Pleural Disease Flashcards
What are the types of Pleural Disease? (3 things)
- Pleural Effusion
- Pneumothorax
- Pleurisy (Pleuritis)
What is Pleural Effusion?
Fluid in the Pleural space
(between layers of Parietal + Visceral pleura)
What happens to the lungs in Pleural Effusion?
Lung exansion limited –> Impaired ventilation
What are the 2 types of Pleural Effusion?
What is the purpose of these classifications?
Transudative Pleural Effusion (Low prot in fluid)
Exudative Pleural Effusion (High prot in fluid)
Helps determine the cause
What is the difference between Transudative vs Exudative causes of Pleural Effusions?
- Transudative: fluid moves accross into pleural space (trans = moving across)
- Exudative: prot leaking out of tissues into pleural space bc inflamm (ex = moving out of)
What are the Exudative causes of Pleural Effusion? (4 things)
To do with inflamm:
- Infection (Pneumonia / TB)
- Lung cancer
- Pulmonary Embolism
- RA
What are the Transudative causes of Pleural Effusion? (5 things)
To do with fluid moving across into pleural space:
- Congestive HF (increased Venous pressure)
- Constrictive Pericarditis (increased Venous pressure)
- Cirrhosis (Hypoalbuminaemia)
- Hypothroidism
- Meig’s syndrome (R sided Pleural Effusion w Ovarian malignancy)
What are the CF of Pleural Effusions? (7 things)
- SOB (worse @ lying down)
- Pleuritic chest pain (worse @ deep inspiration)
- Non-prod cough
@ exam
- Dullness to percussion over Effusion
- Reduced breath sounds
- Reduced chest expansion (assymetrical)
- Tracheal deviation (away from Effusion) (if massive)
What investigations should you do for sus Pleural Effusion? (4 things)
- CXR (PA)
- US
- Pleural aspiration
- Pleural biopsy (if fluid analysis inconclusive)
What will a CXR show in Pleural Effusion? (4 things)
- Blunting of Costophrenic Angle
- Fluid in lung fissures
- Meniscus (a curving upwards where it meets chest wall + mediastinum) (if massive)
- Tracheal + Mediastinal deviation (if massive)
What is the use of a US in sus Pleural Effusion? (2 things)
- Confirms Pleural Effusion
- Shows any Septations in fluid
What does Septations in the fluid of Pleural Effusions seen in a US indicate?
Exudate Peural Effusion (caused by infection e.g TB)
What is the use of Pleural aspiration?
Analyse fluid for:
- Protein count
- Cell count
- pH
- Glucose
- LDH (lactate dehydrogenase)
- Microbiology testing
To check if Transudate / Exudate
What does a HIGH / LOW protein count in aspirated Pleural fluid suggest?
- HIGH = Exudate
- LOW = Transudate
What does a HIGH WBC count in aspirated Pleural fluid suggest?
Infection = Exudate
What does a LOW Glucose / pH levels in aspirated Pleural fluid suggest?
TB / RA / Malignancy = Exudate
What does a HIGH LDH (lactate dehydrogenase) level in aspirated Pleural fluid suggest?
LDG = inflamm marker = Exudate
What are the management options for Pleural Effusions? (4 things)
- Conservative (small effusions)
- Pleural aspiration
- Chest drain
- Pleurodesis (chemical / surgical): removes pleural splace –> prevents fluid accum) (for repeated effusions)
What is the difference between Pleural Aspiration vs Chest drain of Pleural Effusions?
- Pleural aspiration: done with a needle, temporary relieves pressure, but risk of repeated effusions
- Chest drain: drains effusion, stops if from recurring
What can be used for CHEMICAL Pleurodesis of a Pleural Effusion? (3 things)
- Talc
- Bleomycin
- Tetracycline
What is a Pneumothorax?
Air getting into Pleural Space
Who is your classic Pneumothorax patient?
Tall, thin, young man playing sports
What are the Risk Factors for Pneumothorax? (5 things)
- Male
- Smoking
- FHx
- Pre-existing lung diseases: COPD / asthma / pneumonia / CF / lung cancer
- CT disease: Marfans / RA
What are the causes of Pneumothorax? (3 things)
- Primary: Spontaneous (in tall, thin young men) (bc ruptured bulla)
- Secondary: To existing lung disease
- Traumatic: (rib # / stab wound / iatrogenic)
What are the iatrogenic causes of Pneumothorax? (3 things)
- Lung biopsy
- Central line insertion
- Mechanical ventilation
What are the Pathophysiological steps of a Tension Pneumothorax? (6 things)
- One-way valve forms from damaged tissue
- Air enters but can’t escape
- Pleural space pressure builds up (tension)
- Mediastinum shifts away –> compresses other lung –> Hypoxia
- Vena cava + Atria compressed –> Reduced Cardiac function
- Rapid CardioResp collapse
(can develop from any type of pneumothorax)
What are the CF of Pneumothorax? (10 things)
- Asymptomatic (if small)
- Sweating
- SOB
- Pleuritic Chest pain
- Tachypnoea
- Tachycardia
@ exam
- Hyper-resonance @ percussion
- Reduced breath sounds on affected side
- Reduced chest expansion
- Tracheal deviation (away from affected side) (in Tension Pneumothorax)
What are the CF of Pneumothorax in Mechanically ventilated patients? (2 things)
- Hypoxia
- Increase in ventilation pressures
What are CF specific to a Tension Pneumothorax? (5 things)
- Distended neck veins
- Displaced apex beat
- Reduced BP
- Reduced Oxygen sat
- Epigastric pain
What investigations should you do for sus Pneumothorax? (2 things)
- Erect CXR
- CT (for pneumothorax too small to see on CXR)
What investigations should you do for a TENSION Pneumothorax?
None nigga
It’s a clinical diagnosis, as soon as you sus, start management
MEDICAL EMERGENCY
What will you see on a Erect CXR of Pneumothorax? (2 things)
- Edge of lung reduced
- Area of no lung markings (where pneumothorax is)
What will you see on a Erect CXR of a TENSION Pneumothorax? (4 things)
- Tracheal deviation (away from pneumothorax)
- Collapsed lung
- Edge of lung reduced
- Area of no lung markings (where pneumothorax is)
What is the use of a CT scan in Pneumothorax? (2 things)
- Detect small pneumothorax (too small to see on CXR)
- Accurate measurement of Pneumothorax size
What are the British Thoracic Society guidelines for Pneumothorax management? (4 things)
- No SOB, pneumothorax under 2cm –> No management req
- SOB +/- pneumothorax over 2cm –> Aspiration
- Aspiration fails 2x –> Chest drain
- Pneumothorax bc Trauma / Mechanical ventilation –> Chest Drain
- Unstable pt / Bilateral / 2ndary Pneumothorax –> Chest Drain
What is the management for a TENSION Pneumothorax? (2 things)
- Large bore cannula (to relieve pressure ASAP)
- Chest drain (definitive management)
Learn this phrase: Insert a large bore cannula into the 2nd intercostal space in the midclavicular line
Once pressure relieved w Cannula –> Chest drain = definitive management
Where is a Chest Drain inserted for Pneumothorax?
What is this formed by? (3 things)
Triangle of Safety
Formed by:
- 5th intercostal space (aka inf nipple line)
- Mid axillary line
- Ant axillary line
What do you need to keep in mind when inserting a Chest drain? (2 things)
- Insert ABOVE rib, to avoid neurovasc bundle under rib
- Do a CXR after to check positioning
What are the complications of a Pneumothorax? (6 things)
- Resp faliure
- Cardiac arrest
- Pneumomediastinum (air in mediastinum)
- Pneumoperitoneum (air in Peritoneal cavity)
- Re-expansion Pulmonary Edema (higher risk if collapsed for few days)
- Recurrence
What are the complications of the management procedures for Pneumothorax? (3 things)
- Infection / bleeding
- Fistula formation / air leaks
- Intercostal nerve damage (if u put chest drain under rib like an idiot)
