Pleural Disease Flashcards
Describe the normal pleura
- Glistening, smooth, thin membrane which covers the thoracic cavity and the lung
- Outer layer : Parietal Pleura
- Inner Layer : Visceral Pleura
- In between : Pleural fluid
Pleural problems
- Collection of fluid: Pleural effusion
- Collection of Air : Pneumothorax
- Pleural malignancy : Mesothelioma
What is pleural effusion?
- Collection of fluid in the pleural space
- Imbalance between production and absorption
- Absorption : Pleural lymphatics in the parietal pleura
Types of effusion
- Transudate: Non inflammatory
- Exudate: Inflammatory
- Protein content of exudate: 3g/dl or more
What are the causes of transudates?
Very common causes
- Left ventricular failure
- Liver cirrhosis
Less common causes
- Hypoalbuminaemia
- Peritoneal dialysis
- Hypothyroidism
- Nephrotic syndrome
- Mitral stenosis
Rare causes
- Constrictive pericarditis
- Urinothorax
- Meigs’ syndrome
Causes of exudates
Common causes
- Malignancy (Pulmonary and non pulmonary)
- Parapneumonic effusions, empyema
- Tuberculosis
Less common causes
- Pulmonary embolism
- Connective tissue disease
- Benign asbestos pleural effusion
- Pancreatitis
- Post-myocardial infarction
- Post-coronary artery bypass graft
- Haemothorax, chylothorax
Rare causes
- Yellow nail syndrome (and other lymphatic disorders eg, lymphangioleiomyomatosis)
- Drugs (see table 2)
- Fungal infections
investigations and management of pleural disease
- US : more sensitive than CXR , mark site for aspiration, assess pleura, bedside
- CXR : accessible , easy to interpret
- CT Thorax : Complex effusions , visualising the pleura , vascular and mediastinal structures
Pleural fluid analysis
- Aspiration : simple and safe, trained operator
- Inspect the fluid
- PH ( bedside ABG machine ), biochemistry,microbiology and cytology
Management of pleural disease
- PH less than 7.2 with pneumonia, pus or blood may need a chest drain
- Transudate : treat the underlying cause, may not need CT imaging
- Exudate : Unless cause identified will need further investigation for eg further imaging , and or pleural biopsy
Presentation of pneumothorax
- Sudden event
- Chest pain or breathlessness
- Tall thin young men
- Underlying lung disease
- History of biopsy /line insertion/mechanical ventilation
Examination of pneumothorax
- Breathing fast : tachypneic
- Hypoxic
- Reduced chest wall movement and reduced or no breath sounds
- Not uncommonly examination may be normal
Diagnosis of pneumothorax
- CXR
- US experienced operator usually A and E and ITU
- CT Thorax
Management of pneumothorax
- Size
- Effect on the patient ( underlying lung disease )
- Trained operator and staff for aftercare
- Observe : small and patient well
- Aspiration : over 2 cm in size , patient well
- Chest drain insertion
- Surgery : recurrent events, unresolving
Pleural aspiration/drain
- Safe triangle
- 2nd intercostal space midclavicular line
Pleural tumours
- Benign : Rare
- Malignant Pleural effusions are common and associated with a poor outcome
- Primary malignancy : Mesothelioma is the most frequent
