Pleura Diseases - pleural effusion Flashcards
What are the three known diseases of the pleura
Pleural effusion
Pneumothorax
Mesothelioma
The pleura is a single layer of what type of cells?
What is the pleura lubricated with?
What is the pressure in the pleura?
mesothelial cells
2-3ml pleura fluid
-0.66kPa
What is the pressure pulling pleura fluid out of the pleura cavity
Plasma osmotic/oncotic pressure
What pressure is pulling pleura fluid into the pleura cavity
Systemic and arterial negative intra pleural pressure
What is the definition of pleura effusion
collection of fluid in pleural space that is
greater than 2-3ml of pleural fluid
What is the symptoms of pleura effusion
Increasing breathlessness pleuritic chest pain dull ache dry cough weight loss malaise fevers night sweats
When can a pleural effusion by asymptomatic
when its small and accumulates slowly
What activates coughing in pleura effusion
The feeling of heaving your lungs squished causes breathlessness activating receptors triggering you to cough
What is the signs of pleura effusion on chest examination
reduced chest expansion
stony dulness on percussion - due to water density
decreased breath sounds
decreased vocal resonance
What are further signs of pleural effusion on general examination
Clubbing, tar staining of fingers Cervical lymphadenopathy Trachea away from large effusion Peripheral oedema increased jugular venous pressure
What causes transudate pleural effusion
An imbalance of hydostatic forces influencing the formation and absorption of pleural fluid
Dont affect permeability
Usually bilateral
What causes exudate pleural effusion
is fluid that leaks around the cells of the capillaries caused by inflammation, increasing the permeability of of the local capillaries
e.g. malignancy
How much protein is roughly present in Exudate effusion and transudate effusion
exudates >35g/l
transudates <25g/l
Whats the most common cause of transudate pleural effusion
heart failure - left ventricle failure
Liver cirrhosis
hypoalbuminemia
Peritoneal dialysis- gut cleaning
Less common: hypothyroidism Kidney disorder narrowing of heart valves Pulmonary embolism
What is the most common cause of exudate pleural effusion
Malignancy (Lung/breast)
Pulmonary embolism
parapneumonic effusion
Less common Rheumatoid arthritis autoimmune disease Pancreatitis Post myocardial infarction
What is parapneumonic effusion
a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis
What is very rare cause of transudate effusion
Constrictive pericarditis - inflammation of pericardium
Ovarian hyperstimulation syndrome
Meigs’ Syndrome - benign ovarian fibroma
What is the very rare causes of exudate effusion
Yellow nail syndrome
and certain Drugs
Why don’t transudate effusions need much investigation
and when would they be investigated
as usually you can just treat the underlying cause
Investigate if:
Unusual features
Failure to respond to appropriate treatment
What investigation confirms the presence of a pleural effusion
Chest x ray - 200ml is detectable pleural aspiration and a biopsy CT of thorax blood gas analyser Thorascopy - direct
What does a more enhanced CT of the thorax enable you to see in a pleural effusion
Differentiates between malignancy or benign disease
looks for lumps on pleural surface
mediastinal and pleural thickening
parietal thickening above 1cm
other malignant manifestations
What is the possible complications of an aspiration
Pneumothorax Empyema Pulmonary oedema Vagal reflex Air embolism Tumour cell seeding Haemothorax -person is on anticoagulation and you hit a blood vessel
what is the difference between aspiration and biopsy
aspiration is the removal of fluid with a needle and biopsy is the removal of tissue
What does foul smelling pleural aspirin indicate
anaerobic empyema - pus
What does food particles in the pleural aspiration indicate
oesophageal rupture
What does a milky plural aspiration indicate
chylothorax - lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct
What does a blood stained pleural effusion usually indicate
Possible malignancy
What does blood in the pleural effusion indicate
haemothroax
trauma
When would a blood gas analyser be taken in the investigation of pleural effusion and what does it show us
If pus isn’t present in pleural aspiration
pH and if the operation is infected
When the pleural aspiration is sent to the laboratories what biochemistry is analysed
Protein levels - transudate or exudate
LDH - Lactate dehydrogenase
amylase levels
glucose levels
What does glucose levels below 3.3mM indicate in pleural effusion
empyema rheumatoid arthritis TB malignancy Systemic lupus erythematosus (SLE) - autoimmune disease
What would high amylase levels indicate in a pleural effusion indicate
pancreatitis, oesophageal rupture, or malignancy
What does the cytology of an pleural effusion aspiration potentially show
lymphocytes
malignant cells
eosinophils
What does the microbiology of a pleural effusion aspiration allow
Gram staining
test for acid-alcohol fast bacilli (resist decolorisation)
culture
When protein levels are between 25g/l how do you distinguish between transudate and exudate
Lights criteria
Using lights criteria when is it classed as an exudate
1) Pleural fluid : Serum protein ratio > 0.5
2) Pleural fluid LDH > 2/3 of the upper limit of the serum reference range
3) Pleural fluid : Serum LDH ratio > 0.6
How many biopsies should be taken and where are each of these samples sent
4 biopsies
Send at least 3 in formaldehyde for histology
Send at least 1 in saline to microbiology if TB suspected
What does treatment of pleural effusion dependant on
how do you treat the symptoms of pleural effusion
Underlying cause
Chest drain
Pleurodesis
When would you use a chest drain in treating pleural effusion
Palliative care in treating effusion due to malignancy
If pH is below <7.2
Or if Pleural Aspiration shows infection
When would you perform a Pleurodesis and what is the procedure
In cases of severe recurrent pleural effusion
A procedure that causes the membranes around the lungs to stick together and prevents the buildup of fluid in the pleural space
Where is a chest tube placed?
How does the process work?
What additional resource helps the process?
4th intercostal space mid-axillary line
repeated pleural aspiration 1-1.5 litres at any one time
a seal -drains the pleural cavity to dryness
What checks the success of a pleurodesis and chest drain treatment
A chest X ray to see if lungs has re-expanded
What are the two forms of pleurodesis and what is the processes
Chemical:
lindocaine or a slurry of talc can be introduced into the pleural space through a chest drain or in thorascopy causing irritation between the parietal and the visceral layers of the pleura which closes off the space between them and prevents further fluid from accumulating
surgical:
Performed in thorascopy, mechanically irritate pleural closing space and preventing re-accumulation fluid
