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103-theme 4 > pleural and chest wall disease > Flashcards

pleural and chest wall disease Flashcards

1
Q

explain altered respiratory mechanics? 2

A
  • chest wall (kyphoscoliosis)

- respiratory muscle weakness

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2
Q

describe the pleural space? 5

A
  • normally at a negative pressure keeping the lungs inflated
  • only has a few ml of fluid to help lubricate the normal movement of lungs during breathing
  • pleura is 0.3-0.5mm thick
  • fluid contains protein and a small number of cells
  • pH around 7.6
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3
Q

name some common pleural conditions? 2

A
  • pneumothorax

- pleural effusion: pleural infection/empyema, malignant pleural effusion, heart failure, haemothorax

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4
Q

what are the presenting features of the pneumothorax? 8

A
  • breathless
  • chest pain
  • cough
  • features within the history
  • raised respiratory rate– may have low oxygen saturations
  • if unwell with tension pneumothorax, may be very unwell
  • on examination= reduced breath sounds, increases percussion note, reduced expansion, tracheal deviation
  • abnormal CXR
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5
Q

what is a pneumothorax? 4

A
  • air in the pleural space
  • entry of air creates a positive pressure leading to the collapse of the lung
  • tension pneumothorax–> one way valve
  • primary/ secondary/ traumatic/ iatrogenic
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6
Q

describe a primary spontaneous pneumothorax? 6

A
  • occurs in healthy young tall males
  • apical bleb
  • more common in smokers (especially cannabis smoking)
  • tension- rarely occurs
  • management according to the size and symptoms of the patient
  • wont always need a drain or admission
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7
Q

describe a secondary primary spontaneous pneumothorax? 3

A
  • background of known lung disease: COPD, bronchiectasis, ILD
  • most will need a drain
  • tension is more common
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8
Q

what is the follow up for a primary pneumothorax? 3

A
  • 54% reoccurrence in the first 4 years
  • 20-30% reoccurrence in the first 2 years
  • Recurrent primary= surgical/ medical thoracoscopy and pleurodesis
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9
Q

what is the follow up for a secondary pneumothorax?

A
  • Attempt pleurodesis after first episode as the recurrence rate is high
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10
Q

what is the advice for people after a pneumothorax? 6

A
  • No deep-sea diving ever (any sudden change in pressure risk is higher)
  • Normal swimming and diving no less than 10 feet depth is fine
  • Air travel- one week after full re-expansion of the lungs
  • Coast guards, naval officers, air force will need to change jobs
  • High altitude sports and travel should be done with caution and should be discouraged
  • Stop smoking
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11
Q

what is a pleural effusion? 2

A
  • Small volume of lubricating fluid is maintained via a delicate balance of hydrostatic and oncotic pressure and lymphatic drainage
  • Disturbances in these mechanisms may lead to pathology and cause a pleural effusion
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12
Q

what are the clinical features of pleural effusion? 5

A
  • SOB
  • Cough
  • Pleuritic chest pain
  • Reduced breath sounds
  • Dull percussion on examination
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13
Q

name the most common causes of pleural effusion? 3

A
  • heart failure
  • pneumonia
  • malignancy
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14
Q

name more specific causes of pleural effusion? 6

A
  • Acute vs chronic, benign vs malignant
  • Altered permeability of pleural membranes (inflammation, infection, cancer)
  • Reduced oncotic pressure (low albumin renal disease, liver cirrhosis)
  • Increased capillary hydrostatic pressure (heart failure)
  • Decreased lymphatic drainage or blockage (malignancy, tumour)
  • Increased peritoneal fluid (liver cirrhosis, peritoneal dialysis
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15
Q

what are causes of benign pleural effusion? 4

A
  • High oncotic pressure (heart failure, fluid overload)
  • Low protein state (nephrotic syndrome, protein losing enteropathy, chronic liver disease)
  • Auto immune disease
  • Reactive PE
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16
Q

what are the causes of malignant pleural effusion? 2

A
  • Primary mesothelioma

- Secondary primary lung, breast, gynaecological, haematological, renal, GI tra

17
Q

describe pleural infection? 5

A
  • 100,000 hospital admissions per year due to pneumonia in the UK
  • > 50% of pneumonias develop an effusion. Having an effusion increases mortality x3
  • 10% become infected and progress to empyema (pus in pleural space)
  • More than 30% of patients with pleural infection either die or require surgery
  • Prolonged hospital admission
18
Q

what are the risk factors of pleural infection? 7

A
  • Diabetes
  • Immunosuppression
  • Alcohol, IVDU
  • Poor oral hygiene and aspiration
  • Iatrogenic
  • Trauma
  • Recent hospitalisation
19
Q

how do we diagnose pleural infection? 2

A
  • Pleural effusion seen on CXR with systemic features of infection such as fever, raised CRP/WCC suggest pleural infection
  • Take pleural fluid sample
20
Q

what are the predictors of a worse outcome for pleural infection? 4

A
  • pH<7.2
  • low glucose
  • positive culture
  • loculations seen on US or CT
21
Q

what is the spectrum of parapneumonic effusions? 3

A
  • uncomplicated parapneumonic effusion
  • complicated parapneumonic effusion
  • empyema
22
Q

what do we do for people with uncomplicated parapneumonic effusion?

A

resolve on treatment of the underlying pneumonia, may not need to br drained

23
Q

what do we do for people with complicated parapneumonic effusion? 3

A
  • bacterial invasion into the pleural space
  • fibrin deposition may form locules/sepations
  • patient will most likely need a drain
24
Q

what is empyema? 2

A
  • frank pus within the pleural cavity

- may organise with thickening of the pleural space, preventing lung re-expansion and impairing lung function

25
Q

what are the principles of care for someone with pleural infection? 3

A
  • accurate diagnosis
  • control infection choosing the correct antibiotics
  • drainage of infected material chest drain (under US with consent, when safe to do so) management of chest drain is key! The aim is to remove infection from the pleural space, so avoid blockages
26
Q

what is a malignant effusion? 6

A
  • malignant effusion has high recurrence rate
  • median life expectancy for malignant effusion due to any cause 6 months
  • significant impact of quality of life
  • impact on wider health economy
  • mostly unilateral
  • massive unilateral effusion is usually not benign
27
Q

what are the clinical features of malignant effusion? 4

A
  • breathlessness
  • cough
  • hypoxia
  • haemorrhagic
28
Q

how do we manage clinical features of malignant effusion? 5

A
  • minimally invasive and reduce number of interventions
  • aspiration >90% recurrence rate
  • chest drain +/- pleurodesis 60-70% success
  • indwelling pleural catheter
  • thoracoscopic drainage and pleurodesis
29
Q

what is an indwelling pleural catheter? 4

A
  • avoids patient admission to hospital
  • suitable for long term drainage
  • improves quality of life
  • 50% spontaneous pleurodesis
30
Q

describe talc pleurodesis for pleural effusions (without infections)? 6

A
  • To prevent recurrence
  • Medicated talc
  • Creates talc slurry to stick the pleura together
  • Works in about 70% of people
  • Lung needs to be reinflated and output <200ml/24hr
  • Drain can’t be blocked! Drain needs to not fall out!
    pain, fever
31
Q

what is the haemothorax? 5

A
  • Not a bloody effusion
  • Traumatic
  • Iatrogenic
  • Aortic dissection
  • Depending on cause resuscitate, urgent drainage, consider VATS

103-theme 4 (19 decks)

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