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Systems: Resp. WK > 22. Pleural Disease > Flashcards

22. Pleural Disease Flashcards

1
Q

What is the lung pleura?

A
  • single layer of mesothelial cells
  • 2 layers; visceral and parietal pleura
  • potential space between visceral and parietal pleura *(pleural cavity)
  • attached by sub-pleural connective tissue
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2
Q

What is the pressure in the pleural cavity ( between the visceral and parietal pleura)?

A
  • NEGATIVE

- Pressure= - 66kPa due to recoiling of the lung

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3
Q

What fluid is found in the pleural cavity?

A

Pleural fluid (lubricant); 2-3ml

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4
Q

What percentage of pleural fluid undergoes dynamic turnover every hour?

A

30-75%/ hour

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5
Q

What pressure absorbs the fluid in the pleural cavity?

A

Osmotic pressure (due to potential space)

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6
Q

Does the pleura extend over the first rib?

A

Yes

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7
Q

What 3 organs can be punctured easily during a pleural procedure?

A
  • kidneys
  • spleen
  • liver
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8
Q

Define pleural effusion.

A

Abnormal collection of fluid in the pleural space.

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9
Q

What do symptoms of pleural effusion depend on? (2)

A
  • cause of pleural effusion

- volume of fluid

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10
Q

When is pleural effusion asymptomatic?

A

If it’s small and fluid accumulates slowly

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11
Q

What are main symptoms of a pleural effusion?

A
  1. Increasing dyspnea (days, weeks, months…)
  2. Pleuritic chest pain (if early then may improve fluid accumulation, if malignant then it’s progressively worse)
  3. Dull ache; similar to having lungs squashed
  4. Dry cough; especially if rapid accumulation
  5. Weight loss
  6. Malaise and fever
  7. Night sweats
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12
Q

What needs to be enquired/ asked about from the patient in a pleural effusion? (4)

A
  1. peripheral oedema
  2. liver disease
  3. ortopnoea
  4. PND; paroxysmal nocturna; dyspnea
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13
Q

What are some causes of a pleural effusion? (8) TIM PICCK

A
  1. congestive heart failure
  2. inflammation
  3. trauma
  4. malignancy
  5. pulmonary embolism
  6. cirrhosis; damage to liver
  7. kidney failure
  8. infection
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14
Q

What clinical signs indicate a pleural effusion? (6)

A
  1. Chest on affected side has:
    - decreased expansion
    - stony dullness to percussion
    - decreased breath sounds (band of bronchial breathing)
    - decreased vocal resonance
  2. clubbing and tar staining
  3. cervical lymphadenopathy
  4. increased JVP; jugular venous pressure
  5. trachea away from large effusion
  6. peripheral oedema
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15
Q

What two groups is pleural effusion categorised into? (what type of fluids involved)

A
  1. transudates

2. exudates

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16
Q

What are transudates?

A
  • an imbalance of hydrostatic forces influencing the formation and absorption of pleural fluid
  • increase in hydrostatic and decrease in oncotic pressure)
  • normal capillary permeability
  • Usually (not always) BIlatera
  • appear clearer as have less protein component
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17
Q

What are exudates?

A
  • increased permeability of pleural surface and/or local capillaries
  • usually UNIlateral
  • fluid that leaks out of cells around capillaries caused by inflammation
  • destruction
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18
Q

How much of pleural fluid protein do transudates and exudates have?

A

Transudates< 30g/l for exam but in reality <25g/l (less protein)
Exudates >30g/l for exam but in reality >35g/l (more protein)

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19
Q

What is the “exam cut off” of protein in pleural effusion?

A

30g/l

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20
Q

What are very common causes for transudates pleural effusion? (4)

A
  1. left ventricular failure
  2. liver cirrhosis
  3. hypoalbuminaemia
  4. peritoneal dialysis
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21
Q

What are the less common causes for transudates pleural effusion? (4)

A
  1. hypothyroidism
  2. nephrotic syndrome
  3. mitral stenosis (narrowing)
  4. pulmonary embolism (2/3rds exudates)
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22
Q

What are the rare causes for transudates pleural effusion? (3)

A
  1. Constrictive pericarditis (previous TB, connective tissue diseases)
  2. Ovarian hyperstimulation syndrome
  3. Meig’s Syndrome (benign ovarian fibroma, ascites, R sided effusion)
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23
Q

What are the common causes of exudate pleural effusion? (2)

A
  1. malignancy (lung, breast, mesothelioma, metastatic)

2. parapneumonic (consider sub-phrenic)

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24
Q

What are the less common causes for exudate pleural effusion ( 6)

A
  1. pulmonary embolism/ infarction
  2. rheumatoid arthritis
  3. autoimmune diseases (SLE, polyarteritis)
  4. benign asbestos effusion
  5. pancreatitis
  6. post-myocardial infarction/ cardiotomy syndrome
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25
Q

What are the rare causes for exudate pleural effusion (2)

A
  1. yellow nail syndrome

2. drugs

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26
Q

What are rare causes for exudate pleural effusion? (8)

A
  • amiodarone
  • nitrofurantoin
  • phenytoin
  • methotrexate
  • carbamazapine
  • penicillamine
  • bromocriptine
  • pergolide
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27
Q

Is investigation needed in exudates and transudates ?

A

Usually ISN’T required in transudates (since clinical picture is usually characteristic), more needed for exudates

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28
Q

When should pleural effusion (either transudate or exudate) be investigated?

A
  • if unusual features (e.g. dull percussion)

- failure to respond to appropriate treatment

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29
Q

Heart failure patients will most likely have which form of pleural effusion?

A

Transudates

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30
Q

What scan method is used to detect and confirm the presence of effusion?

A

chest radiograph

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31
Q

How much of the fluid is required for the pleural effusion to be detected on a chest x ray?

A

at least 200ml

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32
Q

Except from a chest radiograph, what other diagnostic method can be used to detect a pleural effusion?

A

Contrast enhanced CT of thorax

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33
Q

What does a contrast enhanced CT of thorax allow doctors to do?

A

Allows doctors to differentiate between malignant and benign disease (which can cause pleural effusions)

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34
Q

What changes in the thorax can a contrast CT indicate when looking at a pleural effusion?

A
  1. nodular pleural thickening
  2. mediastinal pleural thickening
  3. parietal pleural thickening >1cm
  4. circumferential pleural thickening
  5. other malignant manifestations in lung/liver
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35
Q

During pleural aspiration, when a needle is inserted into the pleural cavity to remove excess fluid, what syringe, needle and anaesthesia is used?

A
  • 50ml syringe
  • 21G needle (green(
  • lignocaine/lidocaine (same thing) anaesthesia

plus sterile universal containers and blood culture bottles

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36
Q

What complications can arise from a pleural aspiration procedure? (7)

A
  1. pneumothorax
  2. empyema
  3. pulmonary oedema (if too much fluid taken out)
  4. vagal reflex
  5. air embolism (if too much air squirted in)
  6. tumour cell seeding
  7. haemothorax
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37
Q

What is used to determine the upper level of fluid before a pleural aspiration is done?

A

percussion; ideal place is 10cm lateral to the spin (mid-scapular line) and 1-2 intercostal spaces below the upper level of the fluid

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38
Q

When is haemothorax more likely to occur during a pleural aspiration? (2)

A
  1. if blood vessels are hit

2. if person is on anticoagulation drugs

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39
Q

What is done to the fluid from a pleural aspiration sample once it’s extracted?

A

Look at the fluid and sniff to determine possible cause for the pleural effusion

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40
Q

If fluid from a pleural aspiration is foul smelling, what could this indicate?

A

anaerobic empyema is the cause of pleural effusion

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41
Q

If fluid from a pleural aspiration has pus, what could this indicate?

A

empyema is the cause of pleural effusion

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42
Q

If fluid from a pleural aspiration has food particles, what could this indicate?

A

oesophageal rupture is the cause of pleural effusion

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43
Q

If the fluid from a pleural aspiration is milky, what could this indicate?

A

chylothorax (usually lymphoma) is the cause of pleural effusion

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44
Q

If the fluid from a pleural aspiration is blood stained, what could this indicate?

A

possible malignancy is the cause of pleural effusion

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45
Q

If the fluid from the pleural aspiration has blood, what could this indicate?

A

haemothorax or trauma is the cause of pleural effusion

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46
Q

When is a chest drain needed after a pleural aspiration?

A

If the fluid is infected and pH<7.2 (blood gas analyser needed for biopsies)

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47
Q

What 3 laboratory branches are needed for a pleural effusion investigation?

A
  1. biochemistry
  2. microbiology
  3. cytology
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48
Q

What 3 things does biochemistry department test for in a patient suspected of pleural effusion?

A
  1. protein (LDH; lactate dehydrogenase)
  2. amylase
  3. glucose
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49
Q

What is suspected if amylase levels are increased in a pleural effusion investigation?

A

possible pancreatitis

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50
Q

What is suspected if glucose levels are <3.3mM in a pleural effusion investigation? (5)

A
  • empyema
  • rheumatoid arthritis
  • SLE (lupus)
  • TB
    -malignancy
    (low glucose linked to metabolic activity)
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51
Q

What tests are done in microbiology department in a pleural effusion investigation? (4)

A
  1. MC&S: microscopy, culture and sensitivities
  2. Gram stain
  3. AAFB: alcohol and acid fast bacilli
  4. culture
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52
Q

What cells are specifically looked at in cytology during a pleural effusion investigation? (3)

A
  1. eosinophils (Churg-Strauss, asbestos, but malignancy as well 25%)
  2. malignant cells
  3. lymphocytes (TB, lymphoma)
53
Q

During interpretation of pleural protein, when do we know if it’s a transudate?

A

transudate if pleural protein< 25g/l ( <30g/l in exams)

54
Q

During interpretation of pleural protein, when do we know if it’s an exudate?

A

exudate if pleural protein >35g/l ( >30g/l in exams)

55
Q

What is the range for Light’s criteria that involves the analysis of pleural proteins?

A

rangeis 25-35g/l

56
Q

In labs, exudate is identified if it matches at least ONE of the criteria. What are these criteria involving: pleural/serum protein, pleural/serum LDH and pleural LDH that means the sample is an exudate.

A
  1. pleural/serum protein >0.5
  2. pleural/serum LDH>0.6
  3. pleural LDH>0.66 of upper limit of serum LDH
57
Q

What needle is used for a BLIND pleural biopsy?

A

Abrams’ needle

58
Q

What needle is used for a CT GUIDED pleural biopsy?

A

Tr-cut needle

59
Q

Where should a needle be inserted on the chest during a pleural biopsy?

A

just above the rib (to avoid VAN; vein, artery, intercostal nerve since collateral branches on top of rib are easier to avoid)

60
Q

How should a biopsy never be taken?

A

It should never be taken upwards as patient will bleed and it will damage the tissue

61
Q

What is a biopsy?

A

Taking a tissue sample for testing

62
Q

What is an aspiration?

A

Taking fluid from the pleural cavity for testing

63
Q

At least how many pleural biopsies should be taken for a pleural effusion diagnosis?

A

at least 4 biopsies

64
Q

How should the 4 pleural biopsies (at least) be split for testing?

A
  • at least 3 sent in formaldehyde for histology

- at least 1 sent in saline to microbiology if TB suspected

65
Q

What 2 investigations are used as a LAST resort if none of the other investigation methods work for a pleural effusion?

A
  1. thoracoscopy
  2. video assisted thoracoscopy
    (allows direct inspection of pleura and thoracic cavity, biopsies taken and therapeutic)
66
Q

What are ALL investigation methods for a pleural effusion?

A
  1. chest radiograph/ x ray
  2. contrast enhanced CT
  3. pleural aspiration
    (ward analysis, laboratories and interpretation of pleural protein)
  4. pleural biopsy
    LAST RESORT:
    - thoracoscopy
67
Q

What are 3 treatment options for a pleural effusion when treatment is directed at the cause?

A
  1. chemotherapy
  2. antituberculous chemotherapy
  3. corticosteroids
68
Q

Which type of pleural effusion (transudate or exudate) is associated with pallative (and usual malignant care) treatment?

A

more likely EXUDANT

69
Q

What is the treatment option for a pallative treatment of a pleural effusion?

A

repeated pleural aspiration, 1-1.5 litres at any one time

patient hospitalised and has limited life expectancy

70
Q

What does pleurodhesis involve as a form of management if pleural effusion? (especially recurrent pleural effusions)

A
  • Excess fluid drained from the pleural space/ cavity completely through tube and dryness checked with a chest x ray
  • Asbestos- free talc will be inserted through a tube to cause inflammation in chest cavity (cehmical pleurodhesis)
  • Once distributed, talc is removed
  • As talc is suctioned out, the pleural cavity will become sealed with scar tissue and fluid will not be able to accumulate in the future
71
Q

Where should the tube be inserted in a pleurodhesis procedure?

A

4th intercostal space mid-axillary line

patient lying on bed at 45 degree arm above head

72
Q

Fluid in pleurodhesis should be drained at what rate?

A

Drain fluid no faster than 500ml/hr ( re-expansion pulmonary oedema)

73
Q

If lung is NOT re-expanded ( it becomes trapped) once drained to dryness, what should be done? (2)

A
  1. apply suction 24 hours

2. remove drain due to infection risk

74
Q

What form of pleurodhesis is the most common one used?

A

Chemical pleurodhesis

75
Q

Describe the process of pleurodhesis once the lung has expanded.

A
  • insill 3mg/kg lignocaine/lidocaine
  • insill talc slurry (2-5g) and clamp drian for 1 hour
  • chemical pleurisy
  • remove drain after 12-72 hours if lung remains re-expanded
76
Q

What is the success rate for a pleurodhesis procedure?

A

90%

77
Q

When is a surgical pleurodhesis performed?

A

During a diagnostic thoracoscopy (talc is insufflated/breathed in)

78
Q

What is a pneumothorax?

A
  • Presence of AIR within the pleural cavity
  • Breach of visceral and parietal pleura with entry of air, lung collapses away from the chest because of elastic recoil of the lung
79
Q

What are 2 types of pneumothorax? (any of them can be a tension pneumothorax)

A
  1. spontaneous
    - primary spontaneous
    - secondary spontaneous
  2. traumatic
    - non-latrogenic
    - latrogenic
80
Q

What chest drainage apparatus is used for a pleurodhesis?

A

underwater seal

81
Q

What is a tension pneumothorax?

A
  • progressive build up of air in the pleural space
  • allows air to escape to the pleural space but not to return
  • postitive pressure ventilation may exacerbate/worsen this “one valve” effect
  • leads to progressive build up of air and pressure in the pleural space
  • air comes in but can’t come out
82
Q

What does pneumothorax cause in the chest?

A
  • pushes mediastinum to the opposite hemithorax
  • obstructs venous return to the heart
  • patient becomes hypotensive, clammy and very sick
83
Q

What can be some signs of a tension pneumothorax?

A
  • deviation of trachea away from the site of tension
  • hyperexpanded chest that moves little with inspiration
  • central venous pressure usually raised (but it’s normal or low in hypovoleamic/ less blood volume states)
84
Q

What is a primary spontaneous pneumothorax?

A
  • occurs in lungs which are normal
  • no clinically apparent disease
  • more common in tall, thin, young men (20-30 years)
  • believed to be due to weight of lung inducing development of apical blebs (small sacs of air that are very thin) that rupture and can cause a pneumothorax
85
Q

What is a secondary spontaneous pneumothorax?

A
  • occurs when there is already a pre-existing lung disease (deterioration of lung)
86
Q

What are common disease which can lead to a secondary spontaneous pneumothorax?

A
  • COPD
  • Asthma
  • Pneumonia
  • TB
  • CF
  • Fibrosing alveolitis
  • Sarcoidosis (red and swollen patches; granulomas develop on organs)
  • Histiocytosis X etc and more!
87
Q

What is a non-latrogenic traumatic pneumothorax?

A
  • penetrating chest injury (e.g. stab or gunshot)

- blunt chest injury (rib fractures, bronchial rupture etc)

88
Q

What is a latrogenic traumatic pneumothorax?

A
  • surgical medical causes are quite common
  • pleural aspiration/biopsy
  • sub-clavian vein cannulation
  • lung, liver breast or renal biopsy
  • acupuncture
89
Q

When is a pneumothorax asymptomatic and with no signs?

A

if pneumothorax is small and has a good respiratory reserve or if patient is fit and healthy

90
Q

What are common pneumothorax symptoms?

A
  • acute breathlessness (dyspnea) if worsening of dyspnea and pleuritic chest pain
  • extreme dyspnea if previously unfit patient (tension pneumothorax) or due to chest disease
91
Q

What can occur if there is a significant air leak from a pneumothorax?

A
  • surgical emphysema: air tracking/ trapped in subcutaneous fat
  • skin feels like bubble wrap
92
Q

What are signs of a NON-TENSION pneumothorax? (4)

A
  • trachea deviated to affected side
  • affected side will have:
    1. decreased expansion
    2. hyper resonant sounds absent
    3. decreased breath sounds
93
Q

What are signs of a TENSION pneumothorax? (6)

A
  • trachea deviated AWAY from the affected side
  • haemodynamic compromise (abnormal heart rhythms)
  • increase in jugular vein pressure (JVP)
  • tachycardia
  • low BP
  • patient sweaty and clammy
94
Q

What is a small pneumothorax?

A

rim of air<2cm

95
Q

What is a large pneumothorax?

A

rim of air >=2cm

96
Q

What questions should a doctor ask themselves if a patient presents with a pneumothorax? (5)

A
  • is it tension or non-tension?
  • is it primary or secondary?
  • is it small or big?
  • is patient breathless?
  • what does chest x ray show?
97
Q

What is the management plan for a TENSION pneumothorax?

A
  • cannula (large grey venflon) inserted into 2nd intercostal space in mid-clavicular line
  • intercostal chest drain then inserted
98
Q

What is the management plan for a small primary pneumothorax where patient is NOT breathless? (young people)

A
  1. observe overnight, repeat chest x ray and if no change then hole has sealed
  2. Then discharge patient, advise no vigorous activity and to return if becomes breathless
  3. Review with chest x ray clinic in 2 weeks (pneumothorax will resolve at about 1.25% a day)
99
Q

What is the management plan for a big primary pneumothorax where patient IS breathless?

A
  • aspirate pneumothorax with patient at 45 degrees
  • lignocaine to 2nd intercostal space in mid-clavicular line
  • 50ml syringe, venflon, 3 way tap and tube to water
100
Q

How long to aspirate lung for in the management plan for a big primary pneumothorax where patient is breathless?

A

Aspirate until feel lung surface on tup of venflon just beneath surface of chest wall as lung should become bouncy and expand (aspirated> 3L means persistent air leak)

101
Q

What to do if in a big primary pneumothorax, aspiration is:

  1. successful or
  2. unsuccessful
A
  • if successful then chest x ray and observe for 24 hours

- if unsuccessful then chest drain

102
Q

What is the management plan for a big secondary pneumothorax and the patient IS breathless?

A
  1. if relatively small then aspiration could be tried but it’s less successful
  2. insert intercostal chest drain in 4th intercostal space, miaxillary line
    - small bore 10-14F
    - if large emphysema, large 24-32F
103
Q

What is used if there is a large air leak (bubble wrap in subcutaneous region)?

A

undereater seal (always used for big aspirations)

104
Q

Where should chest drains be inserted?

A

4th intercostal space in mid-axillary line

105
Q

Where should canulas be inserted in tension pneumothorax?

A

2nd intercostal space in mid-clavicular line

106
Q

What 3 things would happen ideally after an intercostal chest drain is inserted?

A
  1. lung inflates in 1-2 days
  2. drain stops bubbling
  3. chest x ray confirms lung inflated
107
Q

What is the next stop if chest drain inflates the lung?(ideal situation)

A

Clamp drain for 24 hours, re-do chest x ray and if no change then remove the drain (can detect small air leaks)

108
Q

What non-ideal scenario can occur in a chest drain?

A
  1. lung fails to re-inflate after 48 hours

2. drain continues bubbling

109
Q

What should be the next stop if chest drain doesn’t inflate the lung? (non-ideal situation)

A
  1. apply suction to drain (high volume, low pressure, 10-20cm water)
  2. if still lung fails to re-inflate then contact thoracic surgeons at 3 days
110
Q

If lungs fails to re-inlfate after a chest drain, what do thoracic surgeons look for?

A
  • thorascopic inspection of visceral pleura
  • identification of blebs, tears clipping and talc poudrage pleurodesis (inducing inflammation for adhesion of two pleurae)
111
Q

What are the statistics showing a high risk of a subsequent pneumothorax?

A
  • 54% recurrence within 4 years
  • 10-25% recurrence in first 4 months
  • 10-15% recurrence contralateral pneumothorax
112
Q

What 4 types of pneumothorax should be referred for a pleurodesis?

A
  1. second ipsilateral pneumothorax
  2. first contralateral pneumothorax
  3. bilateral spontaneous pneumothorax
  4. first pneumothorax in high risk professions (e.g. pilots, drivers etc)
113
Q

What are 3 options for subsequent recurring pneumothorax?

A
  1. surgical pleurodesis
  2. talc poudrage (powdering to create pleural adhesions)
  3. pleurectomy (removal of pleura)
114
Q

In summary, what is the management plant for:

  1. tension PT
  2. small primary PT (not breath.)
  3. big primary PT (breath.)
  4. secondary PT (breath)
A
  1. Tension: cannula then chest drain
  2. Small p. PT (not breath): observe overnight, CXR, if no change then discharge
  3. Big p. PT (breath): aspirate with lignocaine
  4. Secondary PT (breath): chest drain
115
Q

What is asbestos?

A

highly fibrous naturally occuring material (can be woven into fabric or added to other material)

116
Q

What are 3 main types of asbestos?

A
  1. chrysotile (white)
  2. amosite (brown)
  3. crocidolite (blue)
117
Q

Which type of asbestos is the most dangerous to health?

A

Chrysotile (most widely used too ~90%)

118
Q

What is an asbestos related pleural tumour?

A

mesothelioma

119
Q

What professions are highly exposed to asbestos?

A

boiler men, engineers, electricians, plumbers, building trade, ship building, clothing of someone in the house working with asbestos

120
Q

Does disease start to develop straight after asbestos exposure?

A

No, it starts at 20-40 years after exposure (pleural plaques build up)

121
Q

Why is asbestos commercially profitable?

A
  • high tensile strength
  • fire resistance
  • insulation to electrical charge
  • resistant to chemical attack
    (found in building materials)
122
Q

What is a mesothelioma?

A
  • pleural malignancy on mesothelium layer (that covers organs)
  • 80% due to asbestos
  • uniform mortality
  • can also occur in peritoneum (membrane around abdominal cavity)
123
Q

What is the most common clinical presentation of mesothelioma? (2)

A
  1. breathlessness

2. chest wall pain

124
Q

What does radiology in a mesothelioma patient usually show? (2)

A
  • usually unilateral

- diffuse or localised pleural thickening

125
Q

What is the order if investigation steps for a mesothelioma? (4)

A
  1. chest x ray
  2. CT scan
  3. pleural aspiration
  4. pleural biopsy
126
Q

If the patient is diagnosed very early with a mesothelioma, what surgery is recommended?

A

pleuropneumonectomy (resection of lung with the parietal pleura)

127
Q

What pallative options are given to patients with advanced malignant mesothelioma? (4)

A
  • radiotherapy to drain bipsy sites
  • chemotherapy
  • pleurodesis
  • analgesia (pain relief)
128
Q

What is the approximate life expectancy in mesothelioma patients?

A

~ 18 months

129
Q

What are the management options for a pleural effusion? (5)

A
  1. chemotherapy
  2. antituberculous chemotherapy
  3. corticosteroids
  4. repeated pleural aspiration (pallative)
  5. pleurodhesis (4th intercostal space, mid-axillary for chest drain)

Systems: Resp. WK (40 decks)

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