Pleural Flashcards
When is it safe to fly after a spontaneous pneumothorax?
At least 7 days after full radiological resolution
For how long must you wait to fly after traumatic pneumothorax?
Recommended to wait for at least 2 weeks before flying after full resolution.
Is it safe to scuba dive after an episode of traumatic pneumothorax?
Yes, but only once traumatic pneumothorax has healed and the person has a normal CT scan and demonstrated normal lung function including flow volume loop
What is the mean inpatient stay for tube drainage and talc pleurodesis in malignant pleural effusion?
4 days
What features in cytology would be suggestive of an effusion due to malignant mesothelioma?
Shouldn’t ideally diagnose on cytology alone- seek thoracoscopy and biopsy if fit.
If not look for at least:
2 POSITIVE MESOTHELIAL markers:
Calretinin, Cytokeratin (CK) 5/6, Wilms tumour, D-240
2 NEGATIVE ADENOCARCINOMA markers:
CEA, TTF-1, Ber-EP4
What systemic anti-cancer treatment should be offered in people with malignant mesothelioma?
If good performance status (WHO 0-1) then should be offered platinum-based chemotherapy
Cisplatin and permetrexed are the first line agents, with bevacizumab added where licensed
If unable to tolerate cisplatin then can substitute for carboplatin
Which nerve provides the sensory supply to the mediastinal pleura?
Phrenic nerve
The mediastinal pleura is part of the parietal pleura and is innervated by the phrenic nerve. Intercostal nerves provide sensory supply to the costal pleura.
What are the biochemical features of chylothorax on pleural aspirate? How does this differ from pseudochylothorax?
High triglycerides >1.1g/dL. Excluded if value <0.5
Chylomicrons visible on microscopy
Typically low cholesterol
Pseudochylothorax has high cholesterol (>2g/L) with visible cholesterol crystals on microscopy
Name some causes of chylous pleural effusion
Trauma/iatrogenic with damage to the thoracic duct
Liver cirrhosis (usually transudative)
Tuberculosis
Malignancy (lymphoma/metastatic)
LAM is a rare cause
Pseudochylotorax may be caused by TB or RA
1: Are pleural plaques pre-malignant?
2: Does the extent of plaques increase with time of exposure?
3: Can people with pleural plaques claim compensation?
4: What proportion of people with asbestos exposure will go on to develop pleural plaques?
1: No evidence to suggest they are pre-malignant
2: The incidence of plaques increases with increased exposure but not the extent
3: No.
4: Around 50% of those with >30 years exposure to asbestos will develop pleural plaques
If an effusion is suspected to be exudative via protein/LDH (Light’s criteria) but may be due to HF, what other tests can be checked?
Pleural fluid NT-pro BNP, although correlates well with serum values so can just use serum.
Check serum/pleural albumin gradient with a gradient >12g/L indicating a transudate
Effusions may seem exudative in HF, especially if on chronic diuretic therapy
What are Light’s criteria when interpreting pleural fluid results?
What other test can be performed if a transudate is suspected?
ANY ONE of the following:
Pleural protein: Serum protein >0.5
Pleural LDH: Serum LDH >0.6
Pleural Fluid LDH >2/3 normal upper limit for serum LDH
Very SENSITIVE for exudate, less specific. If queries then perform serum-pleural albumin gradient, with the cut off <12g/L as an EXUDATE
How is a haemothorax defined biochemically? What is the most appropriate initial management?
Pleural fluid: Blood Haematocrit ratio of >50%. Initial management should be with a wide bore chest drain >36F as conservative management gives high risk of empyema, fibrothorax or lung entrapment
If large volume initial blood >1.5L or shock and persistent bleeding after drain insertion then these are also indications for surgery.
What can cause an eosinophilic pleural effusion?
Most commonly in the presence of blood or air in the pleural space, infections and malignancy. Can also be caused by drug-associated pleural effusions and those associated with PE or pleural plaques.
What are the components of the RAPID score? How is it interpreted?
R- Renal function Urea <5 (0), 5-8 (1) >8 (2)
A- Age <50 (0), 50-70 (1), >70 (2)
P- Purulence of fluid- Purulent (0), Non-purulent (1)
I- Infection source - Community (0), Hospital (1)
D- Dietary - Albumin >27 (0), <27 (1)
Low risk 0-2
Moderate risk 3-4
High risk 5-7
Risk stratification for empyema
What features may you expect in a pleural effusion relating to peritoneal dialysis?
Transudative effusion typically and glucose likely to be elevated due to the high presence in PD fluid.
What is the likely cause of SVC obstruction in a patient previously treated for TB?
Fibrosing mediastinitis. Associated with TB infection and histoplasmosis. Dense invasive fibrotic infiltration of the mediastinum causing narrowing/occlusion of important structures such as blood vessels.
At what glucose cut-off would suspicion be raised of a complicated pleural effusion if pH not available?
3.3. If <3.3 then chest drain may be required in the instance of a supportive history.
What is the cut off triglyceride/cholesterol level for diagnosing chylothorax?
Triglycerides >110g/dL/>1.24mmol/L
Cholesterol <5.18mmol/<200mg/dL
What is the gene defect associated with Birt-Hogg Dube syndrome? On which chromosome is it located?
FLCN gene- folliculin gene located on Chromosome 17
Autosomal dominant inheritance
Clinical features of BHD include increased risk of pneumothoraces, fibrofolliculomas (face and upper trunk) and renal cancers (often rare subtypes)
What are the typical radiological appearances in BHD?
Which gene is responsible?
Folliculin gene FLCN on Chromosome 17
Typically thin-walled cysts. Lower-zone predominant and usually bilateral. Predilection for subpleural region/perifissural/paramediastinal
Variable in size
Prone to rupture and pneumothorax
Early VATS pleurodesis often recommended following pneumothorax
What is Swyer James MacLeod Syndrome? (SJMS)
A syndrome involving post-infective bronchiolitis obliterans.
Often viral infection/mycoplasma in early childhood. Unilateral small lung with air trapping/volume loss.
Has lung and pulmonary vascular hypoplasia on the affected side. As a result can be more prone to infections such as NTM
What is Williams-Campbell syndrome?
Absence of bronchial wall cartilage leading to bronchiectasis. It is a form of congenital cystic bronchiectasis. Distal deficiency of bronchial wall cartilage (4th-6th order segmental bronchi)
Confirmation is via bronchoscopy showing deficiency in bronchial wall cartilagenous plates
What is the most common cause of hospital-acquired pleural infection?
What is the most common cause of community-acquired pleural infection?
MRSA. More common if risk factors such as increased age or recent surgery.
Streptococcus milleri group infections are the most common community cause.
Strep pneumoniae is the most common organism for CAP but doesn’t always cause effusion (but may cause empyema)
According to BTS, what is the minimum amount of pleural fluid recommended to be sent for cytology in suspected malignant pleural effusion?
25ml
The recommended amount is ideally 50ml to be sent for cytology but BTS recommends at least 25ml
What biochemical test can be useful in assessing TB-related pleural effusion?
Adenosine deaminase (ADA). The higher the level of ADA in pleural fluid , the more likely TB is. Persistently low levels on aspirations effectively rules out TB.
Usual cut off 40 U/L
Aside from asbestos, what other risk factors are there for mesothelioma?
Erionite exposure- found in rocks, especially in the Cappadocia region of Turkey. Carcinogenic and can cause pleural and peritoneal mesothelioma. More common in stone masons.
Meso also associated with BAP1 tumour suppressor gene, male and older age. Smoking associated with meso but only in the context of asbestos exposure
What organisms are most common in IPC pleural infection?
Staphylococci are the most likely, with S. Aureus is the most common pathogen. Pseudomonas is the next most likely.
What frequency of observation is recommended after chest drain insertion?
Immediately after the procedure then every 15 MINS for 1H then 30mins for 1h then 4 hourly
What frequency of observation is recommended after thoracoscopy?
Continuous during the procedure then 15 mins after the procedure. Continue with 30 minute observations for the next hour then 4 hourly.
