Block 3: Pneumoconiosis, Pneumothorax Flashcards
1
Q
Asbestosis mangement
A
- No specific cures
- Avoiding further asbestos exposure
- Smoking cessation
- Annual influenza and pneumonia vaccination
- Pulmonary rehabilitation
- Screening for other asbestos-related diseases
- Long-term oxygen therapy
- Prognosis is better than in idiopathic pulmonary fibrosis (IPF)
2
Q
Asbestosis features
A
- dyspnoea and reduced exercise tolerance
- clubbing
- bilateral end-inspiratory crackles
- lung function tests show a restrictive pattern with reduced gas transfer
- typically causes lower lobe fibrosis
- Treated conservatively
3
Q
Types of asbestos
A
- Serpentine- long curly whit fibres
- Amphibole- blue and brown asbestos which are short needle like structures that lodge in the alveoli and cant be cleared
- The lower sub-pleural zones are most affected
4
Q
Other causes of asbestos related lung disease: BAPE and pleural plaques
A
- Pleural plaques: benign and do not undergo malignant change, dont require any follow up. Typically asymptomatic but may cause pleural rub and reduce lung volume if extensive. They are smooth areas of hyaline fibrosis
- Benign asbestos pleural effusion (BAPE): unilateral effusion, usually occurs within 10 years of exposure, will be exudate fluid and blood stained. Diagnosis of exclusion. Resolves spontaneously after a few months but might need aspiration or pleurodesis.
5
Q
Other causes of asbestos related lung disease: mesothelioma and lung cancer
A
- Mesothelioma: malignant disease of the pleura. Crocidolite (blue) asbestos is the most dangerous form. Offered palliative chemotherapy and limited role for surgery and radiotherapy, poor prognosis. Risk is not dose related. Diagnosis by biopsy, 50% die in the first year
- Lung cancer: advised to stop smoking
6
Q
Occupational exposure to asbestos
A
Construction, insulation, fireproofing, brake lining, ship building, boiler fitting, carpentry and electrical repair.
7
Q
Malignant mesothelioma investigations
A
- CXR: pleural effusion with associated pleural plaques
- CT Thorax: would show pleural thickening, calcified pleural plaques and a pleural effusion
- Pleural aspiration: sent for cytology, microbiology and biochemistry. Cytology would show reactive mesothelial cells, pleural fluid is exudate
- VATS with pleural biopsy: gold standard, biopsy is needed to confirm diagnosis and allows pleurodesis to be performed at the same time.
- Local anaesthetic thorascopy can be used to investigate cytology
8
Q
Features of mesothelioma
A
- Dyspnoea, weight loss, chest wall pain
- Clubbing
- 30% present as painless pleural effusion
- Only 20% have pre-existing asbestosis
- History of asbestos exposure in 85-90%, latent period of 30-40 years
9
Q
Lights criteria for a pleural fluid exudate re:
A
- Pleural fluid : serum protein ratio > 0.5
- Pleural fluid : serum LDH ratio > 0.6
- Pleural fluid LDH > 2/3 the upper limit of normal serum LDH
- Causes of an exudate include: infection (lung and pleural), malignancy, connective tissue diseases, pulmonary embolism, chylothorax, ARDS and pancreatitis.
10
Q
Management of mesothelioma
A
- Symptomatic
- Industrial Injuries disablement benefit is available for patients with diffuse pleural thickening, asbestosis, mesothelioma or lung cancer associated with asbestos exposure. Pleural plaques alone do not qualify.
- The Diffuse Mesothelioma Payment Scheme: provides payouts when the employer is not contactable
- Chemotherapy (cisplatin and pemtrexed), Surgery if operable
- Prognosis poor, median survival 12 months
11
Q
Pneumothorax risk factors
A
- pre-existing lung disease: COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia
- connective tissue disease: Marfan’s syndrome, rheumatoid arthritis
- ventilation, including non-invasive ventilation
- Menstruating women
12
Q
Pneumothorax classification (primary/secondary)
A
- Primary spontaneous pneumothorax (PSP): Occurs without underlying lung disease, often in tall, thin, young individuals. PSP is associated with the rupture of subpleural blebs or bullae.
- Secondary spontaneous pneumothorax (SSP): Occurs in patients with pre-existing lung disease, such as chronic obstructive pulmonary disease (COPD), asthma, cystic fibrosis, or interstitial lung disease. Likely if >50 with significant smoking history
13
Q
Pneumothorax classification: Traumatic/Iatrogenic
A
- Traumatic pneumothorax: Results from penetrating or blunt chest trauma, leading to lung injury and pleural air accumulation.
- Iatrogenic pneumothorax: Occurs as a complication of medical procedures, such as thoracentesis, central venous catheter placement, mechanical ventilation, or lung biopsy.
14
Q
Pneumothorax features
A
- Sudden onset pleuritic chest pain and dyspnoea, occasional dry cough
- Primary: sometimes after exertion but not always
- Examination: diminished breath sounds, hyper resonance on percussion, decreased vocal resonance and decreased chest wall movement on the affected side
- Severe cases: hypoxia, tachypnoea, tachycardia and hypotension
- Tensions pneumothorax; life threatening condition that presents with severe respiratory distress, tacheal deviation, jugular venous distension and haemodynamic instability
15
Q
Pneumothorax investigations
A
- CXR in posteroanterior (PA) and lateral view: reveals a visceral pleural line, absence of lung marking peripheral to the line
- CT: can confirm diagnosis
- Point of care ultrasound (POCUS): in rapid bedside diagnosis especially in tension pneumothorax and unstable patients
16
Q
Primary pneumothorax management
A
- if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered: follow up over 2-4 weeks
- otherwise, aspiration should be attempted
- if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
17
Q
Secondary pneumothorax management
A
- if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
- otherwise aspirate if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
- if the pneumothorax is less the 1cm then give oxygen and admit for 24 hours
18
Q
Other treatment for pneumothorax: iatrogenic, persistent, recurrent
A
- Iatrogenic: majority will resolve with observation, if treatment required use aspiration. For ventilated patients and many with COPD use a chest drain
- Persistent/recurrent pneumothorax: If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.
19
Q
Treatment for pneumothorax: discharge advice
A
Sop smoking, don’t fly for 1-2 weeks and radiological resolution, ban on scuba diving unless the patient has had a bilateral surgical pleurectomy and now normal lung function and chest CT
20
Q
Tension pneumothorax CXR
A
Loss of lung markings, trachea moves away from the pneumothorax. Treatment is needle decompression in the mid-clavicular line second intercostal space
