L04: Effusions Flashcards
What is the pleural space
The space betwwen the viscera and the parietal plerua
What does the visceral pleura cover
The lungs
What does the parietal pleura cover
The chest wall
What is in the pleural space
Pleural fluid
Low protein content
What are the 2 types of pleural disease
Pleural effusion
Pneumothorax
What is pleural effusion
Build up of fluid in the pleural space
What is pneumothorax
Build up of air in the pleural space
What are the types of pleural effusion according to the fluid
Transudate
Exudate
What is transudate
Fluid that appears clear and protein content is low
What is exudate pleural effusion
Due to an inflammatory process, fluid is cloudy and fluid content is high protein
What are the causes of transudate fluid
Failures: heart failure, liver failure, renal failure
Hypoabuminaemia
What are the causes for exudate fluid
Infections
Malignancy
PE
Inflammation; pancreatitis
What are the presentations/symptoms for pleural effusion
Short of breath
Pleuritic chest pain
Cough
If the effusion is more than 300ml what are the physical examination findings that you may find
Dullness to percusion
Decreased tactile fremitus
Decreased breath sounds
Decreased focal resonance
What is the gold standard diagnostic investigation for pleural effusion
Cxr
After confirming that there is a pleural effusion what is the next step
To determine the fluid and take the fluid out
How do we take the fluid out in a pleural effusion
By aspiration (thoracentesis)
When the fluid is taken out by aspiration what happnes to the fluid
Is taken to :
Biochemistry: protein, LDH, protein
Microbiology: for infection, gram stain, microbiology, culture, tb
Cytology: for maligant cells
After sending the pleural effusion sample what is the next question we need to determine
Is the effusion exudate or transudate
How do we tell the difference between exudate and transudate fluid
Exudate: pleural fluid is more than 35
Transudate: pleural fluid is less than 25
What happens if the fluid has a protein content between 25-35, how do we determine what fluid it is
We use the LIGHTS criteria to differentiate
If the fluid is transudate what is the next step
Confirm the cuase by taking a history and examiantion
Lft, renal function and serum protein
Echo or liver ultrasound to exclude heart failure or cirrhosis
What is the management of transudate pleural effusion
Treat the cause
What is the next step if the fluid is exudate
Check: Fluid ph Fluid mcs and afb Fluid cytology Infection markers: crp,esr
What are the types of exudative fluid
Para-pneumonic
Empyema
What are the deatures of parapneumonic
Ph more than 7.2
Fluid cytology: no malignant cells
Fluid mcs and tb negative
Infection markers raised
What are the features of empyema
Fluid ph less tha 7.2
Fluid cytology: no malignant cells
Fluid mcs and tb: negaitve for tb
Infection markers rasied
What is the management of parapneumonic effusion
Antibiotics
Therapeutic drainage- if large and symptomatic
What is the management of empyema effusion
Prolonged antibiotics
Urgent chest drain to drain the fluid
Consider surgical referral to remove the pleural fluid
What is the presentation of tb effusion
General fatigue Night sweats Shortness of breath Unexplained weightloss Fever
What type of fluid will tb effusion have
Exudate
What can malignancy causing pleural effusion be
Primary: mesothelioma
Secondary: cancer
To confirm the diagnosis of pleural effusion what will the fluid be
Exudate
Show malignant cells in cytology
If the is a primary pleural malignancy what is the next step
Pleural biopsy
What is the treatment for malignant effusion
Treat the underlyling malignancy
Treat the symptoms with aspiration or chest drain
If there is recurrence of pleural effusion due to the malignacy what is the management
permanent chest drain
Pleurodesis: chest drain over 24-48 hours and insertion of talc that causes an inflammatory reaction between parietal and visceral pleura so they stick together
What are the types of pneumothorax
Spontaneous pneumothorax
Traumatic pneumothorax
Tension pneumothorax
What is spontaneous pneumothorax
Pneumothorax that occurs without trauma
What is traumatic pneumothorax
Results from penetration or non penetrating chest injury
What is spontaneous pneumothorax due to
Primary: occurs in young tall slim males
Secondary: to an underlying disease e.g copd, asthma, intersitial lung disease
What is the presentation of spontanous pneumthorax
Suddent onset of pleuritic chest pain
Shortness of breath
On examination what would a pneumothorax show
Tachycardia Hyper-resonance to percussion Decreased chest expainsion Decreased breath sounds Decreased focal resonance on the side of pneumothorax
What is the main investigation for pneumothorax
Chest-xray
What is the treatment of primary spontaneous pneumothorax
If patient is asymptomatic and pneumothorax is less than 2cm then dishcarge and outpatient follow up in 2-4 weeks
What is the treatmetn for someone who is symptomatic and has a depth more than 2cm
Aspirate using 12-18 canula if it improves discharge
If the patient remain symptomatic after a pneumothorax what is the treatmetn
Chest drain
What is the treatment for spontaneou secondary pneumothorax
If symptomatic and more than 2cm: chest drain
If depth is between 1-2cm: aspiration
If depth is less than 2cm: observe for 24 hours then discharge
What is tension pneumothorax
When air enters into the the pleural space with each inspiration and is unable to escape on expiration, so pressure build up and compresses the lung and mediastinum
What does the pressure on the mediastinum lead to
Heart becoming comresses which compresses the venous return to the heart leadinf to hypotension and potential cardiac arrest
What is the presentation of tension pneumothorax
Acute respiratory distress Hypotension Raised jvp Tracheal deviation away from the pneumothorax side Reduced air entry on affected side
What is the management of tension pneumothorax
- High flow oxygen
- Insert large bore canulla into the 2nd intercostal space mid clavicular line on side of pneumothorax
- Air will hiss to confirm the diagnosis
When the patient with tension pneumothorax is stable what is the next step
Carry out a chest x-ray
Insert a chest drain
Where is a chest drain inserted
Triangle of safety:
5th ICS
Mid axillary line
Anterior axillary line
When is needle aspiration contraindicated in spontaneous pneumothorax
Tension pneumothorax
Recurrent
Underlying lung disease
