- Pleural Disease Flashcards
What is the pleura composed of?
Single layer of mesothelial cells
What are the forces acting across the pleura?
Where does the pleura extend to?
Pleura over the first rib
Pleura over the liver, spleen, kidney
What is pleural effusion defined as?
Abnormal collection of fluid in the pleural space
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
What are the signs of pleural effusion?
What are the causes for pleural effusion?
What are the two types of pleural effusion?
transudates and exudates
How do you distinguish between transudates and exudates?
Determined by the pleural fluid protein
What is the definition of a transudate?
Pleural fluid protein < 25g/l, for exams < 30g/l
What are the causes of a transudate?
What is the definition of an exudate?
Pleural fluid protein > 35g/l, for exams > 30g/l
What are the causes of exudate?
Do you need to investigate for transudates?
Not usually, clinical picture is usually characteristic
When should you investigate a transudate?
If there are unusual features
Failure to respond to appropriate treatment
How do you confim 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?
You use (
50ml syringe 21G needle (green), lignocaine anaesthesia
(guidelines recommend bedside US guidance)
Sterile universal containers
Blood culture bottles)
Pneumothorax
Empyema
Pulmonary oedema
Vagal reflex
Air embolism
Tumour cell seeding
Haemothorax
Define 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
How do you tell the difference between the two types of pleural aspiration?
Transudate if <25g/l, exudate if >35g/l
How do you perform a biopsy without hitting the colateral branch of a rib?
Biopsy immediately above a rib
What are the two common needles used in a biopsy?
Abram’s needle for blind biopsies
Tru-cut - for CT guided biopsies
What happens to the 4 biopsies taken?
Send at least 3 in formaldehyde for histology
Send at least 1 in saline to microbiology if TB suspected
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?
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 is pneumothorax defined as?
Presence of air within the pleural cavity, lung collapses away from chest wall because of elastic recoil of the lung.
What are the two different types of pneumothorax?
Spintaneous
Traumatic
What are the different types of spontaneous vs Traumatic pneumothoraxes
What are the common feature of a primary spontaneous pneumothorax?
No clinically apparent disease
Most common in young people aged 20-30
People are usually tall and thin
What is thought to be the cause of a spontaneous primary pneumothorax?
Due to the weight of the lung inducing development of apical blebs that rupture
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 non-iatrogenic causes of traumatic pneumothorax?
Penetrating chest injury
Blunt chest injury (rib fractures, bronchial rupture)
What are the iatrogenic causes of traumatic pneumothorax?
Pleural aspiration biopsy
Sub-clavian vein cannulation
Lung, liver, breast, renal biopsy
Acupuncture
What are the symptoms of pneumothorax?
Assymptomatic if good respiratory reserve
Acute breathlessness, worsening breathlessness
Pleuritic chest pain
Extreme dyspnoea
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 distinguishment between a small and a large pneumothorax?
Small: Rim of air is less than 2 cm
Large: Rim of air is greater than or equal to 2
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
What should you do if the lung fails to re-inflate after 48 hours, and the drain continues bubbling?
Apply suction to drain (high volume, low pressure)
If lung fails to inflate contact thoracic surgeon at 3 days
Thosacoscopic inspection of visceral pleura identification of blebs, tears, clipping and talc poudrage pleurodesis
What is the chance of getting a subsequent pneumothoroax within 4 years?
54%
When should you refer someone for surgical pleurodhesis?
If it is the second ipsilateral pneumothorax
First contralateral pneumothorax
Bilaterl spontaneous pneumothoraces
First pneumothorax in high risk professions
What can be used instead of talc poudrage?
Pleurectomy, removal of part of the pleura
What is asbestos?
Highly fibrous naturally occuring mineral
What are the three different types of asbestos?
Chrysotile
Amostile
Crocidolite
What is the purpose of asbestos?
Woven into fabric or added to other materials
It has a high tensile strength
Fire resstance
Insulation to electrical charge
Resistant to chemical attack
Commonly foud in building materials
What is mesothelioma?
Pleural malignancy
Mostly due to asbestos
What is the clinical presentation of mesothelioma?
Breathlessness (pleural effusion)
Chest wall pain
Weight loss
What are the radiological findings of mesothelioma?
Usually unilteral
Diffuse or localised pleural thickening
