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
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
3
Q
What fluid is found in the pleural cavity?
A
Pleural fluid (lubricant); 2-3ml
4
Q
What percentage of pleural fluid undergoes dynamic turnover every hour?
A
30-75%/ hour
5
Q
What pressure absorbs the fluid in the pleural cavity?
A
Osmotic pressure (due to potential space)
6
Q
Does the pleura extend over the first rib?
A
Yes
7
Q
What 3 organs can be punctured easily during a pleural procedure?
A
- kidneys
- spleen
- liver
8
Q
Define pleural effusion.
A
Abnormal collection of fluid in the pleural space.
9
Q
What do symptoms of pleural effusion depend on? (2)
A
- cause of pleural effusion
- volume of fluid
10
Q
When is pleural effusion asymptomatic?
A
If it’s small and fluid accumulates slowly
11
Q
What are main symptoms of a pleural effusion?
A
- Increasing dyspnea (days, weeks, months…)
- Pleuritic chest pain (if early then may improve fluid accumulation, if malignant then it’s progressively worse)
- Dull ache; similar to having lungs squashed
- Dry cough; especially if rapid accumulation
- Weight loss
- Malaise and fever
- Night sweats
12
Q
What needs to be enquired/ asked about from the patient in a pleural effusion? (4)
A
- peripheral oedema
- liver disease
- ortopnoea
- PND; paroxysmal nocturna; dyspnea
13
Q
What are some causes of a pleural effusion? (8) TIM PICCK
A
- congestive heart failure
- inflammation
- trauma
- malignancy
- pulmonary embolism
- cirrhosis; damage to liver
- kidney failure
- infection
14
Q
What clinical signs indicate a pleural effusion? (6)
A
- Chest on affected side has:
- decreased expansion
- stony dullness to percussion
- decreased breath sounds (band of bronchial breathing)
- decreased vocal resonance - clubbing and tar staining
- cervical lymphadenopathy
- increased JVP; jugular venous pressure
- trachea away from large effusion
- peripheral oedema
15
Q
What two groups is pleural effusion categorised into? (what type of fluids involved)
A
- transudates
2. exudates
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
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
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)
19
Q
What is the “exam cut off” of protein in pleural effusion?
A
30g/l
20
Q
What are very common causes for transudates pleural effusion? (4)
A
- left ventricular failure
- liver cirrhosis
- hypoalbuminaemia
- peritoneal dialysis
21
Q
What are the less common causes for transudates pleural effusion? (4)
A
- hypothyroidism
- nephrotic syndrome
- mitral stenosis (narrowing)
- pulmonary embolism (2/3rds exudates)
22
Q
What are the rare causes for transudates pleural effusion? (3)
A
- Constrictive pericarditis (previous TB, connective tissue diseases)
- Ovarian hyperstimulation syndrome
- Meig’s Syndrome (benign ovarian fibroma, ascites, R sided effusion)
23
Q
What are the common causes of exudate pleural effusion? (2)
A
- malignancy (lung, breast, mesothelioma, metastatic)
2. parapneumonic (consider sub-phrenic)
24
Q
What are the less common causes for exudate pleural effusion ( 6)
A
- pulmonary embolism/ infarction
- rheumatoid arthritis
- autoimmune diseases (SLE, polyarteritis)
- benign asbestos effusion
- pancreatitis
- post-myocardial infarction/ cardiotomy syndrome
25
What are the rare causes for exudate pleural effusion (2)
1. yellow nail syndrome
| 2. drugs
26
What are rare causes for exudate pleural effusion? (8)
- amiodarone
- nitrofurantoin
- phenytoin
- methotrexate
- carbamazapine
- penicillamine
- bromocriptine
- pergolide
27
Is investigation needed in exudates and transudates ?
Usually ISN'T required in transudates (since clinical picture is usually characteristic), more needed for exudates
28
When should pleural effusion (either transudate or exudate) be investigated?
- if unusual features (e.g. dull percussion)
| - failure to respond to appropriate treatment
29
Heart failure patients will most likely have which form of pleural effusion?
Transudates
30
What scan method is used to detect and confirm the presence of effusion?
chest radiograph
31
How much of the fluid is required for the pleural effusion to be detected on a chest x ray?
at least 200ml
32
Except from a chest radiograph, what other diagnostic method can be used to detect a pleural effusion?
Contrast enhanced CT of thorax
33
What does a contrast enhanced CT of thorax allow doctors to do?
Allows doctors to differentiate between malignant and benign disease (which can cause pleural effusions)
34
What changes in the thorax can a contrast CT indicate when looking at a pleural effusion?
1. nodular pleural thickening
2. mediastinal pleural thickening
3. parietal pleural thickening >1cm
4. circumferential pleural thickening
5. other malignant manifestations in lung/liver
35
During pleural aspiration, when a needle is inserted into the pleural cavity to remove excess fluid, what syringe, needle and anaesthesia is used?
- 50ml syringe
- 21G needle (green(
- lignocaine/lidocaine (same thing) anaesthesia
plus sterile universal containers and blood culture bottles
36
What complications can arise from a pleural aspiration procedure? (7)
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
37
What is used to determine the upper level of fluid before a pleural aspiration is done?
percussion; ideal place is 10cm lateral to the spin (mid-scapular line) and 1-2 intercostal spaces below the upper level of the fluid
38
When is haemothorax more likely to occur during a pleural aspiration? (2)
1. if blood vessels are hit
| 2. if person is on anticoagulation drugs
39
What is done to the fluid from a pleural aspiration sample once it's extracted?
Look at the fluid and sniff to determine possible cause for the pleural effusion
40
If fluid from a pleural aspiration is foul smelling, what could this indicate?
anaerobic empyema is the cause of pleural effusion
41
If fluid from a pleural aspiration has pus, what could this indicate?
empyema is the cause of pleural effusion
42
If fluid from a pleural aspiration has food particles, what could this indicate?
oesophageal rupture is the cause of pleural effusion
43
If the fluid from a pleural aspiration is milky, what could this indicate?
chylothorax (usually lymphoma) is the cause of pleural effusion
44
If the fluid from a pleural aspiration is blood stained, what could this indicate?
possible malignancy is the cause of pleural effusion
45
If the fluid from the pleural aspiration has blood, what could this indicate?
haemothorax or trauma is the cause of pleural effusion
46
When is a chest drain needed after a pleural aspiration?
If the fluid is infected and pH<7.2 (blood gas analyser needed for biopsies)
47
What 3 laboratory branches are needed for a pleural effusion investigation?
1. biochemistry
2. microbiology
3. cytology
48
What 3 things does biochemistry department test for in a patient suspected of pleural effusion?
1. protein (LDH; lactate dehydrogenase)
2. amylase
3. glucose
49
What is suspected if amylase levels are increased in a pleural effusion investigation?
possible pancreatitis
50
What is suspected if glucose levels are <3.3mM in a pleural effusion investigation? (5)
- empyema
- rheumatoid arthritis
- SLE (lupus)
- TB
-malignancy
(low glucose linked to metabolic activity)
51
What tests are done in microbiology department in a pleural effusion investigation? (4)
1. MC&S: microscopy, culture and sensitivities
2. Gram stain
3. AAFB: alcohol and acid fast bacilli
4. culture
52
What cells are specifically looked at in cytology during a pleural effusion investigation? (3)
1. eosinophils (Churg-Strauss, asbestos, but malignancy as well 25%)
2. malignant cells
3. lymphocytes (TB, lymphoma)
53
During interpretation of pleural protein, when do we know if it's a transudate?
transudate if pleural protein< 25g/l ( <30g/l in exams)
54
During interpretation of pleural protein, when do we know if it's an exudate?
exudate if pleural protein >35g/l ( >30g/l in exams)
55
What is the range for Light's criteria that involves the analysis of pleural proteins?
rangeis 25-35g/l
56
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.
1. pleural/serum protein >0.5
2. pleural/serum LDH>0.6
3. pleural LDH>0.66 of upper limit of serum LDH
57
What needle is used for a BLIND pleural biopsy?
Abrams' needle
58
What needle is used for a CT GUIDED pleural biopsy?
Tr-cut needle
59
Where should a needle be inserted on the chest during a pleural biopsy?
just above the rib (to avoid VAN; vein, artery, intercostal nerve since collateral branches on top of rib are easier to avoid)
60
How should a biopsy never be taken?
It should never be taken upwards as patient will bleed and it will damage the tissue
61
What is a biopsy?
Taking a tissue sample for testing
62
What is an aspiration?
Taking fluid from the pleural cavity for testing
63
At least how many pleural biopsies should be taken for a pleural effusion diagnosis?
at least 4 biopsies
64
How should the 4 pleural biopsies (at least) be split for testing?
- at least 3 sent in formaldehyde for histology
| - at least 1 sent in saline to microbiology if TB suspected
65
What 2 investigations are used as a LAST resort if none of the other investigation methods work for a pleural effusion?
1. thoracoscopy
2. video assisted thoracoscopy
(allows direct inspection of pleura and thoracic cavity, biopsies taken and therapeutic)
66
What are ALL investigation methods for a pleural effusion?
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
What are 3 treatment options for a pleural effusion when treatment is directed at the cause?
1. chemotherapy
2. antituberculous chemotherapy
3. corticosteroids
68
Which type of pleural effusion (transudate or exudate) is associated with pallative (and usual malignant care) treatment?
more likely EXUDANT
69
What is the treatment option for a pallative treatment of a pleural effusion?
repeated pleural aspiration, 1-1.5 litres at any one time
| patient hospitalised and has limited life expectancy
70
What does pleurodhesis involve as a form of management if pleural effusion? (especially recurrent pleural effusions)
- 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
Where should the tube be inserted in a pleurodhesis procedure?
4th intercostal space mid-axillary line
| patient lying on bed at 45 degree arm above head
72
Fluid in pleurodhesis should be drained at what rate?
Drain fluid no faster than 500ml/hr ( re-expansion pulmonary oedema)
73
If lung is NOT re-expanded ( it becomes trapped) once drained to dryness, what should be done? (2)
1. apply suction 24 hours
| 2. remove drain due to infection risk
74
What form of pleurodhesis is the most common one used?
Chemical pleurodhesis
75
Describe the process of pleurodhesis once the lung has expanded.
- 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
What is the success rate for a pleurodhesis procedure?
90%
77
When is a surgical pleurodhesis performed?
During a diagnostic thoracoscopy (talc is insufflated/breathed in)
78
What is a pneumothorax?
- 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
What are 2 types of pneumothorax? (any of them can be a tension pneumothorax)
1. spontaneous
- primary spontaneous
- secondary spontaneous
2. traumatic
- non-latrogenic
- latrogenic
80
What chest drainage apparatus is used for a pleurodhesis?
underwater seal
81
What is a tension pneumothorax?
- 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
What does pneumothorax cause in the chest?
- pushes mediastinum to the opposite hemithorax
- obstructs venous return to the heart
- patient becomes hypotensive, clammy and very sick
83
What can be some signs of a tension pneumothorax?
- 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
What is a primary spontaneous pneumothorax?
- 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
What is a secondary spontaneous pneumothorax?
- occurs when there is already a pre-existing lung disease (deterioration of lung)
86
What are common disease which can lead to a secondary spontaneous pneumothorax?
- COPD
- Asthma
- Pneumonia
- TB
- CF
- Fibrosing alveolitis
- Sarcoidosis (red and swollen patches; granulomas develop on organs)
- Histiocytosis X etc and more!
87
What is a non-latrogenic traumatic pneumothorax?
- penetrating chest injury (e.g. stab or gunshot)
| - blunt chest injury (rib fractures, bronchial rupture etc)
88
What is a latrogenic traumatic pneumothorax?
- surgical medical causes are quite common
- pleural aspiration/biopsy
- sub-clavian vein cannulation
- lung, liver breast or renal biopsy
- acupuncture
89
When is a pneumothorax asymptomatic and with no signs?
if pneumothorax is small and has a good respiratory reserve or if patient is fit and healthy
90
What are common pneumothorax symptoms?
- 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
What can occur if there is a significant air leak from a pneumothorax?
- surgical emphysema: air tracking/ trapped in subcutaneous fat
- skin feels like bubble wrap
92
What are signs of a NON-TENSION pneumothorax? (4)
- trachea deviated to affected side
- affected side will have:
1. decreased expansion
2. hyper resonant sounds absent
3. decreased breath sounds
93
What are signs of a TENSION pneumothorax? (6)
- 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
What is a small pneumothorax?
rim of air<2cm
95
What is a large pneumothorax?
rim of air >=2cm
96
What questions should a doctor ask themselves if a patient presents with a pneumothorax? (5)
- 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
What is the management plan for a TENSION pneumothorax?
- cannula (large grey venflon) inserted into 2nd intercostal space in mid-clavicular line
- intercostal chest drain then inserted
98
What is the management plan for a small primary pneumothorax where patient is NOT breathless? (young people)
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
What is the management plan for a big primary pneumothorax where patient IS breathless?
- 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
How long to aspirate lung for in the management plan for a big primary pneumothorax where patient is breathless?
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
What to do if in a big primary pneumothorax, aspiration is:
1. successful or
2. unsuccessful
- if successful then chest x ray and observe for 24 hours
| - if unsuccessful then chest drain
102
What is the management plan for a big secondary pneumothorax and the patient IS breathless?
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
What is used if there is a large air leak (bubble wrap in subcutaneous region)?
undereater seal (always used for big aspirations)
104
Where should chest drains be inserted?
4th intercostal space in mid-axillary line
105
Where should canulas be inserted in tension pneumothorax?
2nd intercostal space in mid-clavicular line
106
What 3 things would happen ideally after an intercostal chest drain is inserted?
1. lung inflates in 1-2 days
2. drain stops bubbling
3. chest x ray confirms lung inflated
107
What is the next stop if chest drain inflates the lung?(ideal situation)
Clamp drain for 24 hours, re-do chest x ray and if no change then remove the drain (can detect small air leaks)
108
What non-ideal scenario can occur in a chest drain?
1. lung fails to re-inflate after 48 hours
| 2. drain continues bubbling
109
What should be the next stop if chest drain doesn't inflate the lung? (non-ideal situation)
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
If lungs fails to re-inlfate after a chest drain, what do thoracic surgeons look for?
- thorascopic inspection of visceral pleura
- identification of blebs, tears clipping and talc poudrage pleurodesis (inducing inflammation for adhesion of two pleurae)
111
What are the statistics showing a high risk of a subsequent pneumothorax?
- 54% recurrence within 4 years
- 10-25% recurrence in first 4 months
- 10-15% recurrence contralateral pneumothorax
112
What 4 types of pneumothorax should be referred for a pleurodesis?
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
What are 3 options for subsequent recurring pneumothorax?
1. surgical pleurodesis
2. talc poudrage (powdering to create pleural adhesions)
3. pleurectomy (removal of pleura)
114
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)
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
What is asbestos?
highly fibrous naturally occuring material (can be woven into fabric or added to other material)
116
What are 3 main types of asbestos?
1. chrysotile (white)
2. amosite (brown)
3. crocidolite (blue)
117
Which type of asbestos is the most dangerous to health?
Chrysotile (most widely used too ~90%)
118
What is an asbestos related pleural tumour?
mesothelioma
119
What professions are highly exposed to asbestos?
boiler men, engineers, electricians, plumbers, building trade, ship building, clothing of someone in the house working with asbestos
120
Does disease start to develop straight after asbestos exposure?
No, it starts at 20-40 years after exposure (pleural plaques build up)
121
Why is asbestos commercially profitable?
- high tensile strength
- fire resistance
- insulation to electrical charge
- resistant to chemical attack
(found in building materials)
122
What is a mesothelioma?
- pleural malignancy on mesothelium layer (that covers organs)
- 80% due to asbestos
- uniform mortality
- can also occur in peritoneum (membrane around abdominal cavity)
123
What is the most common clinical presentation of mesothelioma? (2)
1. breathlessness
| 2. chest wall pain
124
What does radiology in a mesothelioma patient usually show? (2)
- usually unilateral
| - diffuse or localised pleural thickening
125
What is the order if investigation steps for a mesothelioma? (4)
1. chest x ray
2. CT scan
3. pleural aspiration
4. pleural biopsy
126
If the patient is diagnosed very early with a mesothelioma, what surgery is recommended?
pleuropneumonectomy (resection of lung with the parietal pleura)
127
What pallative options are given to patients with advanced malignant mesothelioma? (4)
- radiotherapy to drain bipsy sites
- chemotherapy
- pleurodesis
- analgesia (pain relief)
128
What is the approximate life expectancy in mesothelioma patients?
~ 18 months
129
What are the management options for a pleural effusion? (5)
1. chemotherapy
2. antituberculous chemotherapy
3. corticosteroids
4. repeated pleural aspiration (pallative)
5. pleurodhesis (4th intercostal space, mid-axillary for chest drain)
