Pleura And Mediastinum Flashcards
Pneumothorax size to intervene
2 cm or above from apex
High risk features
Tension
Hypoxia
Bilateral Ptx
Pregnant
Underlying lung disease
Over 50 and smoker
Haemothorax
Algorithm Ptx
Not symptomatic
Conservative
Primary old 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 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
Pleural effusion mx by pH less than 7.2
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
Ph 7.2 to 7.4
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
Ph more than 7.4 low risk
Monitor
Most common causes MPE
Breast
Lymphoma
Meso
GU
GI
Management MPE
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
Pleural sample
25-50 ml cyto
60% sensitivity
CABG effusion
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
Haemothorax
Trauma vs iatrogenic
HCT over 0.5
Surgical chest drain vs thoracotomy
Bleeding major haemorrhage
Ipc infection
Try Abx if without removal if stable
MO
Staph aureus
Pseud
Ra pleural fluid
Yellow or green
UL or bilateral
Gluc < 1.5
Ph <7,2
Pseudo Chylothorax
Tuberculous effusion
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
Trapped lung
Measure pressure pleural space if tubed
Thoracoscopy measure under GA
Mx
Pleurodesis works in 50%
IPC mainstay
Effusion raised amylase
Pancreatitis
Oesophageal rupture
Low glucose fluid
Empyema
TB
Malignancy
RA
Oesophageal rupture
Very low glucose < 1.6 empyema and RA
Lymphocytes in fluid
TB
Malignancy
RA
HF
PE
Chylothorax
Sarcoid
Uraemia
Yellow nail
Phenytoin or CM
Eosinophils pleural fluid
Asbestos
Sodium valproate
Vasculitis
Chest drain size
12F ok
Parapneumonic effusion
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
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
Rapid
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
Ep pneumothorax
9 in 100,000
Risk factors pneumothorax
Smokers
LAM
LCH
Burt Hogg dube
Marfan
Homocysturia
Primary vs secondary
Primary no underlying lung disease
Apical bleb or Bullae
32% risk recurrence
Secondary
Lung disease
Over 50
Smoker
40% recurrence
Recurrence Ptx
30% primary
50% secondary then 10% mortality
After Ptx
Fly 7 days after lung up
Dive only once treated surgically
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
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
Poor ps
Valve or blood patch
Pregnancy Ptx
Chest drain as high risk features
Forceps avoid ventilation
Surgery referral after delivery
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
Iatrogenic Ptx
Chest drain if secondary or ventilated
Traumatic Ptx
Ct
Surgical chest drain
Cardiothoracics rv
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
Pleural thickening
Infection
RA
Haemothorax
Asbestos
Sob
Cxr blunt cp angles
CT with contrast +- PET
Conservative
Pleural Bx
Ps 0-1
Under GA
Ps 2 and above
LA and thoracsocopy
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
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
Pseudochylothorax
Milky effusion
High cholesterol >5.17 with cholesterol crystals
Low TG
No chylomicrons
TB
RA
Chronic Ptx or Haemothorax
Hydrothorax
Ascites pleural space
Exudate
Neut more than 250
Cirrhosis with r sided effusion
Stop etoh and salt
Abx
Diuretic
Avoid ICD
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
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
Ptx on uss
M mode
Stratosphere sign
Cause ipc infection
Staph epidermis
Pseud
Emterobacter
Talc chemicals
25mcg mean particle size
Talc
Tetracycline
Bleomycin
Mean inpatient stay 4d
Slurry via ICD or pondrage Thoracoscopy same efficacy
Air after Ptx after 72 hours
Alveopleural fistula
Bullectomy approach
Open
Catamenal Ptx approach
Symptoms 72hrs pre period
R sided
Bg endometriosis
Hormonal vs Vats
Renal stones and effusion mx
ICD
Lung obstruction
Lumen obstruction
Endobronchial due to lung tumour
Thymoma classification
Masaoke-Koga
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
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%
Meso cause
Asbestos
amphibole blue and crocidolite most potent
40y latency
Smoking
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
Meso stains
2 positive and 2 negative
Positive
Cyto 5 and 6
Calretinin
D240
Wilms
P53
Negative
TTF
CEA
BerEP4
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
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
Innervation
Parietal phrenic and intercostal
Diaphragmatic phrenic and intercostal
Visceral SNS and vagus no sensory
Appearance large Ptx and stable
Think bulla
CT first
Thoracic suction
Low pressure high volume
-10 to -20cmh20
Otherwise high pressure worsen air leak
Indication Ptx chest drain air leak 48h
Hydropneumothorax
IPC
VATS
Prognosis Meso
Adenoca 2m
Meso 10m
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
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
Other pericardial cyst or vascular abn
Posterior
Cystic neurogenic schwannoma meningocele
Solid LN neuroblastoma schwannoma neurofibroma
Fat then haemop
Buergers disease
Large vessel vasculitis
Necrotising mediastinitis
IV abx anaerobes
Surgical debridement to drain
CX recurrent abscess so repeat CT
Pneumomediastinum
Cough vomit
Post ogd Ebus bronch
Post surgery
Rf Copd
Retrosternal chest pain
Mx
Observe 24h
No exercise
Analgesia
O2 to help resorption
Sx indication HD compromise
VATS or Thoracotomy
Meso ct
Large UL effusion
Pleural nodularity
Uniform encasement of the lung
Local invasion chest wall ribs mediastinum
Plaques and fibrosis
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
Features malignant mediastinal mass
20-40
Symptom cough chest pain sob /dysphagia strider svco horners /systemic/paraneoplastic
Anterior
Neural tumours
Peripheral nerve
Schwannoma or neurofibroma
Asymptomatic
Sx
Malignant peripheral nerve
Neurosarcoma
Local invasion
Autonomic
Neuroblastoma or ganglioneuroma
Benign sx or malignant chemo
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
Avoid Bx seeding
Surgery benign if malignant then chemo rad after
Thymectomy better outcomes mACHR and younger
Paraneop
MG
Red cell aplasia
Hypogammaglobinaemia
Thymic cyst
Benign
Congenital or acquired
Large compressive sx
Large excise
Thymic carcinoid
Associated Cushing
Sx chemo rad octreotide
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
Lymphoma
Hodgkin ant med
Bx
Chemo
Cancers met med LN
Breast
Lung
Oesophageal
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
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
Mediastinitis
Oesophageal perf
Pain and fever
Effusion pneumomed Ptx
Repair defect tpn abx
High mm
Mediastinal fibrosis
Older
Cxr widened med
Bx
Supportive
Steroid and surgery ineffective
If pH not available effusion
Glucose less than 3.3 high risk empyema
Pleural fluid centrifuge
Low pH
Empyema
RA
Meso
Local anaesthetic or heparin
Talc Ptx
After first Ptx in severe Copd
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
Benign asbestos effusion
Pleural plaque
Undiagnosed effusion
2y fu
Tb effusion
Pleural thickening more than 1cm
Involvement mediastinal surface
Nodularity
No chest wall invasion
Ddx cancer
Lymphoma effusion
Pleural fluid lymph subset
Pleural effusion infection failed fibrinolysis
Switch abx for 6w
Rib resection then IPC
Non expandable
Visceral pleural thickening prevent expansion
Non expansable
Endobronchial obstruction
PD effusion
High glucose
Transudate
Pleural Bx lower
Mets closer to diaphragm
Obs post chest drain
Immediately
30 min for 1h
Every 4h
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
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
Drugs effusion
TKI
Mtx
Amiodarone
NF
Phenytoin
Bb
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
Smallest volume effusion detected by
US up to 5ml
Risk of Meso
And pleural thickening so ? Ca
Proceed to Thoracoscopy
RA vs SLE effusion symptom
SLE is painful
Percentage HF UL
40%
Right CT for pleural disease
Need delayed venous phase
Percentage MPE transudate
10%
Long standing effusion
TB
Lymphoma
HF
PE
Rule 40%
40% effusions no MO
40% CAP cause effusions
Lidocaine effect pH
Lowers it
Other causes contamination
Delay
Air
Heparin
Loculations
Indications CT pleural infection not improving
BPF
Subdiaphragmatic abscess
Lung abscess
Check position
Risk Ptx smoking
Men 22x
Women 9x
Syndromes Ptx
LAM
LCH
Birt Hogg Dube
Catamenial
Marfans
Benefit ICD in Ptx
Symptoms and air leak
No effect on visceral defect - surgery to fix this faster
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
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
