Pleura & Mediastinum Flashcards
1
Q
What anti-epileptic drug causes lymphocytic pleural effusion?
A
Phenytoin, particularly in early stage of treatment . Carbamazepine, though less common
2
Q
What type of effusion does Sodium Valproate cause?
A
Eosinophilic pleural effusion
3
Q
What is the most common hospital acquired pleural infection?
A
Methicillin- resistant staph aureus
4
Q
What is mesothelioma?
A
Malignant tumour of mesothelial surfaces (most commonly pleura) usually resulting from asbestos exposure
5
Q
What causes Mesothelioma?
A
ASBESTOS
- history of occupational exposure in up to 90% of cases
Other; Non asbestos fibres (erionite) found in rocks in Turkey, Simian Virus 40 (contaminated polio vaccine) , Spontaneous in children
6
Q
What is the latent interval between first exposure to asbestos and death?
A
Around 40 years
7
Q
What is the most potent type of asbestos for mesothelioma?
A
Amphibole - blue (Amisite - brown , and crocidolite)- crocidolite most dangerous
(Serpentine - chrystolite , white , previously thought to be safer)
8
Q
Is mesothelioma dose related ?
A
Not dose related and no threshold of exposure
9
Q
Is there an association between mesothelioma and smoking ?
A
No
10
Q
What is the main clinical feature of mesothelioma?
A
Chest pain
Also; breathless, profuse sweating
11
Q
What are the CT features of mesothelioma?
A
- Moderate to Large pleural effusion and pleural modularity and enhancement and involvement of mediastinal pleural
- Localised pleural mass/ thickening without free fluid
- Uniform en casement of the lung - small hemithorax
- Local invasion of chest wall, ribs, heart , mediastinum, hilar nodes and diaphragm, transdiaphragmatic spread to contralateral pleura
- Associated pleural plaque and fibrosis in minority of cases
12
Q
What are the histological subtypes of mesothelioma?
A
EPITHELOID - 50% of cases , may be confused with adeno, better prognosis
SARCOMATOID (Fibrous / Lymphohistiocytoid and desmoplastic pattern) - worse prognosis
MIXED
13
Q
How diagnose mesothelioma histologically
A
Need 2 positive mesothelial immunohistochemical markers (Calretin , Cytokeratin 5/6 , Wilma Tumour 1 and podoplanin D240) AND 2 negative adenocarcinoma immunohistochemical markers (thyroid transcription factor TTF1 ,CEA and Ber EP4)
14
Q
What are the poor prognostic factors in mesothelioma?
A
Transdiaphragmatic muscle invasion
Involvement of mediastinal LNs
Male
> 75 years
Chest pain
Poor PS
High WCC
Thrombocytosis
Non epitheloid histology
15
Q
What are the prognostic tools in Mesothelioma?
A
EORTC
CALGB Score
Modified Glasgow predictive score MGPS
LENT score (if effusion)
Brim’s decision tree : (WL /PS/ Hb / Albumin/ Histo) ** used in clinical practice
16
Q
Is radiotherapy used in mesothelioma?
A
Only for palliative radiotherapy for chest wall pain etc
17
Q
Is surgery used in mesothelioma ?
A
Not recommended not shown to be beneficial in trial of EPP and EPD
18
Q
What SACT is used in mesothelioma?
A
1st line : NIVOLUMAB and IPILUMAB
2nd line : Pemetrexed and Cisplatin
19
Q
What is the prognosis for mesothelioma?
A
4-12 months from diagnosis
20
Q
What proportion of mediastinal masses are benign?
A
2/3
21
Q
What increases likelihood of a mediastinal mass being malignant ?
A
- Age 20-40 years
- Symptoms
- Anterior location of mass
22
Q
What are the symptoms of mediastinal disease ?
A
Cough, chest pain , dyspnoea
Symptoms related to compression: dysphagia, stridor, SVCO, Horners
Systemic effects : night sweats , WL (lymphoma)
Paraneoplastic - myasthenia with thymoma
23
Q
What is the Anterior Mediastinum?
A
Pre-Vascular (Anterior) mediastinum is the area behind the sternum and infront of fibrous pericardium and great vessels
Contains Thymus, Fat, LN and left brachiocephalic vein
24
Q
What masses can you get in anterior (pre-vascular) mediastinum ?
A
4 Ts:
Thymus (Thymoma, Thymic cyst , Thymic hyperplasia, Thymic carcinoma)
Terrible Lymphoma
Teratoma (Germ cell tumours)
Thyroid goitre
Also: parathyroid adenoma, Lipoma , Morgagni Anterior diaphragmatic hernia
25
What makes up the paravertebral (posterior) mediastinum?
The area adjacent to the vertebral bodies , contains:
- thoracic spine
- neurovascular bundles
- spinal ganglion
- sympathetic chain
- lymphoid tissue
26
What are masses in the posterior compartment most likely to be ?
- Neural tumours (Neurofibromas/Neurosarcomas) Schwannoma most common
- Meningocoeles
- Spinal lesions
27
What makes you the visceral (middle) mediastinum?
Anterior to a vertical line connecting a point on each thoracic vertebral body 1cm posterior to its anterior margins Contains: heart , pericardium, great vessels, thoracic duct, trachea, oesophagus, LNs
28
What are masses in middle (visceral) mediastinum most likely to be ?
Bronchogenic cyst
Pericardial cyst
Foregut duplication/cyst
Lymphadenopathy (lymphoma, sarcoid, Mets)
Oesophageal cancer
Vascular abnormalities
29
Outline neural tumours
Most occurs in the posterior mediastinum, 75% benign in adults and MRI is often useful
Schwannomas/Neurofibromas : benign peripheral nerve sheath tumours , dumbbell shaped and straggle intervertebral foramen. Asymptomatic usually and can be surgically excised
Malignant peripheral nerve sheath tumours or neurosarcomas: new malignant growths and benign neurofibromas that undergo malignant change. Can invade locally
Autonomic Nervous System tumours (Neuroblastomas/Ganglioneuromas) - range from benign>malignant . Surgical removal (if malignant then for chemoradiotherapy)
30
Outline thymomas
- Found in anterior compartment
- Tumour of epithelial origin arising in the thymus , may contain functioning thymus tissue
- Male=Female , rare <20
- Myasthenia Gravis is present in 30-40% of patients often unimproved after thymectomy AND can develop after removal , also 20% of patients w myasthenia gravis have a thymoma particularly if male and > 50 (+ve AChR Antibodies)
- Symptomatic - pain, dyspnoea , dysphagia or MG
- Thymomas within Thymic capsule : benign but have malignant potential , those that have extended outside are malignant
Dx: CT (avoid FNA /biopsy due to seeding)
Tx : Surgically excise (if invasive post op radiotherapy and chemotherapy)
NB thymectomy often recommended even without MG as may lead to symptomatic improvement but best results are in those with detectable autoAb to AChR and younger patients
31
What are the other paraneoplastic syndromes associated with thymoma bar MG?
Pure Red Cell Aplasia
Good Syndrome (Acquired hypogammaglobulinaemia and thymoma associated with recurrent infections, diarrhoea and lymphadenopathy)
32
Outline Thymic cyst
Congenital or acquired due to inflammation
Asymptomatic unless large and causing symptoms of compression
Benign but often have surgical excision as dx certainty is difficult
33
Outline Thymic carcinoid
Not associated with MG but behaves aggressively with local recurrence and Mets , can be associated with Cushing’s
Tx: Surgery / Chemotherapy/ Radiotherapy / Octreotide
34
Outline germ cell tumours
Arise from immature germ cells that fail to migrate during development
Mature Cystic Teratomas:
- 80% of GCTs
- Benign, young adults , M:F
- Asymptomatic but can erode
- Normal AFP
- Potential for malignant degeneration
- Tx = surgical excision
Seminoma:
- Male, 20-40
- Malignant
- Arise within thymus but histological indistinguishable from testes , can be Mets from testes (so need exam + US)
- Lobulated anterior mass
- AFP normal
- Dx : Biopsy; Tx: Cisplatin chemo , radiotherapy if bulky (surgery difficult as usually incomplete)
Non Seminomatous GCT:
- Choriocarcinoma /Teratocarcinoma/ Yolk sac tumours
- Malignant
- Men in their 30s
- Symptomatic due to local invasion and metastasize
- Dx with biopsy
- BHCG and AFP raised , fall with tx
Tx: Cisplatin based chemo , radiological residual disease is resected
35
Outline thyroid goitre
Retrosternal goitre, more common in older women
Usually asymptomatic unless large and causing tracheal obstruction- Dyspnoea and stridor
DX: CT and radioisotope scans
Tx: Surgery if airway compromise but NB surgery can cause tracheomalacia
36
Outline lymphoma in mediastinum
- Frequently involved in Hodgkin’s lymphoma
- Dx : Biopsy (FNA not enough for dx)
- Tx: Chemotherapy
37
What cancers commonly metastasized to mediastinal LNs?
Breast
Lung
Oesophageal
38
Outline Castleman disease
CD is angiofollicular LN hyperplasia , rare
Unicentric CD: single region of body. Chest - mediastinal / hilar
Asymptomatic / cough / wheeze
May have fever and raised ESR
Biopsy: follicles of pericapillary lymphocytes and proliferation of plump and eosinophilic capillary endothelial cells.
Removal of nodes may improve sx and be curative, may not require treatment
Multicentric CD:
- HHV-8 associated MCD in immunosuppressed (usually HIV)
- Idiopathic MCD
Systemic sx : night sweats , fatigue, WL as well as LN enlargement , hepatosplenomegaly, paraproteinaemia, skin rash
Biopsy- Prominent plasma cell infiltration , related to IL6 overproduction
Tx for HHV-8 assoc MCD- Rituximab if aggressive / poor PS Rituximab +- Steroids +- Chemo but prognosis poor
MCD can progress to lymphoma
39
Outline cysts in mediastinum
Enteric/ Bronchogenic cysts :
- often dx in childhood
- surgical excision
Pleuropericardial cysts / Springwater cysts:
- Mostly @ cardiophrenic angle can measure upto 25cm in diameter
- M=F
- usually asymptomatic but can cause chest pain
- Excision can be carried out at thoracoscopy but conservative mx favoured
40
Outline inflammation in mediastinum
Mediastinitis :
- After oesophageal perforation or rupture due to malignancy / instrumentation / XS vomiting
- Pts will have pain and fever
- CXR: widened mediastinum, air , PTX, pleural effusion
- Tx: repair the defect , parenteral feeding , abx
- High M&M
Mediastinal fibrosis:
- Rare , middle age
- Variable sx depending on aspects involved
- CXR- widened mediastinum
- Dx - biopsy
- Tx - supportive , steroids and debunking ineffective
41
How do you treat mediastinal emphysema / pneumomediastinum?
High flow O2 , resolves spontaneously
42
What makes up the LENT score in mesothelioma ?
Pleural fluid LDH
ECOG PS
Serum neutrophil: Lymphocyte ratio
Tumour type
43
What are the options for ongoing air leak with PTX if not fit for surgery ?
Autologous Blood Patch or Endobronchial therapies
44
How much fluid should we send for Cytology with aspiration?
25-50mls for cytology
45
What is the score used for pleural infection ?
RAPID Score :
Renal (Urea <5: 0, 5-8: 1 , >8: 2)
Age (<50:0 , 50-70: 1 , > 70: 2)
Purulence (Purulent 0, non purulent 1)
Infection Source (Comm 0, Hosp 1)
Dietary factors (Alb >27 0 , <27 1)
0-2 Low Risk
3-4 Moderate Risk
5-7 High Risk
46
What pH is used as cut of for complicated parapneumonic effusion?
<7.2
47
Explain the actions taken at different pH in pleural infection
<7.2 : High risk of CPPE> ICD
7.2-7.4 : Intermediate risk of CPPE ; await LDH , if > 900 can consider ICD IF - high temp / high pleural fluid volume /glucose <4/ pleural contrast enhancement on CT or separation on US
pH > 7.4 very low risk of CPPE
48
What can we use if pH not immediately available ?
Glucose ; cut off of <3.3 indicative of high probability CPPE/ pleural infection
49
What can mimic PPE with low pH?
Rheumatoid effusion
Effusions due to advanced malignancy /mesothelioma
50
What can pleural fluid be contaminated by ?
Local anaesthetic / Heparin : LOW pH
Delays/Air in syringe : HIGH pH
51
What is a spontaneous PTX?
Air in the pleural space in the absence of trauma or medical intervention can be primary or secondary . Primary is the absence of suspected lung disease , secondary is established underlying lung disease >50 with smoking history
(NB patients with PSP majority demonstrate emphysema like changes on CT)
52
How common is recurrence of Pneumothorax?
Recurrence is common: 32% after single episode , 13-39% after first episode of SSP
53
What is the discharge advice for PTX?
- Return to A&E if further breathlessness
- Follow up to ensure full resolution, optimal care of underlying lung disease, explain risk of recurrence and later need for surgical intervention
- Repeat cxr 2-4 weeks if needle aspiration /observation alone
- Can fly 7 days after resolution
- Scuba diving discouraged lifelong
- Smoking cessation
54
What are the accepted indications for surgical advice with PTX?
- Second Ipsilateral PTX
- First Contralateral PTX
- Synchronous bilateral PTX
- Persistent air leak 5-7 days or failure of lung re-expansion
- First PTX associated with tension and first 2ndry PTX associated with significant physiological compromise
- Spont haemothorax
- Pregnancy
- Job (Diving / Airline pilot)
55
What are the surgical options in PTX?
Resection of the lung parenchyma (often visible blebs which are usually 1-2cm and subpleural) or bullae which are >1-2 cm to remove suspected source of air leak and prevent future
OR
Surgical Pleurodesis to obliterate the pleural space via inflammatory symphysis of visceral and parietal pleural to prevent accumulation of air in the space
56
Why do pregnant patients get PTX?
Accelerated breathing in pregnant patients can lead to bleb rupture and also O2 consumption increases by 50% in labour and valsalva manouvre of spontaneous labour may increase thoracic pressure leading to PTX
57
What are the indications for intervention with pregnancy?
Simple observation if not dyspnoeic and small (<2cm) otherwise ICD/Aspiration . Close liasing with surgeons /O&G /thoracics want to avoid spontaneous delivery and c section both of which lead to increased recurrence , ideally should have assisted delivery at or near term with regional anaesthesia (spinal preferable to regional if c section unavoidable)
58
When do catamenial PTX occur ?
Chest pain, dyspnoea and haemoptysis 72 hours before or after menstruation. Incidence approx 25%.
Usually right sided , often patients have history of pelvic endometriosis
59
How do you treat catamenial PTX?
MDT approach, Hormonal treatment or VATs (if have VATs want medical therapy for ovarian rest after procedure)
60
Outline PTX in Cystic Fibrosis
SSP is a complication in Cystic Fibrosis ( 0.64% per annum and 3.4% overall). Often older patients with more advanced lung disease, associated with a poor prognosis and median survival is 30 months, contralateral PTX in 40%
Associated with increased morbidity , increased hospitalization and reduction in lung function
61
Patient presents with pneumothorax but asymptomatic , what is the management ?
Conservative :
PSP: regular review as app (2-4 days) and if stable follow up 2-4 weeks
SSP: Review inpatient and if stable follow up in 2-4 weeks
62
What are the high risk characteristics for a pneumothorax?
Haemodynamic compromise (tension PTX)
Signficant hypoxia
Bilateral PTX
Underlying lung disease
>50years with significant smoking hx
Haemopneumothorax
63
If symptomatic PTX but no high risk characteristics and safe to intervene
Assess patients main priority :
1. Procedure avoidance
2. Rapid sx relief (ambulatory)
3. Rapid sx relief (short term drainage)
If 1: Conservative
2: Ambulatory device and regular review as OP 2-3 days and review when resolved follow up 2-4 weeks
3. Needle aspiration and if resolves then f/u 2-4 weeks if not then chest drain
64
If symptomatic PTX and high risk characteristics and safe to intervene what are next steps?
Chest drain
(NB if not sure if safe to intervene - CT)
65
What is safe to intervene with PTX?
≥ 2cm laterally or apically on CXR or any size in CT scan that can be safely accessed with radiological support
66
Who gets talc pleurodesis of PTX?
Talc Pleurodesis considered on first episode of PTX for high risk patients whom repeat PTX would be hazardous (ie severe COPD)
67
What are the common causes of transudative pleural effusions?
CCF
Nephrotic Syndrome
Hypoalbuminaemia
Liver Cirrhosis
68
What are the less common causes of transudative pleural effusions?
Mitral stenosis
Constrictive pericarditis
Peritoneal dialysis
Chronic Hypothyroidism
69
What are the common causes of exudative effusion?
Malignancy
Pleural Infection
PE
Autoimmune pleuritis
70
What are the less common causes of exudative effusion?
Drugs, Lynphatic disorders , Meig’s Syndrome , Post CABG, Benign asbestos related pleural effusion
71
What are the causes of a lymphocytic pleural effusion ?
Malignancy, TB, Lymphoma, CCF, RA, Post CABG, Chylothorax , Yellow Nail Syndrome
72
What are the causes of bilateral effusions?
CCF, hypoalbuminaemia , renal failure , liver failure , SLE and other AI diseases, widespread malignancy including abdominal /pelvic , bilateral PEs
73
What are the causes of chylothorax?
Trauma: Thoracic surgery (especially if involving posterior mediastinum for example oesophagectomy) , thoracic injuries
Neoplasm: Lymphoma / metastatic cancer
Miscellaneous: Disorders of lymphatics (including LAM) , TB , cirrhosis, obstruction of central vein, chyloascites , TB
Idiopathic
74
What are the causes of pseudocyhlothorax ?
TB
RA
75
What is a pseudochylothorax?
Occurs due to cholesterol crystal deposition in chronic effusions , can cause milky effusion , raised pleural fluid cholesterol (>5.17) and cholesterol crystals at polarised light microscopy distinguish it from chylothorax
76
What are the most common drugs causing exudative effusion?
TKI
77
With unilateral pleural effusion and intervention not safe , what should we do?
CT CAP if malignancy suspected , CT chest if no concern re malignancy
78
What are the imaging features of a malignant pleural effusion ?
Circumferential pleural thickening with nodularity invading the mediastinal surface
79
What are the radiological fx of pleural infection?
Lentiform configuration of pleural fluid
Visceral pleural thickening (split pleura sign)
Hypetrophy of extra pleural fat >2mm
Increased density of the extra pleural fat
presence of pulmonary consolidation
80
What are the radiological fx of benign asbestos pleural effusion?
Calcified pleural plaques
81
What are the radiological fx of post cardiac surgery effusion?
Temporal relationship with surgery, usually left sided
82
If undiagnosed pleural effusion , how long follow up?
Usually 2 years
83
What is difference between TB pleuritis and cancer ?
TB pleuritis can mimic with circumferential pleural thickening >1cm , involvement of mediastinal surface and modularity but unlike malignancy no chest wall invasion. In US TB effusion usually very complex
84
Additional pleural fluid tests for Chylothorax
Pleural fluid Cholesterol and Triglycerides
85
Additional pleural fluid tests for Haemothorax?
Pleural fluid haematocrit
86
Additional pleural fluid tests for Empyema
Pleural fluid centrifuge
87
Additional pleural fluid tests for RA
Pleural fluid pH and glucose
88
Additional pleural fluid tests for lymphoma
Pleural fluid lymphocyte subsets
89
Describe pleural infection and empyema
Pleural infection is bacterial entry and replication in the pleural space, does not require to be associated with pneumonia and empyema is macroscopic detection of purulent pleural fluid
90
What is the prognosis with pleural infection?
Poor , up to 20% will die after an episode of pleural infection over 12 months and req surgery in 15%
91
What are the intrapleural treatments in pleural infection ?
TPA and DNAse : reduce LOS, reduce likelihood of surgery and improve changes in CXR
92
What improves microbiological yield for pleural infection?
BC bottles
93
What are the majority of community acquired pleural infection?
Gram +ve aerobic organisms - Staph Aureus
94
What are the hospital acquired micro-organisms?
Hospital acquired : Resistant gram +ve organism , including MRSA and gram -ve including E. Coli , Enterobacter and Pseudomonas with significant anaerobic involvement
Fungal pleural infection very rare (<1%) usually immunosuppressed , if found check no oesophageal leak
95
In which patients with pleural infection should we consider direct surgical referral following drain insertion?
Clinically unstable or profound pleural thickening /pleural collection on imaging
96
What is a marker of poor prognosis following chest drain insertion?
Persistent pleural shadowing on imaging plus static or worsening inflammatory markers . If occurring - get CT chest
97
If worsening fx despite chest drain and abx what are the options
Thoracic CT
Then
If suitable for surgery - VATs
If suitable but >48 hours delay - TPA and DNAse
If not suitable for surgery - TPA and DNAse
98
If patients fail the intrapleural therapy what are the options ?
Switch abx
Prolonged abx
Non intubated surgical procedure (rib resection)IPC
99
What are the 2 most common causes of pleural malignancy?
Lung and Breast Cancer
Other common sites for pleural Mets:
Lymphoma
GI malignancy
GU malignancy
100
How much drain for pleural fluid is acceptable and safe ?
1.5L in first hour then 1 l each hour . To avoid re-expansion pulmonary oedema which has increased M&M
101
Why do we call it non expandable lung ?
Visceral pleural thickening limiting re-expansion and endobronchial obstruction preventing re-expansion so seem as more appropriate
102
A 36-year-old pilot developed a right-side spontaneous tension pneumothorax. He is a non-smoker and has no history of chronic lung disease. The pneumothorax was successfully managed with intercostal tube drainage.
What is the best way of preventing recurrence in this patient?
Open thoracotomy , BTS recommends open thoracotomy and surgical pleurodesis for high risk occupations like pilots
NB VATs is the general surgical approach otherwise
103
What type of characteristics do you see for pleural effusion related to peritoneal dialysis?
High glucose, transudate. In patients who receive peritoneal dialysis the fluid can seem from peritoneal cavity into pleural cavity and cause pleural effusion.
104
What organisms most common post IPC insertion?
Staph Aureus and Pseudomonas Aeruginosa
105
What is the most common community acquired pleural infection?
Strep Milleri
106
Where should thoracocentesis be performed and why?
Above a rib, to minimise damage to NV bundle
107
When can patients bathe /swim after IPC?
After both sutures are removed but need to take care not to get it wet
108
When do you consider IPC removal?
Output <50ml on 3 consecutive occasions , absence of sx and no residual effusion
109
What position are patients placed in for US pleural biopsy ?
Lateral decubitus
110
Why are inferior biopsy sites preferred?
Closer to diaphragm more effective as predilection for Mets in this area
111
If we use suction with PTX what type is it?
Low pressure , high volume
112
When do you stop Warfarin for pleural procedure ?
Stop Warfarin 5/7 prior and check INR <1.5 prior
113
When do you stop DOACs for pleural procedure ?
24-48 hour prior
114
When do you stop Clopidogrel/prasugrel for pleural procedure ?
5/7 before
115
When do you stop Dypirimadole for pleural procedure ?
7 days prior
116
When do you stop Aspirin/ LMWH for pleural procedure ?
You don’t need to stop these medications
117
What is the maximum Lidocaine dose ?
3mg/kg ; upto max 250mg =25 ml
(If combined with adrenaline can be higher upto 7mg/kg)
Larger volume better , hence 1% preferred
NB 1% =10mg in 1ml
118
How frequent are obs meant to be post chest drain?
Immediate , then every 30mins for 1 hour , followed by 4 hours
119
What are the relative contraindications to pleural aspiration ?
- Uncoperative patient
- Coagulopathy or concurrent anticoagulation
- Local infection (cutaneous disease at proposed puncture site)
- No safe site for aspiration
NB mechanically ventilated patients should have chest drain rather than aspiration due to risk of PTX and bronchopleural fistula
120
What is the most common complication of aspiration ?
Pneumothorax
121
What increases risk of PTX with pleural aspiration?
- Larger volume of fluid removed in underweight patients
- operator expertise
- smaller depth of fluid
122
What are other risks with pleural procedures ?
Bleeding - preferred site of entry is safety triangle
RPO- can be life threatening , new hypoxia and new diffuse infiltrates
123
What is the diagnostic sensitivity of cytology on pleural fluid ?
60% for all malignancies (but 47% often insufficient for markers)
124
What size needle for pleural procedures ?
Small bore, 21G/40mm , green needle
125
What are lights criteria
If any of these 3 are met , fluid is an exudate:
Pleural fluid protein is more than half of serum protein
Pleural fluid LDH is more than 0.6x serum LDH
Pleural fluid LDH is more than 2/3 upper limit of normal for serum LDH
126
What values are in keeping with chylothorax ?
Triglycerides >1.24 mmol
Chylomicrons usually present
Cholesterol low
Cholesterol crystals absent
127
What is the max aspiration volume of therapeutic aspiration?
1.5L
128
What is the size in mm of 12french drain?
4mm
Roughly 1/3 of Fr is the drain size
129
If patient needs a talc slurry what size should the drain be?
Greater of equal to 12 French
130
What is the mortality associated with chest drains
0.1%
131
How often are IPCs usually drained ?
Usually 3x week but if aiming for pleurodesis then daily
132
Is there any benefit of prophylactic irradiation with IPC?
No benefit
133
Who gets Local Anaesthetic Thoracoscopy ?
WHO PS 3 or better
Need to be able to lie flat for >1 hour
Parietal biopsies
134
Is surgical emphysema a problem in PTX?
Common and often of minimal clinical concern
135
What to do if surgical emphysema worsens?
Check drain patent and functioning , flush if needed
CXR for sentinel hole of drain , if outside consider replacing
If draining appropriately and failing to expand - suction or replace with larger drain
If expanded appropriately check suture not too tight , if not too tight then give high flow
If still worsens - surgery
136
What percentage of heart failure effusions are unilateral?
40%
137
How long does it take post CABG effusions to improve ?
3 months usually resolve
138
What drugs cause effusions?
MTX
Amiodarone
Phenytoin
Nitrofurantoin
BB
Now most common is TKI
139
What is diagnostic yield of thoracoscopy ?
90%
140
What are the risk factors to having pleural infection?
Albumin <30
CRP>100
Plt >400
Na <130
IVDU
Chronic EtOH abuse
141
What is the serum/pleural albumin gradient ?
Can use to identify transudates >1.2g/dl
Subtracting pleural effusion albumin concentration from serum albumin concentration
142
What are the absolute contraindications to tPA and DNAse ?
- Concurrent use of anti-coagulants (warfarin and NOACs must be stopped ) or coagulopathy (INR should be <1.5)
- Hypersensitivty to either of the agents
-< 18 years old
- Prev use of fibrinolytics within same episode of empyema
- Pleural bleeding or major haemorrhage of any kind
- Coincidental stroke
- Recent surgery <5 days
- Pregnancy or breast feeding
- Severe hepatic or renal insufficiency
143
What does a PTX of 2cm @ hilum indicate ?
Approx 50% reduction in size of the lung
