Lecture Notes Flashcards
What is pleural effusion?
Abnormal collection of fluid in the pleural space.
What are the symptoms of a pleural effusion?
- asymptomatic if the volume of fluid is small and accumulates slowly.
- increasingly SOB
- pleural pain (inflammatory will be resolved by draining fluid but malignancy will get progressively worse)
- dull ache
- dry cough
- weight loss, fever, night sweats
What are the clinical signs of a pleural effusion?
On affected side- Decreased expansion Stoney dullness on percussion Decreased breath sounds Decreased vocal resonance
Clubbing, tar staining
Trachea may have changed position
Peripheral oedema
What are the differences between translates and exudates?
Transudates
- imbalance of hydrostatic forces influencing the formation and absorption of pleural fluid
- normal capillary permeability
- 30m/l
What are the four types of pneumothorax and give examples of each?
Spontaneous
- primary
• occurs without an apparent disease
• occurs mostly in young people between 20-30 years
• Believed to be due to the weight of lungs inducing the rupture of developing apical blebs
-secondary
•patient has a pre-existing lung disease
•COPD, asthma, CF, TB, sarcoidosis, fibrosing alveolitis ….
Traumatic
-non iatrogenic
•chest injury (stabbing, gun shot, rib fractures)
- iatrogenic •during surgery •sub clavian vein cannulation •lung, liver, breast, renal biopsy •acupuncture
What is pleurodhesis?
A procedure that adheres the outside of the lung to the inside of the chest cavity to prevent the lung from collapsing
Where does the net force of fluid act in the pleural cavity ?
Into the lungs
There is a greater arterial pressure in the systemic blood flow compared to the pulmonary blood flow therefore pushes fluid into the lungs.
How would you investigate pleural diseases?
X-ray -> CT -> Pleural aspiration -> pleural biopsy
Name four common conditions caused by transudates
o Left ventricular failure
o Liver cirrhosis
o Hypoalbuminaemia
o Peritoneal dialysis
Name two common conditions caused by exudates
o Malignancy (lung, breast, mesothelioma, metastatic) o Parapneumonic (consider sub-phrenic)
What is CT useful to differentiate between?
malignant and benign disease
What suggests malignancy on a CT?
These suggest malignancy: nodular pleural thickening mediastinal pleural thickening parietal pleural thickening >1cm circumferential pleural thickening other malignant manifestations in lung/liver
Name some complications of aspiration of pleural effusion
o Pneumothorax o Empyema - infection o Pulmonary oedema o Vagal reflex o Air embolism - pushing air in o Tumour cell seeding o Haemothorax
What two types of needles can be used during a biopsy?
Abrams’ needle (blind biopsies), Tru-cut (CT guided)
Name some treatment methods and management strategies for pleural effusion
Chemotherapy Antituberculous chemotherapy Corticosteroids Palliative (usually malignancy) - Repeated pleural aspiration 1-1.5 litres at any one time Pleurodhesis
What is the sequence of technique that is used for a pleurodhesis if the lung is not re expanding?
- Pleurodhesis ->
- Apply suction 24 hours ->
- Remove drain due to infection risk ->
- Chemical Pleurodhesis (Instill 3mg/kg lignocaine and talc slurry (2-5g), clamp drain 1hour) 90% success ->
- Remove drain after 12-72hours if lung remains re-expanded
What is a tension pneumothorax?
is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return because there is a flap acting like a one way valve.
Name some symptoms of a pneumothorax.
Assymptomatic (if small, good respiratory reserve)
Acute breathlessness, worsening breathlessness
Pleuritic chest pain
Extreme dyspnoea
What do you have to check about a suspected pneumothorax before being able to treat it?
Tension?
small/large? Small: rim of air 2cm
primary/secondary?
breathless?
What is Talc poudrage?
Talc poudrage - the application of powder to a surface, as between the visceral and parietal layers of the pericardium or pleura to promote their fusion in pleurodesis.
Pleurectomy - excision of a portion of the pleura
What is Pleurectomy?
Pleurectomy - excision of a portion of the pleura
Where does malignant mesothelioma form in the body and what type of fluid is produced?
Malignant mesothelioma is a disease in which malignant (cancer) cells are found in the pleura or the peritoneum (the thin layer of tissue that lines the abdomen and covers most of the organs in the abdomen).
This tumour causes inflammation which causes fluid called exudate to form in the lung.
The smell and colour of fluid taken from a pleural aspiration can sometimes be used to make a diagnosis. State the differences and what diagnosis they would suggest.
foul smelling – anaerobic empyema pus - empyema food particles – oesophageal rupture milky – chylothorax (usually lymphoma) blood stained - ?malignancy blood – haemothorax, trauma
what are the four main investigations that should be done for pleural effusion?
X-ray, CT, Aspiration, Biopsy
On a CT scan what would suggest pleural malignancy?
pleural thickening
After an aspiration, what three investigations should be done on the fluid extracted?
biochemistry, microbiology, cytology
what four things can be measured from biochemistry?
protein (transudate/exudate)
amylase
glucose
LDH
what four things can be measured by microbiology?
gram staining
AAFB
culture
MC&S (urine mid stream test)
what three things can be measured using cytology?
malignant cells
lymphocytes
eosinophils
abnormally low glucose levels can suggest??
empyema rhemotoid arthititis TB malignancy lupus
what are the signs of a non tension pneumothorax?
trachea is deviated towards the affected side
decreased chest expansion
hyper resonant
absent breath sounds
what are the signs of a tension pneumothorax?
trachea is deviated away from the affected side
increased JVP
haemodynamic compromise
what should be done for a pleural effusion, if the aspiration and biopsy haven’t found a diagnosis?
video assisted thoracoscopy
at what rate should the fluid of a pleural effusion be extracted?
500ml/hr
what is the management of a small primary not breathless patient?
- observe for 24 hours
- repeat CXR
- if no changes then discharge as the hole has most likely repaired itself
- review CXR for 2 weeks
what should the management for a primary breathless patient?
- aspirate
if successful, CXR and observe for 24 hours
if unsuccessful, chest drain
what should be done for a secondary breathless patient?
- aspirate but usually not very successful
- chest drain
= 4th intercostal space, mid axiliary line
= lung usually inflates in 1-2 days when the drain stops bubbling - clamp the drain for 24 hours
- CXR
- observe for 24 hours
- if no change then remove the drain
What should be done if a chest drain is done and the lung doesn’t re-inflate after 48 hours?
- apply suction to the drain
- contact thoracic surgeons at day three for inspection of visceral pleura by thoracoscopy to identify blebs, tears and clipping
is it likely that a pneumothorax will occur again?
yes
when should a patient be referred for surgical pleurodhesis?
- 2nd ipsilateral pneumothorax
- 1st contralateral pneumothorax
- bilateral spontaneous pneumothorax
- first pneumothorax for high risk professionals
