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Respiratory > Pleural disease > Flashcards

Pleural disease Flashcards

1
Q

What is the pleura?

A

This is a protective layer of connective tissue that surrounds the chest wall and lungs

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2
Q

What are the 2 types of pleura?

A

Parietal pleura (Chest wall)
Visceral pleura (Lungs)

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3
Q

What are the 4 regions of the parietal pleura?

A

Mediastinal
Diaphragmatic
Costal
Cervical

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4
Q

What forms the pulmonary ligament?

A

The 2 main layers of pleura combine around the hilla to form th pulmonary ligament

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5
Q

Where does the pulmonary ligament run?

A

It runs inferiorly and attaches the root of the lung to the diaphragm

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6
Q

What is a pleural effusion?

A

This is an abnormal accumulation of fluid within the pleural space

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7
Q

What are the 2 types of pleural effusion?

A

Exudative
Transudative

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8
Q

What is meant by an exudate?

A

An effusion containing a large amount of protein

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9
Q

What is meant by a transudate?

A

An effusion containing a small amount of protein

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10
Q

What is Light’s criteria for distinguishing between exudates and transudates?

A
  • Pleural fluid protein divided by serum protein is >0.5
  • Pleural lactate dehydrogenase (LDH) divided by serum LDH is >0.6
  • Pleural fluid LDH >2/3rd the upper limit of laboratory normal value for serum LDH
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11
Q

What is a general rule of thumb for protein levels in transudates and exudates?

A

Exudate has >30g / L protein
Transudate has <30g / L protein

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12
Q

What are some conditions that can cause transudative pleural effusion (5)?

A

Heart failure
Liver cirrhosis
Hypoalbuninaemia
Atelectasis (Partial lung collapse)
Peritoneal dialysis

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13
Q

What are some conditions that can cause exudative pleural effusion (4)?

A

Malignancy
Infection including TB
Pulmonary infarction
Asbestosis

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14
Q

What is the usual cause of transudative effusions?

A

Changes in osmotic pressure

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15
Q

What is the usual cause of exudative effusions?

A

Inflammation or lesions

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16
Q

What would a bilateral pleural effusion be suggestive of?

A

Drug use
Left ventricular failure
Pulmonary thromboembolism

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17
Q

What are some symptoms of pleural effusion?

A

Chest pain
Dry cough
Dyspnoea
Difficulty taking deep breath

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18
Q

What are some common clinical signs of pleural effusion?

A

Reduced chest expansion
Stony dull percussion

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19
Q

What are some tests required in pleural effusion?

A

Biochemistry
Aspiration
Cytology
Chest X-ray

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20
Q

What biochemical tests are required in pleural effusion?

A

pH
LDH
Glucose

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21
Q

What is the normal pleural fluid pH?

A

~7.6

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22
Q

What are pH and LDH tests used for?

A

Determining the difference between simple and complicated parapneumonic effusion

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23
Q

What is meant by a simple parapneumonic effusion?

A

pH > 7.2
LDH < 1000
High glucose

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24
Q

What is meant by a complicated parapneumonic effusion?

A

pH < 7.2
LDH > 1000
Low glucose

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25
Q

In what conditions will glucose levels in pleural effusion be low? (4)

A

Infection including TB
Rheumatoid arthritis
Malignancy
SLE

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26
Q

What conditions can cause a straw coloured effusion?

A

Cardiac failure
Hypoalbuminaemia

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27
Q

What conditions can cause a blood effusion?

A

Trauma
Malignancy
Infection
Infarction

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28
Q

What conditions can cause a turbid/milky effusion?

A

Empyema
Chylothorax

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29
Q

What is meant by a chylothorax?

A

Lymphatic drainage into the pleural cavity

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30
Q

What would a could smelling effusion be suggestive of?

A

Anaerobic empyema

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31
Q

What would food particles within an effusion be suggestive of?

A

Oesophageal rupture

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32
Q

What would cytology be used for in pleural effusion?

A

Malignant cells - Cancer
Lymphocytes - Malignancy or TB
Neutrophils - Acute illness

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33
Q

What microbiological testing can be performed in pleural effusion?

A

Gram staining
Cultures
PCR
AFB staining

34
Q

What will most bacteria in complicated parapneumonic effusions stain?

A

Gram positive

35
Q

What will most bacteria in simple parapneumonic effusions stain?

A

Gram negative

36
Q

What levels of effusion are required for a pleural effusion to be visible on CXR?

A

200ml on plain x-ray
500ml will show a clear fluid level

37
Q

What conditions will cause raised amylase in pleural effusion?

A

Pancreatitis
Oesophageal rupture

38
Q

What conditions will cause the presence of triglycerides in the pleural effusion?

A

Chylothorax caused by trauma, malignancy or LAM (Lymphangioleiomyomatosis)

39
Q

What conditions will cause cholesterol crystals to form in pleural effusion?

A

Pseudochylothorax, caused by TB or rheumatoid arthritis

40
Q

What will cause raised creatinine levels within a pleural effusion?

A

Urinothorax (Urine leakage into pleural cavity)

41
Q

What condition will cause a raised adenosine deaminase in pleural effusion?

A

TB

42
Q

What test will be performed if there is no clear diagnosis from fluid sampling?

A

CT guided thoracoscopy

43
Q

How are simple parapneumonic effusions usually treated?

A

Antibiotics only

44
Q

How are complicated parapneumonic effusions usually treated?

A

Chest drain (Thoracentesis) and antibiotics

45
Q

What are the most common cancers that metastasise to the pleura?

A

Lung cancer
Breast cancer

46
Q

What is the median survival time of pleura malignancy?

A

3-12 months

47
Q

How are frequent pleural effusions in pleural malignancy usually treated?

A

Palliation using chemotherapy and radiotherapy
Permanent chest drain
Talc slurry (Pleurodesis)

48
Q

What are some possible complications of talc slurry (Pleurodesis)?

A

Minor pleuritic pain
Fever
Pneumonia
Respiratory failure
Talc pneumonitis
Secondary empyema

49
Q

What is a pneumothorax?

A

This is an abnormal collection of air in the pleural space

50
Q

What are the 3 main types of pneumothorax?

A

Primary spontaneous pneumothorax
Secondary spontaneous pneumothorax
Traumatic or iatrogenic pneumothorax

51
Q

What is meant by primary pneumothorax?

A

This occurs with no underlying lung disease, often as a result of a bulla rupture

52
Q

Who is most at risk of a primary spontaneous pneumothorax?

A

Tall
Thin
Male
Cannabis smoker

53
Q

What is meant by a secondary spontaneous pneumothorax?

A

This occurs due to an underlying lung disease

54
Q

What are some possible presentations of pneumothorax?

A

Asymptomatic - If small enough
Acute onset pleuritic chest pain
Dyspnoea

55
Q

How does pneumothorax cause breathlessness?

A

Pneumothorax abolishes the transmural pressure gradient and so expansion of the chest wall cannot properly inflate the lungs

56
Q

What are some possible clinical signs of pneumothorax?

A

Hypoxia
Tachycardia Hyper-resonant percussion note
Reduced chest expansion
Quiet breath sounds on auscultation
Hamman’s sign (Clock on auscultation of left side)

57
Q

What investigations are required in pneumothorax?

A

Chest X-ray
CT scan

58
Q

What will be seen on CXR in pneumothorax?

A

A small rim of air around the lungs

59
Q

How can CXR differentiate between a small and large pneumothorax?

A

<2cm wide rim = small
>2cm wide rim = large

60
Q

What is the use of CT scanning in pneumothorax?

A

It is important in differentiating between bullous lung disease and small pneumothorax

61
Q

What is the management for a large primary pneumothorax with symptoms?

A

High flow oxygen
Aspirate via 16-18G cannula

62
Q

Where is a needle aspiration performed?

A

IN the Safe triangle in he 4-5th intercostal space on the mid-axillary line

63
Q

What makes up the safe triangle for needle aspiration?

A

Anterior border of latissimus doors
Posterior border of pectorals major
Anterior axial line, superior to the nipple

64
Q

Where in the intercostal space should needle aspiration be performed?

A

Through the centre, in order to avoid the neuromuscular bundles at the top and bottom of the intercostal space

65
Q

What are some management options in small primary pneumothorax with no symptoms?

A

High flow oxygen
Discharge early

66
Q

What is the limit for the amount of fluid that can be drained at once in pneumothorax?

A

2.5L aspirate, as any more than this can cause a rapid expansion oedema

67
Q

What is used in pneumothorax >2.5 L?

A

Suction can be performed over 48 hours

68
Q

What is a tension pneumothorax?

A

This is a life threatening variant of pneumothorax in which a one way valve causes progressively increasing pressure in the pleural space leading to mediastinal shift and cardiorespiratory compromise

69
Q

How will tension pneumothorax usually present?

A

Hypertension
Tachycardia
Tachypnoea
Tracheal deviation
Elevated JVP

70
Q

How is tension pneumothorax treated?

A

Needle decompression, in which a large gauge cannula is inserted into the 2nd or 3rd intercostal space in the midclavicular line

71
Q

What is mesothelioma?

A

This is an aggressive malignant tumour of the mesothelium, mostly arising from the pleura

72
Q

What is the most common cause of mesothelioma?

A

20-40 years post exposure to asbestos, mostly chrysotile asbestos fibres

73
Q

How does mesothelioma usually present?

A

Pleural effusion
Progressive dyspnoea
Stony dull percussion
Chest pain
Weight loss

74
Q

What are some investigations that can be performed in mesothelioma?

A

Chest X-ray
CT scan
Thoracoscopy
Aspiration of pleural fluid

75
Q

What will be seen on CXR in mesothelioma?

A

Pleural effusion
Pleural mass with a lobulated margin
Possible pleural thickening

76
Q

What is an empyema?

A

This is the presence of purulent fluid in the pleural space, most commonly caused by pneumonia

77
Q

What are some risk factors for empyema?

A

Immunodeficiency
Immunosuppression
Abnormal innate immunological defence
Repeated insult e.g. aspiration

78
Q

How will empyema usually present?

A

Slow to resolve pneumonia
The patient will usually get better and then will develop a spike in temperature
Possible signs of pleural effusion

79
Q

What are some investigations that can be performed in empyema?

A

CXR - Fluid level
USS
CT (Not routinely)

80
Q

What is the management for empyema?

A

IV amoxicillin and IV metronidazole
Cultures taken
Oral antibiotics to culture
Chest tube drain in safe triangle

81
Q

What are the 3 basic types of asbestos?

A

Chrysotile - White asbestos
Amosite - Brown asbestos
Crocidolite - Most dangerous

Respiratory (23 decks)

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