatment for a pleural disorder, it is important to follow your treatment plan. You may need to follow up with your doctor regularly to monitor your condition. You will also want to take steps to prevent complications or a repeat pleural disorder.

Receive routine follow-up care
- Pleural Disorders

If your pleural disorder is caused by a disease such as COPD, be sure to follow the treatment plan for that condition.

  • Talk to your doctor about how often you need to schedule follow-up visits. To monitor your condition, your doctor may recommend a chest X-ray six weeks after treatment.
  • See your doctor a few weeks after a pneumothorax to make sure it has cleared up.
  • If you have a Heimlich valve, ask your doctor how often it needs to be inspected by a healthcare provider.

If you have an IPC to drain pleural fluid, it may stay in for a few months or longer. Infection is possible around the insertion site, but infections can usually be treated without removing the IPC.

Return to Treatment to review possible treatment options for your pleural disorder.

Prevent a repeat spontaneous pneumothorax event
- Pleural Disorders

After a spontaneous pneumothorax, you are at risk of having another spontaneous pneumothorax. People who have underlying lung disease are more likely to have another spontaneous pneumothorax.

Quitting smoking if you smoke and not starting if you do not smoke can help reduce your risk.

Learn the warning signs of serious complications and have a plan
- Pleural Disorders

If you have severe chest pain or trouble breathing, call 9-1-1. A tension pneumothorax is a life-threatening medical emergency.

Visit our Cardiogenic Shock health topic to learn the symptoms of shock.

Learn about other precautions to help you stay safe
- Pleural Disorders

If you have or have recently had a pneumothorax, your doctor may recommend the following precautions to help you stay safe.

  • Avoid strenuous exercise and contact sports until your doctor says it is safe.
  • Do not fly. Ask your doctor when it is safe again to fly.
  • Do not go scuba diving unless your doctor says you have zero risk of recurrence. If a pneumothorax recurs during diving, it can cause a tension pneumothorax, which is a life-threatening complication.
  • Tell your doctor if you are pregnant. Talk to your doctor about how to manage your delivery so that the pneumothorax does not get worse. Also talk about whether you should have surgery later to prevent another pneumothorax in a future pregnancy.

Research for Your Health

The NHLBI is part of the U.S. Department of Health and Human Services’ National Institutes of Health (NIH)—the Nation’s biomedical research agency that makes important scientific discovery to improve health and save lives. We are committed to advancing science and translating discoveries into clinical practice to promote the prevention and treatment of heart, lung, blood, and sleep disorders, including pleural disorders. Learn about current and future NHLBI efforts to improve health through research and scientific discovery.

Improving health with current research
- Pleural Disorders

Learn about the following ways the NHLBI continues to translate current research into improved health for people with pleural disorders. Research on this topic is part of the NHLBI’s broader commitment to advancing lung disease scientific discovery.

  • COPD National Action Plan. The NHLBI developed the first-ever blueprint for a multifaceted, unified fight against COPD, which can lead to pleural effusion and pneumothorax. Developed at the request of Congress with input from the broad COPD community, the plan provides a comprehensive framework for action by those affected by the disease and those who care about reducing its burden. Visit COPD National Action Plan for more information.
  • Building on Past NIH-Sponsored Research on Sirolimus (Rapamycin) as a Treatment for LAM. Pleural effusion and pneumothorax are complications of LAM. In 2011, the NIH-funded Multicenter International LAM Efficacy of Sirolimus (MILES) trial published key findings. NHLBI researchers supported the MILES trial, which showed sirolimus to be a safe and effective treatment for LAM. Read about how the NHLBI continues to perform and fund research on sirolimus as a treatment of LAM. Read Sirolimus Therapy Alleviates Symptoms of Lung Disease LAM or Lessons from the MILES Trial to learn about the NIH-supported scientific discovery that led to the current FDA-approved use of sirolimus to treat LAM.
  • Trans-NIH Funding of the Rare Lung Diseases Consortium (RLDC). The NHLBI co-funds some RLDC activities with NIH’s National Center for Advancing Translational Sciences. Through funding the RLDC, the NHLBI is supporting new clinical trials for LAM and its complications.
  • Providing Resources for Research. The Lung Tissue Research Consortium (LTRC) provides human lung tissues to qualified investigators for use in their research. The program enrolls patients who are planning to have lung surgery, collects blood and other clinical data from these donors, and stores donated tissue that otherwise would be discarded after the lung surgery. The LTRC provides tissue samples and data at no cost to approved investigators.

Learn about some of the pioneering research contributions we have made over the years that have improved clinical care.

Advancing research for improved health
- Pleural Disorders

In support of our mission, we are committed to advancing pleural disorders research in part through the following ways.

Learn about exciting research areas the NHLBI is exploring about pleural disorders.

Participate in NHLBI Clinical Trials

We lead or sponsor studies relevant to pleural disorders. See if you or someone you know is eligible to participate in our clinical trials related to LAM, which can lead to pleural disorders.

Trials at the NIH Clinical Center

Monitoring sirolimus dosages to treat LAM

This study aims to identify the right dose of sirolimus to treat people who have LAM. To participate in this study, you must be female, between 18 and 90 years old, and diagnosed with LAM. This study is located in Bethesda, Maryland.

Albuterol in patients who have LAM

This study is examining which delivery method of albuterol—inhaled or nebulizer—is better at improving lung function in adult women who have LAM. To participate in this study, you must be female, between 18 and 80 years old, and diagnosed with LAM. This study is located in Bethesda, Maryland.

Genetic causes of lung damage in patients who have LAM

This study is trying to understand the genes and proteins that are responsible for causing lung damage in patients with LAM. To participate in this study, you must be between 16 and 99 years old and diagnosed with LAM. This study is located in Bethesda, Maryland.

To learn more about clinical trials at the NIH Clinical Center or to talk to someone about a study that might fit your needs, call the Office of Patient Recruitment 800-411-1222.

Are you an adult woman who would like to help develop methods to prevent the worsening of LAM?

This study aims to discover whether earlier and longer treatment with a lower dose of sirolimus can help prevent LAM from getting worse over time. To participate in this study, you must be female, be at least 18 years old, and have been diagnosed with LAM. This study is located in Atlanta, Georgia; Boston, Massachusetts; Chicago, Illinois; Cincinnati, Ohio; Denver, Colorado; Nashville, Tennessee; Palo Alto, California; Philadelphia, Pennsylvania; and Seattle, Washington.

Are you an adult woman willing to help improve treatments for LAM?

This study is examining whether using a combination of resveratrol and sirolimus is more effective than using sirolimus alone to treat LAM. To participate in this study, you must be female, be at least 18 years old, and have been diagnosed with LAM. This study is located in Cincinnati, Ohio.

Are you an adult woman diagnosed with LAM who wants to support future studies of a new treatment?

This study aims to test a new medicine called saracatinib to treat LAM and other cancers. To participate in this study, you must be female, be between 18 and 65 years old, and have been diagnosed with LAM. This study is located in Bethesda, Maryland; Chicago, Illinois; Cincinnati, Ohio; Houston, Texas; and Stanford, California.

More Information

After reading our Pleural Disorders Health Topic, you may be interested in additional information found in the following resources.

Non-NHLBI resources
- Pleural Disorders

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