Pleural Effusion and Lung Fibrosis

On 11 Mar, 2023, Seniors Today hosted their weekly Health Live Webinar Dr Radhika Banka, a Senior Pulmonologist who spoke on and answered questions about Pleural Effusion and Lung Fibrosis.

About Dr Radhika Banka:

Dr Radhika Banka is Consultant Pulmonology at the Hinduja Hospital, Mumbai. She specialises in the management of respiratory illnesses including asthma, COPD, Interstitial Lung Diseases, pneumonia, lung cancer and tuberculosis.

After her MBBS and DNB in Respiratory Medicine, she did an MRCP in the UK. During her stint in the UK, she gained immense experience in multidisciplinary management of common respiratory illnesses including asthma, COPD, Interstitial Lung Diseases, Pneumonia, Lung cancer and tuberculosis. She has sub specialised in the field of respiratory intervention and pleural diseases. She has gained skills in thoracic ultrasound and has been certified with Level 2 Royal College of Radiology Thoracic Ultrasound Competence. She has gained skills in usage of direct ultrasound for pleural procedures and also has achieved competence in Endobronchial Ultrasound and other bronchoscopic interventions. She has gained expertise for ambulatory management of pleural effusions with indwelling pleural catheters, an area which is still in its nascent phase in India. She has been invited as faculty for pleural courses at the British Thoracic Society and European Respiratory Society conferences. She also worked at the frontline during the UK Covid pandemic in Oxford and was involved in recruiting patients to various Covid trials and gained immense experience in Covid management in a high dependency setting. Dr Banka has around 16 international publications and 4 national publications to her credit.

Achievements & Awards:

• Travel Bursary to attend UK Mesothelioma Research Day, London, UK, 2019
• 1st prize at Annual Research Day at P. D. Hinduja National Hospital, 2016
• 2nd prize at NAPCON Conference in National Level Postgraduate Quiz, 2016
• Silver Sponsorship for the ERS Congress, European Respiratory Society, Netherlands, 2015

Affiliations/Associations:

• European Respiratory Society (ERS)
• Royal College of Physicians (RCP)
• British Thoracic Society (BTS)
• UK Pleural Society
• Indian Medical Association (IMA)

The air quality in the city of Mumbai has deteriorated, since Oct 2022, as compared to 2020 and 2021 where the AQI was between 90-100 and has now shot up to 250. Most of this can be attributed to

• The construction in the city- metro, residential and commercial
• Stagnation of air due to the change in the air winds

This has led to a lot of respiratory illnesses- when the air is polluted, there are a lot of foreign and unwanted particles in the air which are foreign to our breathing tubes. So, when we inhale the polluted air, the lungs get inflamed as a response to it and can lead to a chronic cough.

We need to come up with a solution to the polluted air and the drop in the air quality- such as reducing the number of construction hours, improving the quality of the material used, wearing protective gear such as masks- because if not, it can have a massive impact on the health of the adult as well as growing children.

Some precautionary measures that you can take at your end:

• Wearing a mask as a protective gear when stepping out. It can be inconvenient and troublesome but it can also help in filtering some of the pollutants from entering your airway.
• Living a healthy lifestyle where you eat healthy, sleep adequately, avoid smoking and consume alcohol in moderation
• Avoid stepping out during particular times of the day when the AQI is high.

There is data which shows that N-95s are the best masks to wear. Followed by surgical masks. And followed by this is the face covering. Face coverings tend to provide the least amount of protection; but it is still better than nothing.

The order of preference will be N-95 masks > Surgical masks > Face coverings

Pleural effusion is the collection/ accumulation of fluid between the pleural cavities. So, it is not fluid IN the lung, rather a collection of fluid between the lining of the lung. This fluid can compress the lungs and cause symptoms.

Pleural effusions are common- its incidence is 3000 cases / million / year

The pleural cavity is a redundant space and it can hold large volumes/ litres (approx 5-6 L) of fluid. Thereby compressing the lungs.

Common symptoms of pleural effusion include:

• Asymptomatic- rare. Incidentally found on an X ray
• Chest pain- most common symptom. Causes atypical pleuritic chest pain. Sharp- worse on deep inhalation and coughing.
• Shortness of breath
• Cough- dry
• Lethargy
• Fever

Causes of Pleural effusion:

• Unilateral

1. Tuberculosis- most common cause
2. Pneumonia
3. Cancer- lung or metastatic (from other parts of the body)
4. Other causes- drugs, autoimmune conditions

• Bilateral

1. Heart failure
2. Kidney failure
3. Liver failure

Investigation done:

• Chest X-ray
• CT scan
• Ultrasound of the chest- the most sensitive investigation for diagnosis of pleural effusion
• Pleural fluid aspiration- not indicated in all patients.

• All unilateral effusions are aspirated- as a rule
• Helps to identify the cause of the effusion and is also therapeutic- thus helps in relieving the symptoms.

• Thoracoscopy- in certain cases, the pleural fluid alone may not be sufficient to reach a definitive diagnosis.
• Done under general anaesthesia/ sedation.

There are chances of recurrence of pleural effusion. This can be and indication of a malignancy, or heart/ liver/ kidney failure.

Treatment options in case of a recurrent pleural effusion- chest tube insertion for drainage.

Pleurodesis- you try to stick the two pleural linings of the lung together. Can be done using certain chemicals such as sterile talcum powder.

• Indwelling pleural catheter- this can stay in for a few week to months

Take home message:

• Do not ignore the symptoms of chest pain and breathlessness.
• Plural infection in the elderly needs early treatment to prevent complications. To remove the infected fluid from the space to reduce the chances of complications and mortality.
• If diagnosed with pleural effusion, you may be needed to undergo further investigations including removal of the pleural fluid
• Essential to know underlying cause of pleural effusion

Lung fibrosis is also synonymous with pulmonary fibrosis.

It is a common respiratory disorder

It tends to affect elderly

In lung fibrosis our healthy lung tissue is replaced with scarred tissue.

Lung fibrosis is a layman term for fibrosis, the more scientific or generic term for this is Interstitial

Lung Disease.

The lining around the alveoli get extremely thick and the alveolar space decreases in size. And it is at this site where the diffusion and exchange of gases takes place- but because the alveoli have become thick the diffusion becomes difficult. This is when the symptoms appear.

Causes of lung fibrosis:

1. Unknown entity – 65% cases are idiopathic
2. Environmental exposure- pigeon droppings, farming- some individuals are sensitive to these droppings which when inhaled can cause lung fibrosis.
3. Drugs- Nitrofurantoin (antibiotic), Cordarone, Methotrexate
4. Autoimmune conditions- Rheumatoid Arthritis- they primarily affect the joints but can also involve and affect the lungs
5. Family history

Symptoms:

Lung fibrosis is a chronic disease and thus the symptoms do not appear overnight

If not intervened, symptoms can gradually progress over months to years

• Dry cough
• Shortness of breath, particularly on exertion
• Weight loss
• Fever
• Rash, joint pain

Investigation done:

• Chest X-ray
• CT scan- investigation of choice. It is done for diagnosing the disease and for monitoring the disease.
• Pulmonary function tests/ spirometry- for both assessment and monitoring the fibrosis.
• 6 minute walk test
• Blood tests

Treatment of lung fibrosis:

• Wait and watch policy is applied to stable patients with minimal symptoms. Not all fibrosis progress

• Steroids under the supervision your physician
• Antifibrotics to prevent further progression of fibrosis

• Oxygen therapy for patients with low oxygen saturation in the form of oxygen concentrator, portable oxygen machine, etc.
• Pulmonary Rehabilitation
• Lung Transplant

Take home message:

• Lung fibrosis is a chronic illness and you need to be under the care of a respiratory specialist
• You will need regular monitoring with lung function tests, CT scans.
• You need to monitor side effects of the medications you are on, if any.
• There may be progression of disease and symptoms – and will need a multidisciplinary approach.