Pleural disease Flashcards
What are the characteristics of the normal pleura?
• Glistening, smooth, thin membrane which covers the thoracic cavity and the lungs.
What types of cells are found in the pleural fluid?
• Macrophages, lymphocytes, mesothelial cells
How much protein is found in the pleural fluid?
• 1.5g-2g
What is the pressure of the pleural pressure
• Sub atmospheric (negative), -3cm to - 5cm, most negative pressure is at the apex of the lung.
What are the three main pleural problems?
• Pleural effusion, Pneumothorax, Mesothelioma
What is the pleural effusion?
• Collection of fluid
What is the Pneumothorax?
• Collection of air
What is Mesothelioma?
• Pleural malignancy
What is the cause of pleural effusion?
• Imbalance between production and absorption
What cells are responsible for absorption in the pleura?
• Pleural lymphatics in the parietal pleura
What are the two types of effusion?
• Trnasudate and exudate
What is a transudate?
• The non-inflammatory type of effusion (low protein content)
What is a exudate?
• It is an inflammatory type of exudate (high protein content 3g or more)
What are the main causes of transudate?
• Left ventricular failure, liver cirrhosis, renal failure.
What are the common causes of exudates
• Malignancy, Empyema, Parapneumonic effusions, Tuberculosis
How do you investigate and manage pleural effusion?
- Ultrasound: more sensitive than CXR, mark sire for aspiration, assess pleura, bedside
- CXR: accessible, easy to interpret
- CT Thorax: complex effusions, visualising the pleura, vascular and mediastinal structures
How do you analyse pleural fluid?
- Aspiration: simple and safe, trained operator
- Inspect the fluid
- pH (bedside ABG machine), biochemistry, microbiology and cytology
What action is needed for a pH less than 7.2?
• It may need a chest drain
How would you manage a transudate?
• treat the underlying cause, may not need CT imaging
How would you manage an exudate?
• Unless cause is identified, it will need further investigation for eg further imaging and or pleural biopsy.
What is a primary spontaneous pneumothorax?
• When the pneumothorax takes place in an individual with no underlying health conditions.
What is a secondary spontaneous pneumothorax?
• When the lung collapse happens in a person with a pre-existing lung disease.
What lung diseases can lead to a pneumothorax?
• interstitial lung disease, COPD, Asthma, cystic fibrosis
What is traumatic pneumothorax?
• Pneumothorax as a result of injury to the chest wall
What is a iatrogenic pneumothorax?
• It is as a result of a biopsy of the lung.
What is a tension pneumothorax?
• Air within a pleural cavity following a pneumothorax builds up and pushes the central structures of the chest and squashes the opposite lung. It aso squashes the heart and this results in a reduced blood pressure and because of the other squashed lung this can lead to low blood oxygen. This can lead to cardia arrest.
What is tachypneic?
• Breathing fast
What are the symptoms of a pneumothorax?
• Breathing fast, Hypoxic, Reduced chest wall movement and reduced or no breath sounds,
How is a pneumothorax diagnosed?
- CXR
- Ultrasound
- CT Thorax
How is a pneumothorax managed?
- Observe: small and patient is well
- Aspiration: over 2cm in size, patient well
- Chest drain insertion
- Surgery: recurrent events, unresolving
Where does pleural aspiration take place?
• Safe triangle, 2nd intercostal space midclavicular line
How common are benign pleural tumours?
• Not common
What are the characteristics of mesothelioma?
• Rare and agressive
What types of occupations increase risk to mesothelioma?
• Men, plumbers, electricians, shipbuilding, power plants, boilers, engines.
How is mesothelioma caused?
• Inhaled asbestos fibres reach the pleura and cause inflammation provokes tumour formation
What are the main symptoms of mesothelioma?
• Breathlessness, Chest pain, Weight loss, Clubbed, signs of pleural effusion
How would you diagnose mesothelioma?
- CXR
- CT Thorax and Biopsy
- You would see thickened pleura, pleural nodules or masses, pleural plaques, an effusion, soft tissue infiltration.
How would you manage mesothelioma?
• Treatment options are limited, palliative, poor survival, Treating the effusion, Chemotherapy, palliative surgery in select patients
How would you manage mesothelioma?
• Treatment options are limited, palliative, poor survival, Treating the effusion, Chemotherapy, palliative surgery in select patients
Where does the pleura extend to?
Pleura over the first rib
Pleura over the liver, spleen, kidney
What are the symptoms of pleural effusion?
Asymptomatic – if small and accumulates slowly
Increasing breathless (days, weeks, months)
Pleuritic chest pain
(cause of pleural fluid) inflammatory: early, may improve as fluid accumulates
malignancy: progressively worsening
Dull ache
Dry cough – especially if rapid accumulation
Weight loss, malaise, fevers, night sweats
Need to enquire about peripheral oedema, liver disease, orthopnoea, PND
When should you investigate a transudate?
If there are unusual features
Failure to respond to appropriate treatment
How do you confirm presence of effusion?
Chest radiograph
Pleural aspiration and biopsy
Contrast enhanced CT of thorax (
Usually differentiates between malignant and benign disease
nodular pleural thickening
mediastinal pleural thickening
parietal pleural thickening >1cm
circumferential pleural thickening
other malignant manifestations in lung/liver)
What are the possible complications for aspiration?
Pneumothorax Empyema Pulmonary oedema Vagal reflex Air embolism Tumour cell seeding Haemothorax
What is pleural aspiration?
A pleural aspiration is a procedure where a small needle or tube is inserted into the space between the lung and chest wall to remove fluid that has accumulated around the lung.
What does foul smelling pleural fluid indicate?
Anaerobic empyema
What does pus in the pleural fluid indicate?
Empyema
What does food in the pleural fluid indicate?
Oesophageal rupture
What does milky pleural fluid indicate?
Cyclothorax - usually lymphoma
What is cyclothorax?
A chylothorax (or chyle leak) is a type of pleural effusion. It results from lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct.
What is the biochemistry anaysis of the pleural fluid?
Measures levels of protein, Lactate dehydrogenase (LDH), amylase (increase could indicate pancreatitis), looking out for empyema, rheumatoid arthritis, SLE
(Systemic lupus erythematosus (SLE) is an autoimmune disease. In this disease, the body’s immune system mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs.)
TB
Malignancy
What do Microbiology test the pleural fluid for?
Gram stain (determines the class of bacteria)
AAFB - Alcohol, acid fast bacilli?
Culture
Microscopy, culture and sensitivity
What is cytology?
The branch of biology concerned with the structure and function of plant and animal cells.
What do cytlogy do with the pleural fluid?
Search for malignant cells, lymphocytes (Tb, lymphoma)
eosinophils
If there is no dagnosis from investigating the pleural fluid, what is the next thing to do?
Thoracoscopy involving direct inspection og the pleura, directed biopsies, therapeutic
What are the treatment plans for pleural disease?
Directed at the cause
Chemotherapy
Antituberculosis chemotherapy
Corticosteroids
Palliative
Repeated pleural aspiration
What is pleurodhesis?
Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae.
How is pleurodhesis carried out?
Drain fluid until dry - chest X-ray confirms this
If the lung has not re-expanded - apply suciton and remove the drain becuase of infection risk
If the lung has re-expanded, chemical pleurodhesis - The instilled chemicals via chest drain cause irritation between the parietal and the visceral layers of the pleura which closes off the space between them and prevents further fluid from accumulating. Chemicals used can be (slurry of talc)
What is surgical pleurodhesis?
Performed during thoracectomy or thoracoscopy. Involves mechanically irritating the parietal pleura, often with a rough pad. Removal of the parietal pleura is also an effective way of achieving a stable pleurodesis.
Tunneled pleural catheters used inconjunction with portable vacuum bottles are used to stimulate auto-pleurodesis. Constant excavation of pleural fluid keeps the pleura together, resulting in physical agitation by the catheter, which slowly causes the pleura to scar together.
What are pulmonary blebs?
Pulmonary blebs are small subpleural thin walled air containing spaces, not larger than 1-2 cm in diameter. Their walls are less than 1 mm thick. If they rupture, they allow air to escape into pleural space resulting in a spontaneous pneumothorax.
What are the suspected reasons for a secondary spontaneous pneumothorax
Pre-existing lung disease
COPD
Asthma
Pneumonia
TB
Cystic Fibrosis
Fibrosing alveolitis
Sarcoidosis
Histocytosis X
What are the iatrogenic causes of traumatic pneumothorax?
Pleural aspiration biopsy
Sub-clavian vein cannulation
Lung, liver, breast, renal biopsy
Acupuncture
What are the signs of pneumothorax?
Perhaps none
Surgical emphysema if significant air leak (air tracking in subcutaneous fat), bubble wrap feeling
Non-tension
Trachea deviated to affected side
Affected side: decreased expansion
hyper resonant
absent, decreased decreased breath sounds
Tension
Trachea deviated away from affected side
Haemodynamic compromise
Increased JVP
What is the management for a small primary pneumothorax?
Observe overnight, repeat chest X-ray, if no change, hole has sealed
Discharge -
Advise no vigorous activity, to return if becomes breathless
Pneumothorax will resolve at about 1.25% /day
Review with CXR clinic 2 weeks
How do you manage a breathless primary pneumothorax?
Aspirate
Patient at 45 degrees - allows the air to travel to the apex of the lung
Lignocaine to second intercostal space (local anaesthetic), mid clavicular line
50ml syringe, venflon, 3 way tap, discharges into a bucket of water
When do you stop aspirating a pneumothorax?
Until you can feel the tip of the venflon just beneath the surface of the chest wall
Stop if you have aspirated 3 litres - indicates persistant air leak
What is the post aspiration management?
Repeat chest X-ray to confirm success
If unsuccessful - chest drain
How do you manage a secondary pneumothorax?
Try aspiration if small, but usually less successful
Insert intercostal chest drain - 4th intercostal space mid-axillary line
What is likely to happen after a chest drain?
Lung will inflate in 1-2 days
Drain stops bubbling in the underwater seal
Chest X-ray confirms the lung is inflated
What is the management of a patient after an intercostal chest drain?
- Clamp drain for 24 hours, re-xray, if no change remove drain
OR
- Re xray chest after 24 hours, no change, remove drain
