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Respiratory (Zoe) > Pathology (Pleuritic disease) > Flashcards

Pathology (Pleuritic disease) Flashcards

1
Q

What is the dual blood supply to the lungs?

A

Pulmonary arteries and bronchial arteries

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2
Q

Is the pulmonary system low or high pressure compared to the systemic circulation?

A

Low

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3
Q

Where does fluid accumulate in the lungs and what is this called?

A

In the interstitum and in the alveolar spaces.

Pulmonary odema

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4
Q

Will pulmonary oedema show a restrictive or obstructive pattern on spirometry?

A

Restrictive

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5
Q

Give two generalised causes of pulmonary oedema?

A

Haemodynamic (increased hydrostatic pressure due to left sided heart failure)
Cellular injury: In the alveolar lining cells or in the alveolar endothelium

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6
Q

What is ARDS?

A

Acute respiratory distress syndrome: a severe, life-threatening medical condition characterized by widespread inflammation in the lungs.

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7
Q

Give some reasons that ARDS would occur?

A

Sepsis, trauma, diffuse infection, lack of oxygen

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8
Q

What is the pathogenesis of ARDS?

A 
Injury (for example a bacterial endotoxin)
Infiltration of inflammatory cells
Cytokines
Oxygen free radicals
Injury to cell membranes
Fibrous exudate lining alveolar walls
Cellular regeneration
Inflammation
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9
Q

Give three possible outcomes for ARDS?

A
  1. Death
  2. Resolution
  3. Fibrosis
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10
Q

What is respiratory distress syndrome of the newborn?

A

When babies are born prematurely their type 2 alveolar cells are not yet mature enough to produce high enough levels of surfactant. Surfactant reduced alveolar surface tension and so without this neonates have to put a massive effort into expanding the lungs. They therefore struggle to breath.

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11
Q

What is an embolus?

A

A detached intravascular mass carried by the blood so a site of infection distant from the site of origin.

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12
Q

What are most emboli? Give some rarer examples also.

A

Thrombi (from blood)

Can also be gas, fat, tumour clumps

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13
Q

What is the source of most pulmonary emboli?

A

DVT

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14
Q

What are the three prongs of virchows triad? What do these put you at risk for?

A

Hypercoaguability of the blood
Stasis of the blood/abnormal flow
Endothelial damage
Put you at risk for a DVT or a PE.

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15
Q

What are the symptoms of a PE?

A

Severed pleuritic chest pain
Dysponea
Haemoptysis
Sudden death or collapse

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16
Q

What two factors are required for a pulmonary infarct?

A

Embolus

Compromised bronchial artery supply

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17
Q

What are the mechanisms by which you get pulmonary hypertension?

A
  1. Hypoxia due to vascular constriction (most pressure on the lungs)
  2. Increased blood flow through the pulmonary circulation.
  3. Blockage due to a PE
  4. emphysema which causes a loss of the pulmonary vascular bed.
  5. Back pressure from left sided heart failure.
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18
Q

Describe the morphology of pulmonary hypertension

A
  1. Arteries become hypertrophied
  2. Fibrosis of these arteries
  3. Atheroma
  4. Right ventricular hypertrophy (due to increased back flow into the right side of the heart
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19
Q

What is cor pulmonale?

A

Enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lungs (pulmonary hypertension)

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20
Q

What are some symptoms of cor pulmonale?

A

Dysponea, Fatigue, syncope,

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21
Q

What are some signs you would see in for pulmonale?

A

Ankle/sacral oedema, hepatomegaly, raised JVP, tricuspid regurgitation ( pan systolic murmur)

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22
Q

What is the pleura made of?

A

Mesothelial cells designed for fluid reabsorption, which make up a surface lining for the lungs and the mediatstinum.

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23
Q

What is a transudate effusion and what does it show?

A

Pleural effusion containing less 30g of protein, shows that their is organ failure (e.g. cardiac)

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24
Q

What is an exudate effusion and what does it show?

A

Pleural effusion showing more than 30g of protein. This shows that there is pneumonia, connective tissue disease, malignancy, TB (NOT ORGAN FAILURE)

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25
Q

What is a pneumothorax?

A

Air in the pleural space

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26
Q

What is a primary pneumothorax?

A

A pneumothorax that occurs with no known cause.

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27
Q

What is a secondary pneumothorax?

A

One that occurs in the context of existing lung pathology.

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28
Q

What is a tension pneumothorax?

A

When the pleura rips a one way valve is formed meaning that, with each inspiration, more air is drawn into the thoracic cavity and cannot renter the lung. It is a medical emergency!

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29
Q

What are bullae?

A

Air pockets within the lungs that can burst and cause a pneumothorax.

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30
Q

Give an example of primary pleural neoplasia?

A

Benign

Malignant mesothelioma

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31
Q

Give an example of a secondary pleural neoplasia and sites of its likely origin:

A

Adenocarcinomas

Lung, ovary

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32
Q

What is a mesothelioma?

A

An asbestos related tumour found in the pleural cavity.

It has mixed epithelial and mesenchymal differentiation.

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33
Q

What would you expect the pleural fluid to be like in malignant mesothelioma?

A

Bloody

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34
Q

How would you make a definitive diagnosis of mesothelioma?

A

Histology following a pleural biopsy. (Abrams needle thorascopy)

35
Q

How many ml of serous fluid are secreted into the pleural cavity?

A

4mls

36
Q

What are the two layers of pleura, where are they, and what do they sense?

A

Visceral: Covers the lung and senses stretch.
Parietal: Covers the inner surface of the thoraces wall and senses pain.

37
Q

What is the function of the pleural fluid?

A

Allows the pleura to slide smooth during respiration.
Surface tension allows a lung surface to stay touching the thoracic wall and therefore creates a seal between the 2 surfaces.

38
Q

What happens to the two pleural surfaces at the lung root?

A

The two layers combine around the root of lthe lung so the root of the lung itself actually has no pleural coverage. They ;ayers combine to form the pulmonary ligament.

39
Q

What does the pulmonary ligament do?

A

Runs inferiorly and attaches the root of the lung to the diaphragm.

40
Q

What is the nervous supply of the visceral pleura?

A

Sensory ending of Vagus nerve. Vasomotor fibres

41
Q

What is the nervous supply of the parietal pleura?

A

Intercostal nerves and phrenic nerve

42
Q

What colour would a pleural effusion be on a chest x ray?

A

White

43
Q

What finding on examination most clearly suggests a pleural effusion?

A

Stony dull to percussion.

44
Q

What tests could you do if you suspected a pleural effusion?

A 
CXR
Pleural aspirate
CT
Cytology
Pleural biopsy
Thoracoscopy
Biopsy if you were concerned about malignancy.
45
Q

What colour should the pleural fluid be?

A

Straw coloured

46
Q

What would you suspect if the pleural fluid was bloody?

A

Trauma, malignancy, infection, infarction

47
Q

What would you suspect t if the pleural fluid was turbid or milky?

A

Empyema, chylothorax

48
Q

What is a chylothorax?

A

A kind of pleural effusion consisting of lymphatic fluid.

49
Q

What would you suspect if the pleural fluid was foul smelling?

A

Anaerobic empyema

50
Q

If there had been an oesophageal rupture what would there most likely be in the pleural fluid?

A

Food

51
Q

What pathology would give you a very viscous pleural aspirate?

A

Mesothelioma

52
Q

If your aspirate had a very high neutrophil count what would you suspect had happened?

A

Parapnemonia(pneumonia that has travelled into the pleural space) or a PE

53
Q

What would the cell cytology look like in someone who suffered from chronic effusions?

A

Mononucleur cells

54
Q

What would you strongly suspect if the pleural aspirate was rich in lymphocytes?

A

TB

also could be sarcoid, lymphoma or rheumatoid

55
Q

What could be causing an exudate (low protein) pleural aspirate?

A
  1. Cardiac failure
  2. Liver cirrhosis
  3. Nephrotic syndrome
  4. Ateclectasis
  5. Hyperthyroidism
  6. Meig’s syndrome
  7. Urinothorax
  8. Pericarditis
56
Q

What could be causing a transudate (high protein) pleural aspirate?

A
  1. Parapneumonia
  2. Pulmonary emboli
  3. Malignant effusion
  4. Rheumoatoid
  5. Mesothelioma
  6. TB
  7. Oesophageal rupture
  8. Chylothorax
  9. Benign asbestos effusion
  10. Drugs
57
Q

What is the normal pH of pleural fluid?

A

7.4

58
Q

At what pH would drainage be required?

A

Below 7.2 as this suggests parapneumonia or empyema.

59
Q

Would glucose levels be low or high in the pleural fluid at times of infection?

A

Low. Would also be low in TB, rheumatoid, malignancy, oesophageal rupture.

60
Q

What is pleurodesis? When would this be indicated?

A

When the visceral and parietal pleura are stuck together with talc or surgery. This would only ever be done in malignancy.

61
Q

What is a negative implication of pleruodesis?

A

Reduces exercise tolerance.

62
Q

You see fluid on a chest x - ray which is sticking to the wall rather than being seen at the bottom of the lungs, what is it most likely to be?

A

Empyema.

63
Q

What would be indications that you needed a chest drain?

A 
Tension pneumothorax
Symptomatic pneumothroax 
Complicated parapneumonia
Malignant pleural effusion
Traumatic haemopneumothorax.
64
Q

Give some complications of chest drains

A

Pain, inadequate placement, surgical emphysema, infection, haemorrhage, organ damage, re expansion pulmonary oedema,large effusions that drain to quickly, vasovagal reaction (patient may faint)
Sudden death as a result of extreme vagal reaction.

65
Q

List some asbestos related pathologies

A 
Benign pleural plaques
Asbestos related pleural effusions
Asbestosis
Mesothelioma
Diffuse pleural thickening
Rounded ateletasis
66
Q

When looking at a x ray what would benign pleural plaques look like?

A

Calcified regions.

67
Q

What is the usual treatment for benign pleural plaques?

A

No treatment required and these are usually asymptomatic.

68
Q

Give some features of asbestos related pleural effusions

A

Small and unilateral, resolve spontaneously, bloodstained. They require symptomatic treatment.

69
Q

What is diffuse pleural thickening?

A

Extensive fibrosis of the viscera pleura which then forma adhesion to parietal pleura. The patient will suffer from SOB and chest pain and you will see a restrictive spirometry. It is difficult to treat but very important to diagnose as the patient is entitled to compensation

70
Q

What investigations would you carry out if you suspected mesothelioma and what would results would you expect to find?

A

Aspiration of pleural aspiration (Low cytological yield)
CXR and CT (effusion, pleural nodularity, local invasion)
Biopsy under Ct or US guidance.

71
Q

What treatments are available for mesothelioma?

A 
Pleurodesis
Radiotherapy
Chemotherapy
Surgery
Mostly palliative
Family will be entitled to compensation so all deaths must be reported
72
Q

What MRI findings would you expect to see with mesothelioma?

A

Pleura will be clearly enlarged and visible (should not be able to see the pleura at all under normal circumstances)

73
Q

What is classified as a small pneumothorax?

A

Less that 2cm rim of air

74
Q

What is classified as a large pneumothorax?

A

More that 2cm rim of air

75
Q

What does 2cm of air represent in a pneumothorax

A

50% of the thoracic cavity.

76
Q

How would you treat a pneumothorax that was asymptomatic and small?

A

No treatment would be required.

77
Q

What treatments may be given for a larger pneumothorax?

A

Aspiration
Chest drain
Suction
Surgery

78
Q

What would be indications for surgical intervention is the case of a pneumothorax?

A

Your second pneumothorax on the same lung (ipsilateral).
Your first pneumothorax but on the opposite lung(contralateral).
Bilateral pneumothorax
A persistant air leak after 5 days of drainage.
A spontaneous heamothorax
High risk professions such as pilots and drivers.

79
Q

What follow up treatment is required after a pneumothorax?

A

Follow up chest x ray

Stop smoking

80
Q

Can you fly again after a pneumothorax?

A

After 6 weeks you should be fine to drive

If you have had surgery this should be confirmed by a chest x ray

81
Q

Should you dive again after a pneumothorax?

A

No

82
Q

What happens in a tension pneumothorax?

A

A one way valve is created so whit each inspiration more air floes into the thoraces cavity.
This is a medical emergency
Chest contents move away

83
Q

What signs and symptoms would you see in a patient with a tension pneumothorax?

A

Trachea deviates away from the side where there is a pneumothorax
Raised JVP
Hypotension
Reduced ir entry
Patients would be in respiratory distress

84
Q

How do you treat a tension pneumothorax?

A

Needle decompression with a large bore venflon.

This is inserted in the second intercostal space anteriorly, mid clavicular line.

Respiratory (Zoe) (7 decks)

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