16. Spontaneous pneumothorax. Empyema pleurae. Metastatic pleural tumors. Flashcards
Spontaneous pneumothorax - Definition
A spontaneous pneumothorax is the sudden onset of a collapsed lung without any apparent cause
Spontaneous pneumothorax - Types
Primary: due to superficial blebs at the apex of one or more lobes (typically the upper lobes) which either leak spontaneously or are triggered by an otherwise unremarkable event = exertion
o More common in young, slim men + 30% chance of recurrence
- Secondary: visceral pleura leaks as part of an underlying lung disease e.g. obstructive airway disease, TB, necrotising tumours
Spontaneous pneumothorax - Clinical Presentation
sharp pleuritic pain (absent in complete collapse)
dyspnea
cardiac apex deviation
tracheal deviation
no breath sounds
sudden deterioration of ventilated pt
Spontaneous pneumothorax - Diagnostic Investgations
CXR – homogenous air shadow (blackening).
May be concomitant hemothorax –when the lung deflates there may be bleeding from adhesions b/w visceral + parietal pleura which tear
Spontaneous pneumothorax - Treatment
may resolve spontaneously
- Needle thoracentesis = large bore iv cannula through 2nd interspace in mid-clavicular line + then insert into chest drain
o Removed while pt performs valsalva’s manoeuvre or during expiration with brisk firm movement
Empyema plurae
Definition
Collection of purulent fluid in pleural space – more purulent in childhood + old age.
Males 2x likely, diabetes, alcoholics
Empyema plurae - Etiology
Community acquired infx that is Gram –ve.
Hospital acquired infx taht is gram –ve.
Post op trauma.
Primary empyema
Empyema plurae - Pathological stages
- Exudative stage: mediated by pro-inflam cytokines + charac by development of sterile exudate
- Fibropurulent stage: sterile effusion is colonised by bact = extensive deposition of fibrin in pleural space producing fluid loculations
o Pleural fluid becomes more purulent as bact invasion progresses + cellular debris accumulates - Organising stage: 3 wks after onset dense fibrous ring forms over visceral + parietal pleural surfaces. This prevents lung from re-expanding = pulmonary collapse
Empyema plurae - Clinical presentation
same as pneumonia (fever, cough, sputum, chest pain, dyspnoea) that fail to resolve
Empyema plurae - - Diagnostic Investigations
Blood – leucocytosis, high CRP;
CXR – parapneumonic effusion (obliteration of Costophrenic angle with fluid level)
Needle aspiration of pleural fluid for gram staining + culture / sensitivity test
Diagnostic hallmark = evaluation of pH + concentration of LDH + glucose in the effusion
- Lights criteria for dx on exudate: p.effusion likely to be exudate if pleural fluid protein to serum protein is >0.5 or PF LDH to serum LDH >0.6
Empyema plurae - - Treatment
Abx. Surgical – chest drainage (tube thoracostomy)
- Open surgery = debridement – controls sepsis by draining infected spaces
o Decortication – obliterate empyema by removing parietal + visceral pleural surfaces
- VATS: video assisted thoracoscopic surgery
Metastatic pleural tumours
Malignant mesothelioma
- Tumour of mesothelial cells that usually occur in the pleura + rarely in the peritoneum or other organs. Assoc with exposure to asbestos (after 30-50 yrs)
Metastatic pleural tumours - Clinical Presentation
10
Clinical cause: poor <2yrs >650 deaths/yr UK
chest pain
dyspnoea
weight loss
finger clubbing
recurrent p.effusions
nausea + vomiting
shortness of breath
wheezing
lung infections
swollen lymph nodes
fatigue
Metastatic pleural tumours
Diagnosis
CXR/CT – pleural thickening / effusion.
Bloody pleural fluid.
Dx made on histology. Often made post mortem
Metastatic pleural tumours
Treatment
Pemetrexed + cisplatin chemotherapy.
Radiotherapy is controversial.
Intra pleural drain
Extra pleura pneumonectomy = removal of entire lung, pericardium, pleura + diaphragm
