Diseases of the Pleura Flashcards
will excess fluid in the pleural space tend to move into the lungs or across the parietal pleura in to the chest wall? why?
into the lungs.
as the pulmonary arterial pressure is smaller than the systemic arterial pressure so fluid will tend to move into arteries in the lungs
why is the fact that the pleura extends down over the liver and up over the first rib important clinically?
because a liver biopsy may puncture the pleura at the base of the lung or a when putting a cannula into a subclavicular vein.
what is a pleural effusion?
a collection of fluid in the pleural space
when might a pleural effusion be asymptomatic?
is it is small and accumulates slowly
what are some symptoms of a pleural effusion?
increasing breathlessness pleuritic chest pain dull ache dry cough weight loss, malaise, fevers, night sweats
what are the different causes of pleuritic chest pain from a pleural effusion?
inflammatory- occurs early on and may improve with fluid accumulating
malignant- will get progressively worse
what are the signs of a pleural effusion?
- decreased chest expansion
- stony dullness to percussion
- decreased breath sounds
- band of bronchial breathing above the collection of fluid
- decreased vocal resonance
what is are some other signs that might go along with a pleural effusion?
clubbing tar staining of fingers increased JVP trachea away from large effusion peripheral oedema (heart failure) cervical lymphadenopathy (malignancy)
what are the two types of pleural effusion?
transudates
exudates
what causes a transudate PE?
An imbalance of hydostatic forces influencing the formation and absorption of pleural fluid.
what causes an exudate PE?
an increased permeability of pleural surfaces and/or local capillaries
are transudate usually unilateral or bilateral?
bilateral
are exudates usually unilateral or bilateral?
unilateral
is capillary permeability affected in transudate PE?
no
what is the protein content of a transudate?
<30g/l
what is the protein content of an exudate?
> 30g/l
what are the very common causes of transudates?
left ventricular failure
liver cirrhosis
hypoalbuminaemia
peritoneal dialysis
what is peritoneal dialysis?
a form of dialysis in which fluid the filtration of the blood is done through the peritoneum
what are the less common causes of transudates?
- Hypothyroidism
- Nephrotic syndrome
- Mitral stenosis
- Pulmonary embolism (2/3rds exudates)
what is mitral stenosis?
a narrowing of the mitral valve between the left atrium and ventricle, decreases blood flow through the valve
what are the common causes of exudate?
-malignancy (lung, breast, mesothelioma, mets)
what are the less common causes of exudates?
- Pulmonary embolism/infarction
- Rheumatoid arthritis
- Autoimmune diseases (SLE, polyarteritis)
- Benign asbestos effusion
- Pancreatitis
- Post-myocardial infarction/cardiotomy syndrome
what is cardiotomy syndrome?
an immune response following an operation with an incision in the pericardium
what are the rare causes of exudates?
yellow nail syndrome
certain drugs eg. nitrofurantoin, penicillamine
what are the rare causes of transudate?
constrictive pericarditis
ovarian hyperstimulation syndrome
Meig’s syndrome
are investigations usually required for transudates?
no
why are investigations not usually needed for transudates?
because clinical picture is usually characteristic
when are transudates investigated?
when there are unusual features or a failure to respond to treatment
what investigation is carried out to confirm the presence of a PE?
CXR
what volume of fluid is required before a PE is detectable?
200ml
what is a contrast enhanced CT used for when investigating a PE?
differentiation between malignant and benign disease
what signs of a contrast CT are indicative of a malignant cause of PE?
- nodular pleural thickening -mediastinal pleural thickening
- parietal pleural thickening >1cm -circumferential pleural thickening
- other malignant manifestations in lung/liver
what are the investigations carried out for a PE?
CXR
contrast enhanced CT
aspiration
biopsy
what are the potential complications of a pleural aspiration?
Pneumothorax (if air gets in through) needle
Empyema (if needle is dirty)
Pulmonary oedema (if fluid id drained too fast)
Vagal reflex (if pleura not adequately anaesthatised)
Air embolism
Tumour cell seeding
Haemothorax (if blood clotting is compromised)
if the fluid from a pleural aspiration is foul smelling what is it indicative of?
anaerobic empyema
if the fluid from a pleural aspiration contains pus what is it indicative of?
empyema
if the fluid from a pleural aspiration contains food particles what is it indicative of?
oesophageal rupture
if the fluid from a pleural aspiration is milky what is it indicative of?
chylothorax (usually lymphoma)
if the fluid from a pleural aspiration is blood stained what is it indicative of?
possible malignancy
if the fluid from a pleural aspiration blood what is it indicative of?
haemothorax (maybe from trauma)
what are the tests done on fluid from pleural aspiration in the ward?
look and smell
blood gas analyser (not if pus though)
how is a pleural aspiration carried out?
a 50ml syringe is connected to a 21G needle and lignocaine anaesthetic is administered
what biochemical tests are carried out from the aspirate of a pleural effusion?
protein level
LDH- lactate dehydrogenase
Amylase
glucose
what does a glucose level of <3.3mM in pleural aspirate indicitve of?
empyema RA SLE -systemic lupus erythematosis TB malignancy
which labs are pleural aspirates sent to?
biochemistry
microbiology
cytology
what does cytology look for in pleural aspirate?
malignant cells
lymphocytes
eosinophils
if the pleural protein content is <25g/l what type of PE is it?
transudate
if the pleural protein content is >35g/l what type of PE is it?
exudate
when the pleural protein level is 25-35g/l what criteria is used to determin the type of PE?
Light’s criteria
what are light’s criteria?
the PE is an exudate if any one of the following statements is true:
- pleural/ serum protein >0.5
- pleural /serum LDH >0.6
- pleural LDH >0.66 of upper limit of serum LDH
what two instruments are used to biopsy the pleura?
Abram’s needle
Tru-cut
what sort of biopsy is carried out with an Abram’s needle?
blind
what sort of biopsy is carried out with an Tru-cut?
CT guided
where is a biopsy carried out?
at the base of the intercostal space, the needle is not angled upwards to avoid the neurovascular bundle
where are pleural biopsies sent and how many to each place?
at least 3 sent in formaldehyde to histology
at least 1 sent in saline to microbiology if TB suspected
is there is no diagnosis after the biopsy what are the next tests?
- thoracoscopy
- video assisted thoracoscopy
if the pleural effusion is caused by a malignancy what is the treatment?
chemotherapy
if the PE is caused by TB what is the treatment?
antituberculosis chemotherapy
if the PE is caused by inflammation what is the treatment?
corticosteroids
what is the palliative treatment for PEs (usually caused by malignancy)?
repeated pleural aspiration, 1-1.5litres per day
what is pleurodhesis?
a procedure which aims to obliterate the pleural space
how is a normal pleurodhesis carried out?
- incision made in inferior part of 4th intercostal space, midaxillary line.
- local anaesthetic given to area of insertion, skin and underlying tissues
- thoracostomy tube inserted through incision into pleural space with kelly clamp
what is the fluid drainage rate for a pleurodhesis?
500ml/hr
if the lung does not re-expand after pleurodhesis what do you do?
suction for 24 hours.
if still not expanded remove drain as it is an infection risk.
if the lung re-expands after pleurodhesis what is the nest step?
chemical pleurodhesis
what is chemical pleurodhesis?
a talc slurry is instilled in the pleural space to adhere the pleura together.
when is surgical pleurodhesis carried out?
at the time of thoracoscopy
what is a pneumothorax?
the presence of air within the pleural cavity
what are the two ways that a pneumothorax can form?
breach of the parietal pleura
breach of the visceral pleura
what are the two types of pneumothora?
- spontaneous
2. traumatic
what are the two types of spontameous pneumothorax?
primary and secondary
what are the two types of traumatic pneumothorax?
non-iatrogenic
iatrogenic
what is a primary pneumothorax?
a pneumothorax with no undrlying disease
what is a secondary pneumothorax?
a pneumothorax with an underlysing disease
what is a iatrogenic pneumothorax?
a pneumothorax caused by medical intervention eg. incorrect insertion of a cannula
what is a non-iatrogenic pneumothorax?
a pneumothorax caused by non-medical trauma, eg. car accident
what is a tension pneumothorax?
a pneumothorax in which air can enter the pleural cavity but not leave, it causes the volume of air in the pleural space to increase
what are some underlying diseases that might cause a secondary pneumothorax?
pre-existing lung disease: COPD asthma pneumonia TB cystic fibrosis etc
what are some causes of non-iatrogenic pneumothorax?
penetrating chest injury (stab, gunshot)
blunt chest injury (rib fractures, bronchial rupture)
what are some causes of iatrogenic pneumothorax?
- pleural aspiration
- subclavian vein cannulation
- lung, liver, breast, renal biopsy
- acupuncture
when will a pneumothorax be asympomatic?
if small and good respiratory reserve
what are some symptoms of pneumothorax?
acute breathlessness
wosening breathlessness
pleuritic chest pain (from the tear in lung or chest wall)
what are the signs of a non-tension pneumothorax?
- surgical emphysema
- trachea deviated to affected side
- reduced expansion on affected side
- hyper resonant on affected side
- absent or redused breath sound on affected side
what are the signs of a tension pneumothorax?
trachea deviated away from affected side
haemodynamic compromise
increased JVP
what is haemodynamic compromise?
abnormal or unstable blood pressure
what is surgical emphysema?
air tracking in subcutaneous fat, gives a bubble wrap appearance.
how do you measure the size of a pneumothorax?
measure the size of rim of air at the hilum of the lung.
what are the questions that influence the management of a pneumothorax?
is it tension?
Small or large?
is patient breathless
is pneumothorax likely primary or sencondary
what is the treatment of a tension pneumothorax?
- cannula in 2nd intercostal space, mid-clavicular line
2. then insert intercostal chest drain
what is the management of a small primary pneumothorax?
- Observe overnight, repeat CXR, if no change, hole has sealed
- Discharge
Advise no vigorous activity, to return if becomes breathless
Pneumothorax will resolve at about 1.25% /day
Review with CXR clinic 2 weeks
what is the management of a primary pneumothorax causing breathlessness?
aspirate pneumothorax
If successful, CXR observe 24 hours, unsuccessful - chest drain
how is a pneumothorax aspiration carried out?
patient at 45 degrees
lignocaine to second intercostal space, midcalvicular line.
50ml syringe, venflon, 3 way tap, tube to water
aspirate until you feel lung on tip of venflon just beneath surface of chest wall
if >3litres of air is aspirated from a pneumothorax what is this suggest?
there is a persistent leak in the apparatus
what is the management of a secondary pneumothorax causing breathlessness?
insert intercostal chest drain in 4th intercostal space mid-axillary line
what is the ideal outcome of an intercostal chest drain?
Lung inflates in 1-2 days
Drain stops bubbling
CXR confirms lung inflated
if there is an ideal outcome of a chest drain what is the next step to test the pneumothorax will not return?
either:
Clamp drain for 24 hours, re CXR, no change, remove drain.
or
Re CXR after 24 hours, no change, remove drain.
what is the less than ideal outcome of a chest drain?
Lung fails to re-inflate after 48 hours
Drain continues bubbling
what is the next step of a chest drain is not successful?
Apply suction to drain (high volume, low pressure)
if lungs fail to inflate after chest drain and suction what is the next step?
contact thoracic surgeons at 3 days
Thoracoscopic inspection of visceral pleura,
Identification of blebs, tears, clipping and talc poudrage pleurodesis
people in which professions are in danger of asbestos exposure?
Boiler men, engineers, electricians, plumbers, building trade,
ship building (may not have worked with asbestos, in proximity)
Mothers or wives that clean asbestos-covered clothes.
what is the main disease associated with asbestos exposure?
mesothelioma
what is the presentation of mesothelioma?
breathlessness
chest wall pain
what is observed in radiological examination of mesothelioma?
diffuse or localised pleural thickening
usually unilateral
what is the radical treatment for mesothelioma?
if diagnosed very early in a fit patient then pleuropneumonectomy is offered
