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Revision > Pleural Disease > Flashcards

Pleural Disease Flashcards

1
Q

What causes SOB in pt with pleural effusion?

A

Splinting of diaphragm

Nb. approx 500ml will relieve symptoms

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2
Q

How much does FEV1/FVC and TLC change with 1 litre of pleural effusion removal?

A

FEV1/FVC - increase 0.2 litres
TLC - increase 0.4 litres

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3
Q

Would you expect a drop in SATS with a large pleural effusion??

A

Not if otherwise fit and healthy (as will get shunting of blood to healthy lung)

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4
Q

What radiological modality detects the smallest volume of pleural fluid?

A

USS - can see 5ml

Nb. 200ml needed for CT (or 50ml for lateral CXR)

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5
Q

If you aspirate a pleural effusion, will SATS go up?

A

Probably not as shunting means that blood not going to that lung. Mostly improves symptoms rather than hypoxaemia

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6
Q

What are lights criteria?

A

Exudate
Protein: fluid:serum >0.5
LDH: fluid:serum >0.6
LDH > 2/3 upper limit normal

Nb. confounder = diuretics

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7
Q

How many effusions due to HF are unilateral?

A

40% (R 30%, L 10%)

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8
Q

What are the causes of an transudative effusion:

A
  • Failures: liver/renal/heart (nb. 40% of cardiac = unilateral (30% R, 10% L))

Less common
- Atelectasis
- Peritoneal dialysis
- PE (much more likely exudate)/malignancy, hypothyroid

Rare
- constrictive pericarditis
- Meig (with gynae tumour), urinothorax, ovarian hyperstimulation, subvlavian vein cannulation, duropleural fistula (ass cerebella disease)

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9
Q

What are causes of exudative effusions?

A

Common:
- Malignancy
- Parapneumonic
- TB (nb. micro only +ve in 20%)

Less common:
- Empyema (nb. micro only +ve in 50%)
- PE (contralateral in 30%)
- RA/SLE/CTD
- Chylothorax/pseudochylothorax
- post CABG/MI
- Benign asbestos

Rare
- Pancreatitis, fungal, hydatid
- Drugs: methotrexate, amiodarone, phenytoin, nitrofurantoin, beta blocker

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10
Q

What drugs can cause pleural effusion (exudate)?

A

Methotrexate, amiodarone, phenytoin, nitrofurantoin, beta blocker

Other causes of exudate:
- Malignancy
- Parapneumonic
- Empyema (nb. micro only +ve in 50%)
- PE (contralateral in 30%)
- TB (nb. micro only +ve in 20%)
- RA/SLE/CTD
- Chylothorax/pseudochylothorax
- post CABG
- Benign asbestos
- Pancreatitis, fungal, hydatid

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11
Q

Pt has pleural effusion with protein fluid:serum ratio >0.7. Also has raised triglycerides. What is most likely cause? And what are Light’s criteria?

A

Chylothorax (nb. TG>1.24 and normal cholesterol = chylo, cholesterol >5.18 and TG normal = pseudochylo)

Exudate
Protein: fluid:serum >0.5
LDH: fluid:serum >0.6
LDH > 2/3 upper limit normal

Nb. confounder = diuretics

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12
Q

What causes a chylothorax?

A

Traumatic
Malignancy (lymphoma & lung cancer)
Idiopathic
Cirrhosis (and chylous ascites)
LAM, sarcoid, filiarisis, TB, SVC obstruction

Diagnosis: TG>1.24, normal cholesterol, chylomicrons, milky fluid (may be bile-stained)
–> tend to be acute, unilateral and have normal underlying pleura

Treatment: dietary change +/- somatostatin or ocreotide

N.b aspiration only for symptomatic management

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13
Q

What causes pseuochylothorax?

A

RA & TB pleuritis

Diagnosis: cholesterol >5.18, normal TG, absent chyolmicrons

Nb. always longstanding

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14
Q

What can cause a lymphocytic pleural effusion?

A

TB
RA
Malignancy (metastatic adeno & meso)
Lymphoma
CCF
Post-cardiac bypass
Sarcoid
Chylothorax
Yellow nail
Liver/renal failure (longstanding)

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15
Q

What CT features of the pleura are suggestive of malignant disease?

A

Mediastinal thickening
Nodularity
>1cm
Circumferential (can be benign)

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16
Q

What might cause a pleural effusion with a low glucose? (<3.4)

A

Empyema (can be very low i.e. <1.6)
RA (can be very low i.e. <1.6)
TB
Malignancy
Oesophageal rupture

Nb. these are same things as for low pH

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17
Q

What things can cause a pleural effusion with a low pH (<7.3)?

A

Empyema
RA
TB
Malignancy
Oesophageal rupture

Nb. these are same things as for low glucose<3.4 (and the top 2 for very low glucose (<1.6)

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18
Q

What can cause pleural fluid with elevated amylase?

A

Pancreatitis
Malignancy (esp. adenoca)
Oesophageal rupture

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19
Q

What can cause black pleural fluid?

A

Malignant melanoma
Aspergillus niger
Haemorrhage secondary to SCLC

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20
Q

Pt has unilateral pleural effusion on CXR. They have bilateral pitting oedema to knees. No other examination findings. What investigations should be done?

A

Treat for HF and monitor for resolution (nb. also the case if suspect other causes of transudate e.g. dialysis pt)

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21
Q

What tests should be sent on pleural fluid?

A

Cytology
Protein, LDH, pH
Gram stain
+/- others

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22
Q

Pt has a unilateral pleural effusion. Aspirate shows an exudate but no diagnosis obtained from fluid results. What is next step?

A

Contrast CT (nb. need late venous phase to see pleura well)

+ consider VATS or radiology guided pleural biopsy

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23
Q

Pt has a unilateral pleural effusion. Aspirate shows an exudate but no diagnosis obtained from fluid results. CT and pleural biopsy also not helpful. What is next step?

A

Re-think re PE, TB, CCF and lymphoma.
Can consider watchful wait.

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24
Q

How much fluid is needed for a pleural aspirate?

A

50ml

5ml for micro
2-5ml for biochem
20-40ml for cytology

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25
Q

How should you prepare pleural fluid samples to get maximum yield for infection?

A

Use blood culture bottles (i.e. use if suspect infection)

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26
Q

What is the most likely cause of pleural fluid with a putrid odour?

A

Anaerobic bacteria

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27
Q

What causes a bloody pleural effusion?

A

Malignancy
PE with infarction
Trauma
Benign asbestos effusion
Post-cardiac injury

Nb. haematocrit >50% of patient’s peripheral blood = haemothorax

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28
Q

Pt has a chest drain in for a parapneumonic effusion. They aren’t getting better therefore you test the fluid again. The pH is 7.1. What should you do?

A

Change the tube (change any with pH<7.2)

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29
Q

What is the yield for malignancy on pleural fluid?

A

60%

Increases 15% on repeat

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30
Q

Pt suspected for malignancy. Pleural fluid is sent and comes back negative. What is next step?

A

CT +/- Biopsy of pleura (repeat pleural fluid not helpful) nb. do image guided biopsy first, and if inconclusive then thoracoscopy (under local or VATS)

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31
Q

Are serum tumour markers helpful in the context of pleural fluid?

A

No

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32
Q

What features might help you tell if effusion related to RA?

A

Very low glucose (<1.6), low pH, increased LDH

Painless. May be pseudochylothorax.

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33
Q

What features might help you tell if effusion is post-CABG?

A

<30 days
L>R
Usually small and asymptomatic

Exudate, bloody (but low haematocrit), may have elevated eosinophils

Tend to resolve w/o intervention in 3 months.

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34
Q

What is ovarian hyperstimulation syndrome in context of pleural effusions?

A

Life threatening reaction to ovulation induction - get R pleural effusion with massive ascites/renal & liver failure/ARDS/emboli. Exudate with elevated protein and LDH.

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35
Q

How can you diagnose a benign asbestos pleural effusion?

A

Need exposure to asbestos
Effusion usually small & asymptomatic
Blood-stained, often predominately neutrophils (polymorphs)
May resolve and leave diffuse pleural thickening

No definitive test therefore often need biopsy etc to r/o malignancy

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36
Q

In pt with empyema, how often will you get positive micro?

A

50% (nb. only 30% for TB)

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37
Q

What pleural fluid markers are in keeping with mesothelioma?

A

Positive cytokeratin & calretinin
Negative TTF1 and CEA

38
Q

What treatment is available for mesothelioma?

A

Pemetrexed + cisplatin

–> only treatments that prolong life

39
Q

Pt with known malignancy has a pleural effusion. How should it be managed?

A

No symptoms = observe

Symptoms = aspirate 500-1000ml
–> if prognosis <1month: aspirate to control symptoms
–> if >1month
+ trapped lung (<50% pleural apposition): IPC
+ partial or no trapped lung: drain +/- pleurodesis

–> if pleurodesis fails, do IPC

40
Q

How successful is TALC pleurodesis?

A

80%

41
Q

What is most common cause of metastatic tumour to the pleura?

A

Men - lung cancer
Women - breast

42
Q

Pleural effusion is massive. What is most likely cause?

A

Malignancy

43
Q

What is the max amount of fluid that should be taken on pleural aspiration?

A

1500ml (caution above this)

44
Q

What size drain do you need for talc pleurodesis?

A

10 - 14 is fine (i.e. small is fine)

45
Q

How much lidocaine should be used for talc pleurodesis?

A

Max dose 3mg/kg to a max of 250mg

1% lidocaine = 1g/100ml = 10mg/1ml = max dose 21ml for 70kg person

46
Q

Is there a difference between talc slurry and poudrage with respect to pleurodesis?

A

No - same success

nb. Bleomycin = alterantive scleroscant

47
Q

What are most common SEs of pleurodesis?

A

Pain and fever

48
Q

Do you need to rotate pt during pleurodesis?

A

No

49
Q

How long should chest drain be clamped for after talc administration for pleurodesis?

A

1hr

50
Q

When can chest drain be removed after pleurodesis?

A

<250ml fluid in 24hrs and lung re-exapnded on CXXR

51
Q

Pt has proven mesothelioma. Having chest drain inserted. What else should you do?

A

Prophylactic radiotherapy due to risk of seeding (also do if have thoracoscapy)

Nb. don’t need for aspiration or biopsy

52
Q

Pt has malignant effusion with multiple locules. Drain inserted but not working well. What should you try next?

A

Fibronolytics (streptokinase)

53
Q

When should you do thorascopic pleurodesis in context of malignancy pleural effusion?

A

Good performace status - consider thoracoscopy for diagnosis of suspected malignancy, or drainage/pleurodesis of known malignancy

Or, consider for recurrent malignant effusion

54
Q

What are independent RFs for empyema?

A

Age
Diabetes
Immunosuppression inc steroirds
GORD
Alcohol misuse
IV drug use

55
Q

What is the pH of normal pleural fluid?

A

7.6

56
Q

What are the 3 stages of empyema development?

A

1) Simple exudate (parapneumonic effusion)
- pH>7.2, LDH<1000, Glu>2.2, micro -ve
2) Fibrinopurulent (complicated parapn.)
- pH<7.2, LDH>1000, Glu<2.2, +/- micro
3) Organising (empyema)
- frank pus

57
Q

What is the difference between a simple and complicated parapneumonic effusion?

A

Complicated: pH>7.2, LDH<1000, Glu>2.2, micro -ve

Simple = opposite (and micro -ve)

58
Q

What is the most common cause of communicated acquired pleural infection?

A

Strep milleri (angiosus) > strep pneumonia > anaerobes (fusobacterium/bacteriodes) & staph aureus

Hospital: MRSA > gram -ves (enterobacter/E.coli/pseud)

59
Q

What ancilliary factors should be considered in treatment of pleural infection?

A

Nutrition (hypo alb ass wiith poor outcome)
VTE

60
Q

When assessing non-purulent pleural fluid for infection, what test should always be done?

A

pH, and if not available, glucose

pH>7.2 (glu>2.2) = simple
pH<7.2 (glu<2.2) = complex

However, glucose <3.4 may suggest drainage needed

61
Q

What is the cause of an alkaline effusion?

A

Proteus spp

62
Q

What are the indications for chest drain?

A

Empyema
Positive gram stain from pleural fluid
pH<7.2
Poor clinical progress following treatment with abx alone
Loculated effusion
If needed for symptom benefit (consider aspiration)

63
Q

What size drain is required for drainage of an empyema?

A

10-14 fine (i.e. small bore is fine)

64
Q

What abx should be given for community acquired empyema? (no bug known)

A

Co-Amox and Metro (as covering for Strep milleri, pneumonia and anaerobes)

65
Q

What abx should be given for hospital acquired empyema?

A

Tazocin +/- Vanc (if MRSA)

66
Q

What abx should be avoided in pleural infection?

A

Aminoglycosides (poor pleural penetration)
Macrolides (unless high suspicion of atypical pathogen)

67
Q

How long should abx be continued in pleural infection?

A

3 weeks at least

68
Q

Should fibronolytics be used in pleural infection?

A

No - refer for VATS

However if VATS contraindicated may consider tissue plasminogen activator and DNAase

69
Q

When should pt with empyema be referred for VATS?

A

Failure to improve after 5-7 days
Residual pleural collection despite treatment with drain and abx

70
Q

When should pt with empyema be followed up?

A

4 weeks after d/c with CXR & inflammatory markers

71
Q

What factors are associated with a risk of recurrence of primary pnx?

A

Age >60, Smoking, height

72
Q

What factors are associated with a risk of recurrence of secondary pnx?

A

Age, pulmonary fibrosis, emphysema

73
Q

What is the definition of large vs small pneumothorax?

A

large = >2cm between lung margin and hilum

74
Q

What is the definition of primary and secondary pnx?

A

Age >50 + significant smoking hx OR evidence of underlying lung disease

75
Q

Pt with primary spont pnx. 1.9cm and no symptoms. How should you manage?

A

Consider d/c and r/v in 2-4wks

Nb. if >2cm or SOB, aspirate (16-18G cannula, <2.5L) –> if successful (<2cm and SOB improved) then consider d/c + r/v in 2-4 wks, otherwise drain

Nb2. If minimal symptoms, can consider conservative management even if large PNX

76
Q

How do you manage pt with secondary spont pnx 1.9cm + no symptoms?

A

Aspirate (16-18G cannula, <2.5L) –> if successful (<1cm) then admit for high flow oxygen (unless sensitive) and observe for 24hrs

Nb. if >2cm or SOB then drain

Nb2. if <1cm then admit for high flow oxygen (unless sensitive) and observe for 24hrs

77
Q

Can a pt with secondary spont pnx be d/c at the door w/o any treatment?

A

No - will need at least 24hrs monitoring

If <1cm: high flow oxygen (unless sensitive) and observe
1-2cm + no symptoms: aspirate
>2cm OR symptoms: drain

78
Q

When should consideration of referral to surgeons be done in context of pnx?

A

IP: Secondary spontaneous with persistent air leak >48hr
–> If unfit for surgery, consider medical pleurodesis or Heimlich valve

Ongoing airleak 3-5 days
Tension
Pregnancy (do elective assisted delivery + VATS after deliver)
Spontaenous haemothorax

OP: single pnx and pt choice, 2xipsi or 1xcontra, bilateral disease, professions at risk

79
Q

What is the best surgical approach for managing recurrent pneumothoraces?

A

Open thoracotomy + pleurectomy = lowest recurrence
VATS = best tolerated

80
Q

What is a catamenial pnx?

A

PNx with period

81
Q

Should suction be used in pnx?

A

Not for primary
Secondary can try in ongoing leak (alongside larger or second drain or surgical referral)

82
Q

When can pt fly after pnx?

A

1 week after full resolution on cxr

Nb. ideally 2 after traumatic pnx

83
Q

What can pt dive after pnx?

A

After bilateral surgical pleurectomy (or VATS pleuordesis) + normal lung function and CT scan post-op

Nb. if traumatic pnx, then just normal lung function and CT needed

84
Q

How should you manage iatrogenic pnx?

A

Conservative unless symptomatic/compromised

85
Q

What are some causes of pnx that might come up in the exam?

A

Burt-Hogg-Dube
LAM (woman child-bearing age, ass with tuberous sclerosis, thin walled cysts)
Catamenial (female during period)
Marfan (aortic root dilation, skeletal problems, high arch palate, lens dislocation)
Langerhans histiocytosis

86
Q

What are contraindications for local anaesthetic thoracoscopy?

A

Lung adherent to chest wall throughout hemithorax
Hypercapnia or severe resp distress
Uncontrollable cough

Relative: obesity, ongoing reversible process e.g. infection, high likelyhood of trapped lung, known obstruction central airway tumour

87
Q

Apart from asbestos, what can cause plural plaques?

A

Single plaque may occur with TB trauma and haemothorax.

No evidence plaques are premalignant.
Found in 50% of workers with >30 years asbestos exposure.

88
Q

What is the median survival of lung cancer (adenocarcinoma) presenting with malignant effusion?

A

74 days.

Mesothelioma is > 300 days

89
Q

What can you use to identify effusions misclassified by lights criteria? E.g. due to diuretics

A

Serum/pleural album gradient
>12g/L = transudate

90
Q

What features on imaging might suggest trapped lung, and therefore use of IPC may be better than pleurodesis?

A

Hydropneumothorax
< 50% pleural apposition

91
Q

What is the likely diagnosis in turbid fluid that doesn’t clear on centrifugation?

A

Chylothorax or pseudochylothorax

92
Q

When should CT be done in PNX?

A

Help determine PNX in bullous disease or drain placement in surgical emphysema

Or best way of seeing size or detecting small pnx

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