pleural and chest wall disease Flashcards
explain altered respiratory mechanics? 2
- chest wall (kyphoscoliosis)
- respiratory muscle weakness
describe the pleural space? 5
- 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
name some common pleural conditions? 2
- pneumothorax
- pleural effusion: pleural infection/empyema, malignant pleural effusion, heart failure, haemothorax
what are the presenting features of the pneumothorax? 8
- 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
what is a pneumothorax? 4
- 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
describe a primary spontaneous pneumothorax? 6
- 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
describe a secondary primary spontaneous pneumothorax? 3
- background of known lung disease: COPD, bronchiectasis, ILD
- most will need a drain
- tension is more common
what is the follow up for a primary pneumothorax? 3
- 54% reoccurrence in the first 4 years
- 20-30% reoccurrence in the first 2 years
- Recurrent primary= surgical/ medical thoracoscopy and pleurodesis
what is the follow up for a secondary pneumothorax?
- Attempt pleurodesis after first episode as the recurrence rate is high
what is the advice for people after a pneumothorax? 6
- 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
what is a pleural effusion? 2
- 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
what are the clinical features of pleural effusion? 5
- SOB
- Cough
- Pleuritic chest pain
- Reduced breath sounds
- Dull percussion on examination
name the most common causes of pleural effusion? 3
- heart failure
- pneumonia
- malignancy
name more specific causes of pleural effusion? 6
- 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
what are causes of benign pleural effusion? 4
- High oncotic pressure (heart failure, fluid overload)
- Low protein state (nephrotic syndrome, protein losing enteropathy, chronic liver disease)
- Auto immune disease
- Reactive PE
what are the causes of malignant pleural effusion? 2
- Primary mesothelioma
- Secondary primary lung, breast, gynaecological, haematological, renal, GI tra
describe pleural infection? 5
- 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
what are the risk factors of pleural infection? 7
- Diabetes
- Immunosuppression
- Alcohol, IVDU
- Poor oral hygiene and aspiration
- Iatrogenic
- Trauma
- Recent hospitalisation
how do we diagnose pleural infection? 2
- Pleural effusion seen on CXR with systemic features of infection such as fever, raised CRP/WCC suggest pleural infection
- Take pleural fluid sample
what are the predictors of a worse outcome for pleural infection? 4
- pH<7.2
- low glucose
- positive culture
- loculations seen on US or CT
what is the spectrum of parapneumonic effusions? 3
- uncomplicated parapneumonic effusion
- complicated parapneumonic effusion
- empyema
what do we do for people with uncomplicated parapneumonic effusion?
resolve on treatment of the underlying pneumonia, may not need to br drained
what do we do for people with complicated parapneumonic effusion? 3
- bacterial invasion into the pleural space
- fibrin deposition may form locules/sepations
- patient will most likely need a drain
what is empyema? 2
- frank pus within the pleural cavity
- may organise with thickening of the pleural space, preventing lung re-expansion and impairing lung function
