M103 T4 L14 Flashcards
What are the common causes for chest wall deformities?
Kyphoscoliosis - most common
Respiratory muscle weakness
Osteoperosis - a crumbling spine and an abnormal thoracic cage AAR
How was TB treated before TB medication was approved?
thoracoplasty - people used to have very abnormal chest wounds as a result of this
What was involved in thoracoplasty?
removing lots of ribs from the patient to collapse down an area of TB infected lung
How can chest wall deformities affect the patient?
results in an altered shape of the chest wall,
less efficient at drawing air in
some alterations of respiratory mechanics
What are the features that, if a patient with respiratory failure comes in with, might be caused by a chest wall deformity?
never smoked
not very fat
don’t do drugs
have a big curvature of the spine
What might cause respiratory muscle weakness?
after prolonged critical care
low BMI
muscle wasting diseases
What is the normal pressure of the pleural space?
-2.5 mmHg
negative / subatmospheric
What is the effect of the negative pressure in the pleural space?
keeps the lungs inflated
How thick is the pleura?
0.3-0.5 mm
What is contained in pleural fluid?
proteins
lymphocytes
macrophages
mesothelial cells
What is the pH of pleural fluid?
about pH 7.6
What is the effect of a air or fluid moving into the lung?
causes an accumulation of positive pressure within the pleural space
can lead to a partial or complete collapse of the underlying lung
What are two common pleural conditions?
Pneumothorax
Pleural effusion
What are four types of pleural effusions?
Pleural infection (empyema)
Malignant Pleural Effusion
Heart failure
Haemothorax
What are the presenting symptoms of a pneumothorax patient?
Breathless
Chest pain
Cough
What are features within the history of a pneumothorax patient?
raised respiratory rate
may have low oxygen saturations
If unwell with tension pneumothorax – may be very unwell / peri arrest
What symptoms are found on examination in pneumothorax patient?
reduced breath sounds increased percussion note reduced expansion tracheal deviation Abnormal CXR
What are the four types of pneumothoraxes?
1o and 2o
traumatic
iatrogenic
What might cause an iatrogenic pneumothorax?
putting in a central line or a pacemaker
traumatic resuscitation
a biopsy (a bronchoscopy or radiologically guided)
How is a small iatrogenic pneumothorax treated?
given oxygen
chest x ray
if they don’t feel unwell hopefully it will sort itself out
What type of patient would a primary spontaneous pneumothorax be common in?
a healthy young tall male
What counts as a large iatrogenic pneumothorax?
when the pneumothorax measures more than 2cm from the hilum to the chest wall to the edge of the lung
How is a large iatrogenic pneumothorax treated?
chest drain
What might cause a traumatic pneumothorax?
resuscitation
a fight
a car crash
How is a traumatic pneumothorax treated?
chest drain
What might a primary spontaneous pneumothorax be caused by?
Apical bleb
More common in smokers (especially cannabis smoking)
Which people are apical blebs common in?
smokers, cannabis smoking
What are the features that would be common in a patient with a primary spontaneous pneumothorax?
short of breath
by the time you see them in A&E, they’ve got normal oxygen saturations, don’t short of breath anymore
How do you treat a patient with a primary spontaneous pneumothorax in A&E who is systematically improving?
send them home
see the in a Clinic in two weeks or less
to check that the pneumothorax is resolving
How do you treat a patient with a primary spontaneous pneumothorax is hypoxic or is breathless?
first line - aspiration
may need a chest drain
When is aspirating done?
as a first alternative to a chest drain
What might suggest a secondary pneumothorax?
if the patient has a known background of a lung disease
have previously been mechanically ventilated due to a lung condition
What conditions suggest a secondary pneumothorax?
COPD
bronchiectasis
ILD etc
How do you treat a patient with a secondary pneumothorax and why?
mostly will need a drain
bc tension is more common
Why is the measurement for a large iatrogenic pneumothorax set at more than 2cm?
bc this dimension is about a 50% reduction of the lungs when they collapse
Why is the location of where a pneumothorax is measured from significant?
the Americans do it differently - they measure from the apex up instead
What happens after a patient has been seen for having a primary pneumothorax?
they will be seen as an outpatient
wait till it’s been resolved with chest xrays
they need to be educated on the recurrence rates
they need to stop smoking
What are the recurrence rates for a primary pneumothorax?
54% recurrence in the first 4 years
20-30% recurrence in first 2 years
What happens after a patient has been seen for having a recurrent primary pneumothorax?
they will be referred to surgeons to have a surgical / medical thoracoscopy and pleurodesis
What happens after a patient has been seen for having a secondary pneumothorax?
immediately attempt a pleurodesis after the first episode
bc the recurrence rate is high
What is the advice regarding normal swimming and diving for pneumothorax patients?
as long as it is less than 10 ft depth. it is fine
What is the advice regarding air travel for pneumothorax patients?
officially allowed one week after full re-expansion of the lung but should be longer
Pneumothorax patients with which professions will have to change jobs?
coast guard
naval officer
air force
What will happen to a pneumothorax patient who is a pilot?
would be referred on to have a pre-emptive pleurodesis even without the recurrence
bc even the chance of recurrence would be so hard for them to do that job
What is the advice regarding high altitude sports and travel for pneumothorax patients?
should be done with caution
should be discouraged
What three factors are in a delicate balance to maintain the small volume of lubricating fluid in the pleura?
hydrostatic pressure
oncotic pressure
lymphatic drainage
What happens if any of the mechanisms keeping the volume of pleural lubricating fluid in check is disturbed?
may lead to pathology
may cause a pleural effusion
What are the clinical features of pleural effusion?
SOB, cough
pleuritic chest pain
reduced breath sound
“Dull” to percussion on examination
What are the causes of pleural effusion?
altered permeability of the pleural membranes
reduced oncotic pressure
increased capillary hydrostatic pressure
decreased lymphatic drainage or blockage
increased peritoneal fluid
What conditions might cause altered permeability of the pleural membranes?
inflammation
infection
cancer
What conditions might cause reduced oncotic pressure?
renal disease
liver cirrhosis
What is reduced oncotic pressure caused by?
low levels of albumin
What condition could cause increased capillary hydrostatic pressure?
heart failure
What conditions could cause decreased lymphatic drainage or blockage?
malignancy
trauma
What conditions could cause increased peritoneal fluid?
liver cirrhosis
peritoneal dialysis
What are the three most common conditions that cause pleural effusion?
heart failure
pneumonia
malignancy
What types of infection could cause pleural effusion?
Bacterial - common
Tuberculous - common
Fungal
Viral
What are the benign causes pleural effusion?
High oncotic pressure
Low protein state
Autoimmune disease
Reactive
What are the malignant causes pleural effusion?
1o malignant pleural effusion (mesothelioma)
2o malignant pleural effusion (more common)
Where is the cancer causing a secondary malignant tumour in the pleura most likely to originate from?
lung cancer
breast cancer
What conditions could cause a low protein state?
nephrotic syndrome
protein losing enteropathy
chronic liver disease
What conditions are examples of a autoimmune diseases?
Rheumatoid arthritis
SLE
Where is the cancer causing a secondary malignant tumour in the pleura less likely to originate from?
Gyneacological
heamotological
renal
GI tract
What are the statistics for pneumonias and co-morbidities? (don’t need to know the numbers)
50% develop an effusion - increases mortality x3
10% become infected - progress to empyema
over 30% either die or require surgery
20% have a 1 year mortality
Prolonged hospital admission
What are the risk factors for having a pleural infection?
Diabetes
Immunosuppression (steroids)
Alcohol, IVDU
Poor oral hygiene and aspiration (anaerobic)
Iatrogenic e.g. previous pleural procedure
Trauma
Recent hospitalization
What are the systemic features of an infection in pleural effusion?
fever
raised CRP/WCC suggest pleural infection
What are the predictors of the worse outcome for patients with a pleural infection?
pH <7.2 High LDH
Low glucose (<2/3rd of serum glucose)
Positive culture
Loculations (seen on ultrasound or CT)
What is done to find out more information about a pleural infection?
CXR
pleural fluid sample (after the patient has been on antibiotics, to see if there’s pus in the pleura)
Why are loculations barriers for using a drain on a pleural effusion?
instead of one big collection of fluid, it’s all broken up into lots of pockets
the presence of pockets means that we’re not going to be able to drain
Are antibiotics effective at treating infections in the pleural space?
no, they are notoriously bad at getting into the pleural space
bad pleural penetration
What are the features of an uncomplicated parapneumonic effusion?
occurs earlier on in the infection
the patient might be clinically well
there are no loculations
What is the cause of a complicated parapneumonic effusion?
Bacterial invasion into the pleural space
Fibrin deposition may form locules / septations
What is the cause of an Empyema?
pus within the pleural cavity with the thickening of the pleural surface
What are the three types of parapneumonic effusions?
Uncomplicated
Complicated
Empyema
How is an uncomplicated parapneumonic effusion treated?
will be resolved on treatment of the underlying pneumonia
may not need to be drained
may sort itself out
How is a complicated parapneumonic effusion treated?
Patient will likely need a drain
How effective is a chest drain when treating an empyema?
when you try and put the chest drain and it’ll be thick and hard
very difficult
trapped lung
it’s hard for the lung to re-expand, even with drainage
Is malignant effusion likely to happen again in a patient?
yes - it has a high recurrence rate
What is the median life expectancy for malignant effusion?
6 months
What is the most common type of malignant effusion?
unilateral
What symptoms does a malignant effusion usually present with?
breathlessness
cough
hypoxia
mostly are hemorrhagic
What are the different management treatments available for a malignant pleural effusion?
Aspiration with a >90% recurrence rate
Chest drain +/- pleurodesis – 60-70% success
Indwelling pleural catheter
Thoracoscopic drainage + pleurodesis
What are the four advantages of effusion drainage via an indwelling pleural catheter?
Avoids patient admission to hospital.
Suitable for long term drainage
Improves quality of life
50% spontaneous pleurodesis
Why is a talc pleurodesis used?
to prevent recurrence in patients with COPD who are too ill to have a general anaesthetic
When is a talc pleurodesis used?
for a malignant pleural effusion with no sign of infection
What is talc pleurodesis made up of?
medicated talc that creates a talc ‘slurry’ (a bit like glue) to stick the pleura together
What is the success rate of a talc pleurodesis?
about 70%
What are the two conditions of the lungs for a talc pleurodesis to be performed?
the lung needs to be reinflated for a talc pleurodesis to work
the lungs output needs to be <200ml/24hr
Why is a haemothorax not a bloody effusion?
bc the HCT >50%
What are the causes of a haemothorax?
Traumatic
Iatrogenic
Aortic dissection
How is a haemothorax treated?
resuscitate
urgent drainage (“surgical” drain)
Consider VATS
What is the difference between a primary spontaneous pneumothorax and a secondary one?
primary - SP in a person without an underlying lung disease
2o - SP with an underlying lung disease
What does a talc pleurodesis involve?
sterile talc mixed with saline is inserted via a tube IOT
cause irritation to the lung lining
What is the aim of talc pleurodesis?
to prevent fluid building up in the lining of the lung
