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Respiratory > Diseases of the pleura > Flashcards

Diseases of the pleura Flashcards

1
Q

What does the visceral plura cover and form?

A

Covers the lungs and forms the interlobar fissures

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2
Q

What does the parietal plura cover?

A

Mediastinum, diaphragm and inner surface of the thorax

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3
Q

How much fluid does the plural cavity contain and what is its function?

A

4ml of fluid

Functions: lubrication and surface tension (sticks the lungs to the chest wall)

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4
Q

Where do the two layers of pleura combine and where is there no plural coverage?

A

The visceral and parietal plura combine around the hilar of the lungs therefore the hilar have no plural coverage

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5
Q

What forms the pulmonary ligament and where is it found?

A

Plural layers form the pulmonary ligament which runs to attach the root of the lung to the diaphragm

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6
Q

What is a plural effusion?

A

An abnormal collection of fluid in the plural space

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7
Q

When is a plural effusion concerning?

A

Large unilateral effusion

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8
Q

If a large unilateral plural effusion is found on a CXR what should be done next?

A

A plural ultrasound to confirm its fluid.

Then do a plural aspirate (thoracentesis) to send to biochemistry, cytology and microbiology

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9
Q

Plural aspirates: what does the following imply?

1) Straw coloured
2) Red/bloody
3) Turbid/milky
4) Foul smelling
5) Food particles

A

1) Straw coloured = cardiac failure, hypoalbuminaemia
2) Red/bloody = Trauma, malignancy, infection, infarction
3) Turbid/milky = Empyema, chylothorax
4) Foul smelling = Anaerobic empyema
5) Food particles = oesophageal rupture

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10
Q

What is a chylothorax?

A

Type of pleural effusion. Lymph formed in the digestive system called chyle accumulates in the pleural cavity due to either disruption or obstruction of the thoracic duct.

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11
Q

What can cause a bilateral plural effusion?

A

Left ventricular failure,
PTE (pulmonary thromboendarterectomy)
Drugs- diuretics not working
Systemic pathology

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12
Q

What is a PTE?

A

PTE (pulmonary thromboendarterectomy) an operation that removes organized clotted blood from the pulmonary arteries, which supply blood to the lungs.

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13
Q

Plural effusion: what is a transudates and what can cause it?

A

Tranudate is a fluid with a protein <30g/L
Caused by heart failure, liver cirrhosis, hypoalbumanaemia or peritoneal dialysis
Less concerning

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14
Q

Plural effusion: what is an exudate and what can cause it?

A

Exudate is a fluid with a prtein >30g/L
Caused by malignancy, infection (TB?), primary infarct, asbestosis
More concerning

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15
Q

If a fluid protein is >2/3 of the serum protein level it is an exudate. True or false?

A

True

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16
Q

Plural effusion: apart from protein content, what other biochemical levels should you check in an aspirate?

A

Fluid pH- normal is 7.6. <7.3 suggests infection and <7.2 needs draining
Glucose- low in infection, TB, rheumatoid, malignancy and oesophageal rupture

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17
Q

What are you looking for in cytology of plural effusions?

A

Malignant cells- 2 samples will diagnose 2/3 of malignant effusions
Lymphocyes inmply TB, malignancy, chronic
Neurophils imply an acute process

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18
Q

What are you looking for in microbiology of plural effusions?

A

Gram stain and microscopy

PCR, Acid fast bacilli stain and culture (trying to identify TB)

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19
Q

How many plural aspirates should you do for diagnostic purposes and how much fluid should you take?

A

Up to 2- 2 samples will increase diagnostic yield but anymore will not.
Increasing volume doesn’t increase yield

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20
Q

What causes of plural effusion should resolve in <2 months?

A

CCF, Parapneumonic effusion, Acute pancreatitis, Post CABG, Post trauma, PE, Sarcoidosis, Traumatic chylothorax

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21
Q

What causes of plural effusion should resolve in 2-6 months?

A

Post CABG, TB, Cardiac injury, Sarcoidosis, Benign asbestosis, Chronic pancreatitis

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22
Q

What causes of plural effusion should resolve in 6-12 months?

A

Rheumatoid, benign asbestosis

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23
Q

What can cause a benign persistent plural effusion?

A

Trapped lung- one of the outcomes of fibrinous or granulomatous pleuritis
Lymphangiectasia-pathologic dilation of lymph vessels
YNS- yellow nail syndrome

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24
Q

Plural fluid cytology will diagnose what percentage of mesotheliomas?

A

30%

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25
Q

How can you obtain a tissue biopsy of the pleura?

A

1) CT guided biopsy
2) Blind pericutanious plural biopsy- uncommon
3) Thoracoscopy- ultra sound the pleural space. Insert needle and pump air into the plural space s lung deflates and insert a thoracoscope to take 5 biopsys

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26
Q

Why are biopsies often negative?

A

Poor technique
Involvement of plural disease is discontinuous
The effusion is caused by a malignancy but the effusion is not malignant

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27
Q

What is a mesothelioma?

A

Malignant tumour of the lining of the lung or rarely, the lining of the abdomen.

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28
Q

Mesothelioma can develop from exposure to one asbestos fibre, but the length of time of exposure increase the likelihood of developing mesothelioma. True or false?

A

True

29
Q

How long does it take for mesothilioma to develop?

A

30-40 years

30
Q

What systemic symptoms can mesothilioma cause?

A

Breathless, chest pain, weight loss, fever, sweating, cough

31
Q

What diseases can you claim against the government for?

A

1) Plural plaques
2) Asbestosis- pulmonary fibrosis
3) Mesothilioma
All caused by asbestos exposure

32
Q

What investigations are required if you suspect mesothiloma?

A

1) Imaging- CXR and CT (pleural nodularity, circumfrential pleural thickening, Local invasion, Lung entrapment)
2) Fluid aspirate- low cytological yeild
3) Biopsy- thoracoscopy or CT guided biopsy

33
Q

What can be offered as treatment for mesothilioma?

A

1) Pleurodese effusions
2) Chemotherapy
3) Radiotherapy
4) Palliative care
5) surgery- very unlikely

34
Q

Who must mesothelioma deaths be reported to?

A

Fiscal

35
Q

What are the most common cancers to metastasise to the pleura?

A

Lung and breast cancer

Upper GI, lymphoma, melanoma and ovarian cancer

36
Q

What is pleurodesis?

A

Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae. In hospital for 4 days

37
Q

What are the 2 different types of pleurodesis and what do they involve?

A

Talc slurry = talc in a suspension with NaCl and Lidocaine. Inserted through a chest drain
Talc poudrage = talc in an aerosol. Cannot go through a chest drain

38
Q

What is the success rate of pleurodesis?

A

60%

39
Q

What are the complications of pleurodesis?

A

Common: Minor pleuritic pain and fever
Rare: Pneumonia, Respiratory failure, ARDS, talc pneumonitis, secondary empyema

40
Q

When does pleurodesis work well and when is it less successful?

A

Works well if its clean

Doesn’t work well if there are lots of protein fibres/pockets

41
Q

Why are long term pleural catherters used and what is the maximum volume of fluid they can drain?

A

To allow patients to control effusion symptoms and stay out of hospital. Only 1 overnight stay required. Drain is designed to stay in place for life but can only drain 1L of fluid a day

42
Q

What are the complications of a long term pleural catheter?

A

Incorrect placement, bleeding and infection

But patients can bath/shower and even fly if they don’t have a pneumothorax

43
Q

What is the lent score used for and what does it stand for?

A

LENT score is used to determine survival in malignant pleural effusions. 0-7.
L = LDH- hw much protein in the plural space?
E = ECOG performance score
N = Neutrophil to lymphocyte ratio in serum
T = Tumour type

44
Q

If the pleural effusion is due to left ventricular failure, what is the treatment?

A

Diuretics

45
Q

If the plural effusion is due to infection, what is the treatment?

A

Antibiotics, possible drainage and possible surgery

46
Q

What is the stereotypical person to suffer a pneumothorax?

A

Tall, thin men who smoke cannabis with underlying lung disease

47
Q

What is the difference between a primary and secondary pneumothorax?

A 
Primary = normal lungs. Apical bullae rupture
Secondary = underlying lung disease. Eg COPD
48
Q

What is the presentation of a pneumothorax?

A 
Primary may be assymptomatic even if large
Acute onset pleuritic chest pain 
SOB, hypoxia 
Tachycardia 
Hyperresonant percussion- unilateral
Reduced expansion- unilateral
Quiet breath sounds- unilateral 
Hammans sound (click)
49
Q

What investigations are needed if you suspect a pneumothorax?

A

CXR

CT chest is useful to distinguish bullous lung disease or small pneumothorax

50
Q

How is a small and large pneumothorax classified?

A

Small = <2cm air at the hylum
Large = >2cm air at the hylum
A 2cm rim is approximately 50% of the thoracic volume

51
Q

How is a pneumothorax managed?

A 
Oxygen 
No treatment if asymptomatic and small
Aspiration (aviods chest drain but time consuming) Primary pneumothorax 
Chest drain- secondary pneumothorax
Suction or surgical intervention
52
Q

When would surgical intervention be needed in pneumothorax?

A

Second ipsilateral pneumothorax or first contralateral pneumothorax
Bilateral spontaneous pneumothorax
High risk professions- pilots/divers after first pneumothorax

53
Q

What is required in pneumothorax follow up?

A

CXR until resolution
Risk of recurrence- flying/diving advice
Smoking cessation

54
Q

What is a tension pneumothorax?

A

Emergency!

One way valve progressively increasing the pressure in the plural space.

55
Q

What are the signs of a tension pneumothorax?

A 
Mediastinal shift and compression of the opposite lung 
Acute respiratory distress
Tracheal deviation
Hypotention
Raised JVP
Reduced unilateral air entry
56
Q

What are the risk factors for tension pneumothorax?

A 
Ventilated patient 
Trauma 
CPR
Blocked/ misplaced drain
Airway disease 
Hyperbaric treatment
57
Q

What is the management for tension pneumothorax?

A

Needle decompression with a large bore venflon

2nd intercostal space anteriorally mid clavicular line

58
Q

What is the mortality for pleural infection and does it necessarily follow pneumonia?

A

20%

It doesn’t always follow pneumonia

59
Q

What are the risk factors for plural infection?

A

Diabetes, Immunosupression (inc. steroids), Gastero-oesophageal reflux, Alcohol misuse/PWID

60
Q

How does plural infection progress?

A

Rapid coagulation ad organization to form fibrous peals even with antibiotics

61
Q

What are the presentations of plural infections?

A

Simple paraneumonic effusion
Complicated paraneumonic effusion
Empyema (collection of pus in the plural cavity)

62
Q

What is an empyema?

A

A collection of pus in the pleural cavity

63
Q

What is the difference between a simple and complicated paraneumonic effusion

A 
Complicated = gram +ve stain. pH <7.2, low glucose, septations and loculations 
Simple = none of above
64
Q

What is the treatment for plural infection?

A

Simple effusion = antibiotics if small, drainage and antibiotics if large
Complicated effusion = drainage and antibiotics
Empyema = urgent drainage and antibiotics, surgery maybe required
*Venous thromboembolism prophylactics.
*Fibrinolytics are rarely used

65
Q

What type of antibiotics should be given for pleural infection?

A

Gentamycin does NOT enter the plural space. Use vancamycin (covers S.aureus) instead.
Coammoxiclav and augmenting can be used but increased risk of C. diff

66
Q

What is the function of mesothilial cells?

Linked: what is the hallmark of mesothilial disease?

A

Fluid absorbtion

Effusion

67
Q

It is possible for plural effusion and pulmonary oedema to develop together?

A

Yes

68
Q

What are the common causes of pneumothorax?

A

Trauma: fractured ribs
Iatrogenic: CT guided biopsies
Rupture of bulla

69
Q

What cell type of cancer commonly metastasises to the pleura?

A

Adenocarcinoma

Respiratory (26 decks)

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