L04: Effusions Flashcards by selcan icli

What is the pleural space

The space betwwen the viscera and the parietal plerua

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What does the visceral pleura cover

The lungs

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What does the parietal pleura cover

The chest wall

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What is in the pleural space

Pleural fluid

Low protein content

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What are the 2 types of pleural disease

Pleural effusion

Pneumothorax

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What is pleural effusion

Build up of fluid in the pleural space

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What is pneumothorax

Build up of air in the pleural space

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What are the types of pleural effusion according to the fluid

Transudate

Exudate

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What is transudate

Fluid that appears clear and protein content is low

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What is exudate pleural effusion

Due to an inflammatory process, fluid is cloudy and fluid content is high protein

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What are the causes of transudate fluid

Failures: heart failure, liver failure, renal failure

Hypoabuminaemia

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What are the causes for exudate fluid

Infections
Malignancy
PE
Inflammation; pancreatitis

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What are the presentations/symptoms for pleural effusion

Short of breath
Pleuritic chest pain
Cough

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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

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What is the gold standard diagnostic investigation for pleural effusion

Cxr

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After confirming that there is a pleural effusion what is the next step

To determine the fluid and take the fluid out

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How do we take the fluid out in a pleural effusion

By aspiration (thoracentesis)

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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

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After sending the pleural effusion sample what is the next question we need to determine

Is the effusion exudate or transudate

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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

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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

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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

1. High flow oxygen 2. Insert large bore canulla into the 2nd intercostal space mid clavicular line on side of pneumothorax 3. 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