pleura LGW Flashcards
what is pleural effusion and what is the normal pleural space fluid?
accumulation of fluid in the pleural space
normal fluid 1-15 ml
what does a history of pleuritic chest pain suggest ?
eeither pulmmoonarry embolism or inflammatory pleural process
what does a history of constant dull-aching pain suggest ?
chest wall invasion by bronchogenic carcinoma or malignant mesothelioma
at what level of effusion does pleural effusion manifest ?
once it exceeds 300 ml
what are the signs associated with pleural effusion ?
stony dullness
decreased breath sounds
decreased vocal resonance
mediastinal shift away from the effusion if it is above 1000 ml
if there is displacement of the trachea towards the effusion what may this denote ?
clue to obstruction of a labor bronchus
malignancy or foreign body
what are the two main types of pleural effusion ?
transudate and exudate
what are the causes of transudate pleural effusion ?
compression of the SVC
congestive HF
constrictive pericarditis
hypoalbuminemia
nephrotic syndrome
cirrohsis
what doees exudate arise from ?
asbestos exposure
raditation pleuritis
pulmonary embolism
TB
/
malignancy
what are the three main investigations when it comes to pleural effusion ?
radiology
pleural fluid analysis
pleural biopsy
what arre the findings in chest x ray for pleural effusion ?
P-A view upright film
small effusion - blunting of the costophrenic angle
large effusion - mediastinal shift away from the. effusion
what does hydropneumothorax look like on X-ray ?
air fluid level is seen
what is thoracocentesis ?
method to remove fluid from the fluid or air from the thoracic cavity
either therapeutic or diagnostic
where is the tube placed for thoracocentesis ?
2 rib interspace below the level of stony dullness
what must be done after thoracentesis ?
1- inspiratory chest X-ray to establish a new baseline for patients likely to have recurrent effusions
2- expiratory chest x ray to exclude pneumothorax
what are the relative contraindications associated with thoracentesis ?
1- small volume of fluid
2- bleeding disorder orr systemic anticoagulant
3- mechanical ventilation
4- cutaneous disease over the proposed puncture area
complications of thoraentesis ?
1- pain at the puncture site
2 - cutaneous or internal bleeding
3- pneumothorax
4- empyema
5- spleen or liver puncture
on gross examination what do each of these descriptions indicate ?
frankly, purulent fluid -
milky fluid -
bloody fluid -
empyema
chylothorax
hemothorax
what is seen on X ray suggesting empyema ?
D shaped opacity
at what level of protein is exudative effusion indicated ?
above 2.9 g/dl
low pleural glucose vs very low pleural glucose ?
low pleural glucose - malignant effusion , TB
very low pleural glucose - suggest empyema
what does a high triglyceride level in the pleural fluid suggest ?
chylothorax
what does a pleural fluid ph of less than 7.2 suggest?
empyema
what level of hematocrit suggests hemothorax ?
above 50%
what is light’s criteria ?
fluid is considered an exudate if any of the following apply :
1- ratio of pleural fluid to serum protein is more than 0.5
2- ratio of pleural fluid to serum LDH is more than 0.6
3- pleural fluid LDH is more than 2/3 of the upper limits of normal serum value
need to measure pleural fluid and serum protein and LDH
what are the differentials associated with pleural fluid lymphocytosis ?
more than 85 suggests TB or lymphoma
betweeen 50 to 70 suggests malignancy
how can WBC be used to differentiate between exudate and transudate ?
transudate is less than 1000 mm
exudate is more than 1000 mm
what are the types of pleural effusion in lung cancers ?
1- transudate - compression of the SVC
2- exudate - infection distal to obstruction or malignant cells in pleural fluid
3- hemorrhagic - pleural invasion by the tumor
4- chylothorax - metastasis compressing on thee thoracic duct
5- pyothorax- pyogenic infection on top
what are the characteristics of malignant pleural effusion ?
1-haemorrhagic
2- massive
3- rapidly accumulating
4- mediastinum may be shifted to the same side
what does it mean if light’s criteria is not met ?
then its transudate
what is seen on erect CT in a patient with hemothorax ?
blunting of hemidiaphragm
progressive loss of basal lung field
what is the management for hemothorax ?
crossmatch blood for urgent transfusion
correct coagulopathy with fresh frozen plasma or platelets
small hemothorax - observe with serrial x-ray and mmoniitorr for signs of deterioration
significant hemothorax - insert a large borre chest drain
when should a thoracic surgeon be contacted in a patient with hemothorax ?
if drainage exceeds 1000ml or more than 200ml for 3 hours despite correcting coagulopathy
what is seen on x ray of pneumothorax ?
abnormal collection of air on the pleural space
what are thee three main causes of pneumothorax ?
spontaneous
trumatic
iatrrogenic
what are the spontaneous causes of pneumothorax ?
1- primary - young , thin patient
associated with marfan’s and ehlers danlos
2- secondary - underlying lung disease
COPD
Asthma
CF
what are the three types of pneumothorax ?
closed pneumothorax
open pneumothorax
tension pneumothorax
what are the signs associated with pneumothorax ?
1- asymmetric chest expansion
2- hyperresonance on the affected side
3- absent or decreased breath sounds on the affected side
what is thee management for recurrent pneumothorax ?
pleurodesis
what is thee management of pneumothorax ?
depends if the patient is symptomatic or asymptomatic
1- asymptomatic and no high risk features - thee patient can be discharged
2- symptomatic patients can undergo either : needle aspiration , intercostal chest drain or the insertion of an ambulatory device
what are the high risk characteristics associated with pneumothorax ?
hypoxia
bilateral pneumothoraces
underlying lung disease
haemodynamic compromise
what is the management for tension pneumothorax ?
ABCDE
high flow oxygen
immediate needle decompression
inn the 2nd intercostal space, midclavicular line
so that it is converted from tension pneumothorax to simple pneumothorax
presentation of tension pneumothorax ?
cardiogenic shock and respiratory distress
tachycardia and hypotensive
what tare the pleural fluid findings associated with empyema ?
LDH above 1000
very low glucose levels ( below 30)
pH below 7.2
what are the differentials of pleural fluid esosinophilia?
eosinophils above 10% are often caused by air or blood in the pleural space ass with
1- pulmonary embolism with infarction
2- parasitic disease (paragonimiasis)
3- medication
i the pleural fluid turns out to be exudate with a low glucose level what are the differentials ?
malignancy
bacterial infections
TB
what is the most sensitive radiological option for the diagnosis of pneumothorax ?
CT chest
