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MD2 Respiratory > Diseases of the Pleura > Flashcards

Diseases of the Pleura Flashcards

1
Q

Which respiratory muscles are important in inspiration?

A

Diaphragm
External intercostals
(SCM and scalenes as acccessories)

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2
Q

Which respiratory muscles are important in expiration?

A 
Normally none
(Internal intercostals and abdominal muscles as accessories)
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3
Q

What mechanisms might underlie a pleural effusion? Give specific examples of causes of each

A

Starling forces:
Increased hydrostatic pressure (HF)
Increased capillary permeability (inflammation, malignancy)
Decreased oncotic pressure (liver or renal failure)
Impaired lymphatic drainage (infiltration by tumour, injury, inflammation)

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4
Q

What should be measured when sampling a pleural effusion to assist diagnosis?

A 
Protein
Glucose
LDH
pH
Cytology
MCS
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5
Q

What Ix can be ordered to evaluate a pleural effusion?

A

Biochemistry, cytology, MCS on sample if indicated
Imaging: CXR, US, CT chest
Bronchoscopy (not routine; doesn’t get into pleural space, use if concerned about underlying lung disease)
Thoracoscopy (VAT; may be indicated if complicated or cause unclear)

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6
Q

List some common symptoms of pleural disease

A

Pleuritic chest pain
SOB
Cough

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7
Q

Pleuritic chest pain DDx

A

PE
Pneumothorax
Pneumonia
MSK pain (including rib #)

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8
Q

Signs of air in the pleural space

A

Decreased chest expansion
Hyper-resonant percussion
Decreased breath sounds and vocal resonance

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9
Q

Signs of fluid/solid tissue in pleural space

A

Decreased chest expansion
Dullness to percussion (“stony dullness”)
Decreased breath sounds and vocal resonance

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10
Q

DDx bilateral pleural effusion

A

Increased hydrostatic pressure: HF, fluid overload
Increased capillary permeability: inflammation, malignancy
Decreased oncotic pressure: nephrotic syndrome, liver disease
Impaired lymphatic drainage: malignancy

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11
Q

DDx unilateral pleural effusion

A

Increased hydrostatic pressure: HF (less common)
Increased capillary permeability: infection, inflammation (post-PE), malignancy (primary)
Impaired lymphatic drainage: malignancy

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12
Q

3 risk factors for spontaneous pneumothorax

A

Smoking
Family Hx
Marfan’s syndrome

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13
Q

What are the 3 causes of pneumothoraces?

A

Spontaneous
Trauma
Underlying lung disease

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14
Q

How does underlying lung disease contribute to pneumothorax?

A

At risk of cysts or bullae which may burst, causing a pneumothorax

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15
Q

What are pleural plaques?

A

Areas of fibrous thickening on the pleura or diaphragm

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16
Q

What are the causes of pleural plaques?

A

Asbestos exposure

Previous empyema or haemothorax

17
Q

List 6 asbestos-related lung diseases

A 
Pleural plaques
Pleural thickening
Pleural effusions
Pulmonary fibrosis (asbestosis)
Mesothelioma
Bronchogenic lung carcinoma
18
Q

HF findings on CXR

A 
Alveolar oedema
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels (diversion)
Effusion
19
Q

What does the protein content of a pleural effusion indicate?

A

High: likely exudate
Low: likely transudate

20
Q

What does the glucose content of a pleural effusion indicate?

A

Low: infection or malignancy

21
Q

What does the LDH content of a pleural effusion indicate?

A

High: likely exudate
Low: likely transudate

22
Q

What does the pH of a pleural effusion indicate?

A

Low: infection or malignancy

23
Q

What results on biochemical analysis strongly indicate that a pleural effusion is the result of an infection or malignancy?

A

Low glucose

Low pH

24
Q

Common causes of an exudative pleural effusion

A

LOCAL CAUSE
Cardiac: pericarditis
Vascular: PE
Respiratory: haemothorax, chylothorax (due to disruption or obstruction of thoracic duct)
Abdominal: subphrenic abscess
Inflammatory: infection (pneumonia, pleuritis, empyema), malignancy (breast, lung, pleura)
Immunologic: RA, SLE

25
Q

How is pneumothorax managed initially?

A

Close observation
Drainage (aspiration or ICC with underwater seal)
Analgesia
O2

26
Q

Where is an ICC typically inserted?

A

5th intercostal space in mid-axillary line

Above the rib below to avoid the neurovascular bundle

27
Q

When is surgery indicated to relieve a pneumothorax?

A

With a persisting air leak (no more than 3 days depending on clinical context)

28
Q

What is the aim of surgical intervention to relieve a pneumothorax?

A

Release air
Resect any bullae
Pleurodesis

29
Q

What is a parapneumonic effusion?

A

An exudative pleural effusion associated with underlying pulmonary infection

30
Q

What are loculations in the context of a pleural effusion? Do loculations need to be broken down when draining the effusion?

A

??

Should be broken down to help pus drain

31
Q

What is the significance of calretinin as an immunohistochemical marker?

A

Present in mesothelioma

32
Q

What is pleurodesis?

A

Surgical and/or chemical (e.g. with alcohol iodine or talcum) inflammation to produce scarring between visceral and parietal layers of pleura thereby preventing recurrence

33
Q

How may a malignant pleural effusion be managed?

A

Treat underlying malignancy
Drainage with ICC
Pleurodesis (usually with alcohol iodine for malignant effusions)
Intrapleural catheter

34
Q

Common causes of a transudative pleural effusion

A 
SYSTEMIC ILLNESS
Cardiac: CCF, PE
Abdominal: ascites, cirrhosis, glomerulonephritis, nephrotic syndrome
Endocrine: myxoedema
Immunologic: sarcoid
35
Q

23 year old woman presents with sudden onset SOB and left-sided pleuritic chest pain
O/E: appears unwell, HR 92, BP 120/80, RR 27, SaO2 96% RA, midline trachea, decreased chest expansion on the left, resonant percussion note, decreased breath sounds over entire left lung
What does this suggest?

A

Large left pneumothorax (air in the pleural space with collapse of the left lung)

MD2 Respiratory (9 decks)

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