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Resiratory SCE > Pleura And Mediastinum > Flashcards

Pleura And Mediastinum Flashcards

1
Q

Pneumothorax size to intervene

A

2 cm or above from apex

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2
Q

High risk features PTX

A

Tension
Hypoxia
Bilateral Ptx
Pregnant
Underlying lung disease
Over 50 and smoker
Haemothorax

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3
Q

Algorithm Ptx

A

Not symptomatic
Conservative
Primary opd and 2d rv secondary ip
Both review at 2-4 w dc

Symptomatic yes
High risk NO
Safe to intervene YES
Priority
A Avoid procedures conservative - psp ops every 48h or secondary inpatient
B LESS TIME HOSPITAL ambulatory device then old every 48h then remove device when resolved
C symptom relief then needle aspiration not resolved then chest drain

High risk features YES and symptoms yes
Not safe to intervene then CT
Safe to intervene ICD

Once resolved fu in 2-4 weeks

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4
Q

Pleural effusion mx by pH less than 7.2

A

Ph less than or equal 7.2
ICD
Calculate rapid
—Good prognosis better inflammation and reduced size us then continue
—Bad prognosis consider sx

Surgical candidate vats
Not surgical candidate fibrinolysis TPA DNAse (CI stroke or bleeding)
Alternative change Abx with 6w, rib resection, ipc

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5
Q

Ph 7.2 to 7.4

A

Ldh less than 900
No indication ICD

Ldh more than or equal 900
Consider ICD if temp/large/ gluc less than 4/ pleural enhancement ct/ separation pleural uss

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6
Q

Ph more than 7.4 low risk

A

Monitor

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7
Q

Most common causes MPE

A

Breast
Lymphoma
Meso
GU
GI

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8
Q

Management MPE

A

Pleurodesis lung expanded

IPC
Hydro pneumothorax
trapped lung
not for chemo
failed pleuro

CX local recurrence or infection
Multiloculated can try fibrinolysis

Surgery
Good ps
Pleurectomy vs vats

Pall care

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9
Q

Pleural sample

A

25-50 ml cyto

60% sensitivity

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10
Q

CABG effusion

A

L sided
Weeks after op

Immediately bloody with Eo and Ldh raised
Over 30d clear w lymphocyte

Aspirate vs chest drain if involves more than 1/3 chest
Pred or nsaid

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11
Q

Haemothorax

A

Trauma vs iatrogenic

HCT over 0.5

General
Abx
Resuscitate
CT

Low output
CT
Surgical chest drain
Loculation fibrinolytic and persist sx

Mx high output
Early
- large volume drained and stable VATS, unstable thoracotomy
Late
- surgery 48-72 hrs, thoracotomy if complex

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12
Q

Ipc infection

A

Try Abx if without removal if stable

MO
Staph aureus
Pseud

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13
Q

Ra pleural fluid

A

Yellow or green

UL or bilateral

Gluc < 1.5
Ph <7,2
Pseudo Chylothorax

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14
Q

Tuberculous effusion

A

Ct with contrast

Pleural fluid lymphocyte pred, low glucose, low pH
25% culture positive at 6w
80% Dx at bx
Ada, pleural fluid gen expert
Bronch

Mx RHZE 2m then RH for 4m
Drain then vats if needed
Steroids not evidence based

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15
Q

Trapped lung

A

Measure pressure pleural space if tubed
Thoracoscopy measure under GA

Mx
Pleurodesis works in 50%
IPC mainstay

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16
Q

Effusion raised amylase

A

Pancreatitis
Oesophageal rupture

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17
Q

Low glucose fluid

A

Empyema
TB
Malignancy
RA
Oesophageal rupture

Very low glucose < 1.6 empyema and RA

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18
Q

Lymphocytes in fluid

A

TB
Malignancy
RA
HF
PE
Chylothorax
Sarcoid
Uraemia
Yellow nail
Phenytoin or CM

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19
Q

Eosinophils pleural fluid

A

Asbestos
Sodium valproate
Vasculitis

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20
Q

Chest drain size

A

12F ok

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21
Q

Parapneumonic effusion

A

Exudate
Not empyema with ph less than 7.2/ Ldh over 1000/ pus

Cause
Infection
Oesophageal rupture
Lemieur

MO
CAP strep pneumonia/ staph / strep milleri
HAP mRsa/ enterobacter or enterococcus / pseud AND PROTEUS
IPC staph aureus

Mx start coamox and metro

US with tap
CT with contrast
Septic screen
Bronch if suspect obs lesion

Options
Ph more than 7.4 Abx and monitor

Ph 7.2-7.4 and Ldh more than 900 (septations/pleural contrast / gluc less than 4/ large) ICD
Ldh less than 900 Abx and monitor

Ph less than 7.2 or pus
Chest drain
Review 48 hrs if not improving rapid
—Poor prog Abx 6w. Septations fibrinolysis vs upsize
— Good pg vats at 5-7d vats vs open

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22
Q

Rapid

A

Renal urea <5 or 5-8 or more than 8
Age <50 or 50-70 or >70
Purulence 0 1
Infection source cap 0 vs Hap 1
Albumin <27 is 0

Low risk 0-2
Intermediate 3-4
High 5-7

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23
Q

Ep pneumothorax

A

9 in 100,000

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24
Q

Risk factors pneumothorax

A

Smokers
LAM
LCH
Burt Hogg dube
Marfan
Homocysturia

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25
Primary vs secondary
Primary no underlying lung disease Apical bleb or Bullae 32% risk recurrence Secondary Lung disease Over 50 Smoker 40% recurrence
26
Recurrence Ptx
30% primary 50% secondary then 10% mortality
27
After Ptx
Fly 7 days after lung up Dive only once treated surgically
28
Indications surgery Ptx
Bilateral Tension First controlateral Pregnant Persistent air leak despite suction d5 High risk eg pilot or diver Haemothorax Resection parenchyma or bullae Vs Surgical pleurodesis High risk eg pilot open thoracotomy and surgical pleurodesis
29
Ongoing air leak
Refer to surgery D3-5 if pt well Immediately if unstable Good ps Vats vs open pleurectomy Open 1.5% vs vats 4% recurrence Open less than 2% mortality Poor ps Valve or blood patch
30
Pregnancy Ptx
Chest drain as high risk features Forceps avoid ventilation Surgery referral after delivery
31
Tension
One way valve to pleural space so air in so pressure mediastinum reduces preload and causes obs shock Raised JVP Tracheal deviation away Hypotensive and tachycardia Loc High flow Needle aspiration then chest drain Review
32
Iatrogenic Ptx
Chest drain if secondary or ventilated
33
Traumatic Ptx
Ct Surgical chest drain Cardiothoracics rv
34
Subcutaneous emphysema
Oesophageal vs tracheal perf vs rib fracture Ptx High flow Ensure drain flushed and hole in pleural cavity Upsize drain GA with incision
35
Pleural thickening
Infection RA Haemothorax Asbestos Sob Cxr blunt cp angles CT with contrast +- PET Conservative
36
Pleural Bx
Ps 0-1 Under GA Ps 2 and above LA and thoracsocopy
37
Exudate
Protein over 30 In protein 25-30 lights fluid vs serum - protein more than 0.5 - LDH more than 0.6 or 2/3 Then serum effusion albumin gradient above 1.2 is transudate
38
Chylothorax
Supernatant after centrifuge turbid to clear Thoracic duct invasion causes chyle in pleural space Milky effusion TG >110 Low cholesterol Chylomicrons Trauma Surgery Cancer TB LAM Cirrhosis Sarcoid Subclavian vein thrombosis Aneurysm Ix detected chyle leak with MR lymphogram Mx Mx cause Low fat diet Weak evidence somatostatin analogues
39
Pseudochylothorax
Milky effusion High cholesterol >5.17 with cholesterol crystals Low TG No chylomicrons Doesn’t separate on centrifuge TB RA Chronic Ptx or Haemothorax
40
Hydrothorax
Ascites pleural space Exudate Neut more than 250 Cirrhosis with r sided effusion Stop etoh and salt Abx Diuretic Avoid ICD
41
Hepatopulmomary syndrome
CLD and portal hypertension so R to L shunt causing hypoxia Sob cyanosis clubbing telengiectasia cld Pao2 less than 8.5 Worse oxygenation lye flat Contrast echo rule out cardiac shunt CT O2 Avoid VD TIPS vs Coil 40% mortality
42
Genetic pleural
Burt Hogg Dube FLCN gene Skin tag, cyst, Ptx Kidney cancer Mx early pleurodesis and surveillance skin + renal ca Yellow nail Bromchiectasis pleural effusion yellow nail William Campbell Ig deficiency No bronchial cartilage so Bronchiectasis
43
Ptx on uss
M mode Stratosphere sign
44
Cause ipc infection
Staph epidermis Pseud Emterobacter
45
Talc chemicals
25mcg mean particle size Talc Tetracycline Bleomycin Mean inpatient stay 4d Slurry via ICD or pondrage Thoracoscopy same efficacy
46
Air after Ptx after 72 hours
Alveopleural fistula
47
Bullectomy approach
Open
48
Catamenal Ptx approach
Symptoms 72hrs pre period R sided Bg endometriosis Hormonal vs Vats
49
Renal stones and effusion mx
ICD
50
Lung obstruction
Lumen obstruction Endobronchial due to lung tumour
51
Thymoma classification
Masaoke-Koga
52
LENT
Pleural fluid LDH 1500 cutoff Ecog PS Neut to Lymph ratio <9 or >9 Tumour type - meso or Haem - breast gynae renal - lung cancer Low risk 0-1 Moderate 2-4 High 5-7
53
Thoracoscopy
Contra indication if raised paco2 Relative CI if plt less than 50 Local anaesthetic PS3 or better, lie flat more than an hour Parietal Bx Diagnostic yield 90%
54
Meso cause
Asbestos amphibole blue and crocidolite most potent 40y latency Smoking
55
Meso presentation and Ix
Boring chest pain Effusion Systemic fever chills weight loss lethargy Hoarse voice Paraneoplastic Exudative effusion lymphocytic Low glucose and pH Ct with contrast Pet avidity note for talc Bx gold standard
56
Meso stains
2 positive and 2 negative Positive Cyto 5 and 6 Calretinin D240 Wilms P53 Negative TTF CEA BerEP4
57
TNM Meso
Tx unknown primary T0 no primary T1 limited il T2 involves diaphragm then lung T3 endothor fascia - med fat- chest wall- peric T4 multi focal chest wall - peritoneum- CL - mediastinum- spine- myoC No no LN N1 il N2 CL med or suprac M0 no distant mets M1 distant mets S1 t1-3nomo S2 t1-2n1mo S3 t1-4 no-2mo S4 any tn with m1
58
Management Meso
MPE ICD and talc vs ipc Vats refractory MPE good PS Palliative rt for chest wall pain Pain matches disease distribution SACT First line Nivolumab and Ipilumab Pemtrexed and cisplatin Second line carboplatin and pemtrexed Additional beracizumab or raltrexed Pg 1y
59
Innervation
Parietal phrenic and intercostal Diaphragmatic phrenic and intercostal Visceral SNS and vagus no sensory
60
Appearance large Ptx and stable
Think bulla CT first
61
Thoracic suction Ptx
Low pressure high volume -10 to -20cmh20 Otherwise high pressure worsen air leak Indication Ptx chest drain air leak 48h Stable clinically and chest Xr better observe d2 D3 still bubble suction and consider surgeons 3-5 Any time Deteriorate upsize drain aw surgeons D3-5 surgery referral
62
Hydropneumothorax
IPC VATS
63
Prognosis Meso
Adenoca 2m Meso 10m
64
Fibrinolysis contraindication and moa
Alteplase breaks down septations and lavage DNase works on viscosity and biofilm CI Anticoagulant or coagulopathy with inr above 1.5 Less than 18 Pleural bleed Stroke Surgery less than 5d Pregnancy or breastfeeding Hepatic or renal disease Failed fibrinolysis same effusion
65
Mediastinal masses
Anterior Fluid thymic cyst Solid thymic tumour or teratoma or goitre Mixed lymphoma or cystic thymoma or teratoma Middle Fluid oesophageal cyst or bronchogenic cyst Solid LN or lipoma (same density peric fat) Other pericardial cyst or vascular abn Posterior Cystic neurogenic schwannoma meningocele Solid LN neuroblastoma schwannoma neurofibroma Fat then haemop
66
Buergers disease
Large vessel vasculitis Necrotising mediastinitis IV abx anaerobes Surgical debridement to drain CX recurrent abscess so repeat CT
67
Pneumomediastinum
Cough vomit Post ogd Ebus bronch Post surgery Rf Copd Retrosternal chest pain Ix CTCAP and gastograffin swallow Mx Observe 24h No exercise Analgesia O2 to help resorption Sx indication HD compromise VATS or Thoracotomy
68
Meso ct
Large UL effusion Pleural nodularity Uniform encasement of the lung Local invasion chest wall ribs mediastinum Plaques and fibrosis
69
Meso poor prognosis
Transdiaphragmatic muscle invasion Male Over 75 Chest pain Poor PS High WCC low plt Non epitheliod EORTC CALGB Modified Glasgow predictive Lent Brim decision tree
70
Features malignant mediastinal mass
20-40 Symptom cough chest pain sob /dysphagia strider svco horners /systemic/paraneoplastic Anterior
71
Neural tumours
Peripheral nerve Schwannoma or neurofibroma Asymptomatic Sx Malignant peripheral nerve Neurosarcoma Local invasion Autonomic Neuroblastoma or ganglioneuroma Benign sx or malignant chemo
72
Thymoma
Anterior mediastinum Epithelial origin Equal male to female in 20s Pain sob dysphagia or mg Mg in 40%, there after removal , 20% MG have Thymoma CT in capsule benign outside malignant. Smooth border with soft tissue and cystic component Avoid Bx seeding Surgery benign if malignant then chemo rad after Thymectomy better outcomes mACHR and younger Paraneop MG Red cell aplasia Hypogammaglobinaemia
73
Thymic cyst
Benign Congenital or acquired Large compressive sx Large excise
74
Thymic carcinoid
Associated Cushing Sx chemo rad octreotide
75
Germ cell tumours
Teratoma 80% Benign young equal Asymptomatic Normal afp Surgery Seminoma Male 20s Malignant Cells testes in thymus lobulated anterior med mass AFP normal Bx Cisplatin chemo then Rad bulky Non seminomatous gct Chorioca or teratoca or yolk sac Malignant 30s Local invasion symptoms Bx AFP and bHCG raised Cisplatin chemo then radio
76
Lymphoma
Hodgkin ant med Bx Chemo
77
Cancers met med LN
Breast Lung Oesophageal
78
Castleman disease
Angiofollicular LN hyperplasia Single site Cough wheeze or no symptoms Bx follicles or precap lymphocytes and proliferation Eo cap endothelial cells Sx Multi focal Idiopathic or hhv8 Systemic rash hsm paraproteinaemia Bx plasma cell due to il6 Ritux steroids chemo
79
Mediastinitis
Oesophageal perf Pain and fever Effusion pneumomed Ptx Repair defect tpn abx High mm
80
Mediastinal fibrosis
Older Cxr widened med Bx Supportive Steroid and surgery ineffective
81
If pH not available effusion
Glucose less than 3.3 high risk empyema Pleural fluid centrifuge
82
Low pH
Empyema RA Meso Local anaesthetic or heparin
83
Talc Ptx
After first Ptx in severe Copd
84
Causes effusions
Transudate Failures ccf liver nephrotic hypoalb Mitral stenosis /constrictive peric / pd /hypothyroid Exudate Infection Ca Pe Autoimmune pleuritic Drugs eg TKI Miegs CABG Asbestos
85
Benign asbestos effusion
Pleural plaque
86
Undiagnosed effusion
2y fu
87
Tb effusion
Pleural thickening more than 1cm Involvement mediastinal surface Nodularity No chest wall invasion Ddx cancer
88
Lymphoma effusion
Pleural fluid lymph subset
89
Pleural effusion infection failed fibrinolysis and not for vats
Switch abx for 6w Rib resection then IPC
90
Non expandable
Visceral pleural thickening prevent expansion
91
Non expansable
Endobronchial obstruction
92
PD effusion
High glucose Transudate
93
Pleural Bx lower
Mets closer to diaphragm
94
Obs post chest drain
Immediately 30 min for 1h Every 4h
95
Surgical emphysema
Drain flush Cxr hole inside pleural cavity If working but ongoing then suction vs upsize Suture not too tight high flow Still not improving surgery
96
Surgical emphysema
Drain flush Cxr hole inside pleural cavity If working but ongoing then suction vs upsize Suture not too tight high flow Still not improving surgery
97
Drugs effusion
TKI Mtx Amiodarone NF Phenytoin Bb
98
Cause of hypoxia in large effusion
Weight if effusion prevents diaphragm contracting so respiratory pump failure Neurochemical uncoupling Loss of RV diastole and reduced CO Low BP and high HR
99
Smallest volume effusion detected by
US up to 5ml
100
Risk of Meso
And pleural thickening so ? Ca Proceed to Thoracoscopy
101
RA vs SLE effusion symptom
SLE is painful
102
Percentage HF UL
40%
103
Right CT for pleural disease
Need delayed venous phase
104
Percentage MPE transudate
10%
105
Long standing effusion
TB Lymphoma HF PE
106
Rule 40%
40% effusions no MO 40% CAP cause effusions
107
Lidocaine effect pH
Lowers it Other causes contamination Delay Air Heparin Loculations
108
Indications CT pleural infection not improving
BPF Subdiaphragmatic abscess Lung abscess Check position
109
Risk Ptx smoking
Men 22x Women 9x
110
Syndromes Ptx
LAM LCH Birt Hogg Dube Catamenial Marfans
111
Benefit ICD in Ptx
Symptoms and air leak No effect on visceral defect - surgery to fix this faster
112
Choice valves based on lack of collateral ventilation
Over 95% then valve Less than 80% surgery 80-95% Chartis find defects in collateral ventilation May be candidate for staged valve implantation
113
Mx EBV air leak
Chest drain w topaz Ongoing air leak and stable upsize Then remove 1-2 and staged re implantation IP 72 hours monitor post EBV as worst prognosis Ptx occur at this time
114
CVID and mediastinal mass
Thymoma
115
Gent effusion
Poor penetration pleura
116
Anterior mediastinal mass calcified and in thoracic inlet
Thyroid
117
Traumatic Ptx
Delay air travel 2w post resolution Dive normal lft and CT
118
Sclerosing agent
Talc Doxy Tetracycline Minocycline Bleomycin Strep w benpen
119
Lymphoma causing pleural disease
NHL so diffuse large B cell
120
Prevent meso seeding
Chemo

Resiratory SCE (13 decks)

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