Diseases of the pleural space and chest wall

Question 1

What is the pleural cavity?

Answer 1

The pleural cavity is a potential
compartment separating the
chest wall, lungs, diaphragm and
mediastinum

Question 2

Name 5 initial treatments for a patient with dyspnoea

Answer 2

• Oxygen therapy
• IV access
• Pain relief
• Butorphanol
• Thoratocentesis

Question 3

What are the three sites for a TFAST ultrasound?

Answer 3

• Chest Tube Site 7th – 9th intercostal space on
  dorsolateral thoracic wall
• Pericardial site 5th – 6th intercostal space on
  ventrolateral thoracic wall
• Diaphragmatic view- just behind the xiphoid process with the probe directed cranially

Question 4

What are the indications for thoracocentesis?

Answer 4

Used to remove fluid or air from pleural space.
* Can be diagnostic or therapeutic

Question 5

What are the differentials for pneumothorax?

Answer 5

• Trauma or spontaneous
• Open, Closed, Tension

Question 6

What are the differentials for haemothorax?

Answer 6

• Trauma
• Coagulopathy
• Neoplasia

Question 7

What are the differentials for chylothorax?

Answer 7

• Idiopathic
• Trauma
• Congestive heart failure

Question 8

What are the differentials for pyothorax?

Answer 8

• Foreign body
• Penetrating trauma
• Secondary to pneumonia

Question 9

Name two space-occupying lesions that are differentials for pleural space disease

Answer 9

• Diaphragmatic hernia
• Neoplasia

Question 10

What is pneumothorax?

Answer 10

Air in the pleural space
(usually originates from the oesophagus)

Question 11

How might you treat pneumothorax?

Answer 11

Thoracocentesis / Thoracotomy tube.
* Pain medication / sedation.
* Oxygen therapy.
* Antibiotics if penetrating trauma.
* Radiographs to confirm resolution

Question 12

What surgery would you use to treat thoratocentesis?

Answer 12

Prognosis for conservative management of closed: guarded.
* Thoracotomy following CT to confirm location lesions

Question 13

What are the three types of pneumothorax?

Answer 13

• Closed
• Open
• Tension

Question 14

What is haemothorax?

Answer 14

Blood in the pleural space

Question 15

What are the main causes of haemothorax?

Answer 15

• Trauma
• Coagulopathy
• Neoplasia

Question 16

What further diagnostics would you need for haemothorax?

Answer 16

Need to identify underlying cause as will affect prognosis.
* Biochemistry / haematology.
* Coagulation testing.
* Look for signs bleeding elsewhere like petechiae

Question 17

How would you treat haemothorax?

Answer 17

Treat hypothermia / hypovolaemia.
* Blood transfusion?
* Pain relief.
* Treat underlying cause

Question 18

What is chylothorax?

Answer 18

• Milky effusion.
• Fat droplets, lymphocytes, neutrophils.
• Cholesterol similar to serum levels.
• Triglyceride higher than serum levels

Question 19

What are the causes of chylothorax?

Answer 19

Idiopathic.
* Damage to thoracic duct – traumatic rupture, obstruction.
* Lung lobe torsion, mediastinal masses.
* Heart disease.
* Diaphragmatic rupture

Question 20

What breeds are over-represented in terms of chylothorax?

Answer 20

Siamese, Himalayan cats and Afghan hounds overrepresented

Question 21

How would you treat chylothorax?

Answer 21

Thoracocentesis.
* Often idiopathic but can treat underlying cause.
* Low fat diet?
* Surgical duct ligation

Question 22

What are the main causes of pyothorax?

Answer 22

Foreign body (grass seed, penetrating wound).
* Bite wound (cats).
* Pneumonia (uncommon)

Question 23

How would you diagnose pyothorax?

Answer 23

Appearance and smell!
* Degenerate neutrophils and intracellular bacteria

Question 24

How might you treat pyothorax?

Answer 24

Thoracic drainage (thoracostomy tube) and lavage.
* Surgical FB removal.
* Antibiotics.
* Long and expensive.
* Prognosis Guarded

Question 25

What are the indications for a thoracostomy tube?

Answer 25

Frequent drainage chest required.
* Medical management of pyothorax.
* Following thoracic surgery

Question 26

What are the main management practices for a thoracostomy tube?

Answer 26

• Constant monitoring
• Drain every 4 hours for 24-48 hours then 2-3 times daily
• Use a thoracic lavage with 0.9% sodium chloride or Hartmanns solution
• Change dressing and check connectors daily
• if it appears non-functional will need to flush
• remove once fluid production = 2-4ml/ kg a day
• cover sterile dressing once removed

Question 27

What is a diaphragmatic hernia?

Answer 27

Displacement of organs into the thoracic cavity
Empty appearance in the abdomeb
Intestinal content in the thorax

Question 28

What are the clinical signs of a diaphragmatic hernia?

Answer 28

• Dyspnoea
• Muffled heart and lung sounds
• Intestinal sounds in teh chest
• ‘empty abdomen’ abnormal on palpation

Question 29

How might you treat a diaphragmatic hernia?

Answer 29

• Stabilise the patient
• Surgery- Abdominal approach, Will need IPPV, must drain pneumothorax

Question 30

What are the differentials for chest wall injury?

Answer 30

• Trauma
• Flail chest
• Open pneumothorax
• Penetrating trauma
• Bite wounds

Question 31

What is flail chest?

Answer 31

Free moving section of chest wall secondary to consecutive rib fractures

Question 32

What are the clinical signs of flail chest?

Answer 32

Tachypnoea, dyspnoea
* Thoracic pain
* Paradoxical movement of flail segment
* Subcutaneous emphysema

Question 33

How would you treat flail chest?

Answer 33

Emergency stabilisation
* Chest bandage
* Aggressive pain management
* Surgical stabilisation

Question 34

What are the potential complications of a dog bite?

Answer 34

• Crushing of thorax
• Rib fractures
• Lung laceration
• Intercostal muscle avulsion
• Bacterial innoculation into wound

Question 35

How might you stabilise a dog post bite?

Answer 35

Start antimicrobials early.
* Protective dressing until definitive treatment.
* TFAST to ensure no pleural effusion/pneumothorax.
* Radiography to assess for fractures.

Question 36

How might you treat a dog post dog bite?

Answer 36

Surgical exploration.
* Flush wound for culture and sensitivity.
* Pain relief.
* May require thoracic drainage