Pleural disease Flashcards
What innervates the parietal pleura?
Phrenic nerves and intercostal nerves
What innervates the visceral pleura?
Vagus nerve and sympathetic fibres
What are both the pleura made up by?
Single layer of mesothelial cells and sub-pleural connective tissue
What is a pleural effusion?
Collection of fluid in pleural cavity
What are the symptoms of pleural effusions?
Asymptomatic SOB, increasing Pleuritic chest pain, which can improve itself Dull ache of chest Dry cough Weight loss Malaise Fever Night sweats
What are the clinical signs of pleural effusions?
Decreased chest movement on affected side Decreased expansion Stony dullness on percussion Decreased breath sounds on affected side Decreased vocal resonance Clubbing Cervical lymphadenopathy Increased JVP Tracheal shift Peripheral oedema
What is the difference between transudates and exudates?
Transudates - changes in hydrostatic forces, protein <30g/L, often bilateral and systemic
Exudates - increased permeability, protein >30g/L, often unilateral
How do we determine if a pleural effusion is due to transudates or exudates if protein level is 25-35g/L?
Light’s criteria, exudate if 1 or more of following criteria is met:
- pleural/serum protein >0.5
- pleural/serum LDH >0.6
- pleural LDH >0.66 of upper limit of serum LDH
When are pleural effusions caused by transudates common?
Left ventricular failure Liver cirrhosis Hypoalbuminaemia Peritoneal dialysis Hypothyroidism Nephrotic syndrome Mitral stenosis Pulmonary embolism Constrictive pericarditis Ovarian hyperstimulation syndrome Meigs syndrome (benign ovarian fibroma)
When are pleural effusions caused by exudates common?
Malignancy Parapneumonic effusion PTE (more so than in transudates) Rheumatoid arthritis Benign asbestos effusion Pancreatitis Post MI Yellow nail syndrome Certain drugs
What drugs can cause exudates and pleural effusions?
Amiodarone Nitrofurantoin Phenytoin Methotrexate Carbamazapine Penicillamine Bromocriptine Pergolide
What investigations are carried out for pleural effusions?
Transudates - none unless they don’t respond
CXR - >200ml required to be detectable Contrast enhanced CT Pleural aspiration and biopsy Lab analysis of collected fluid Thoracoscopy Direct inspection - can collapse lung
What are some possible complications of pleural aspiration?
Pneumothorax Empyema Pulmonary oedema Vagal reflex Air embolism Tumour cell seeding Haemothorax
How many samples do you take for biopsy during pleural aspiration?
3 in formaldehyde for histology
1 in saline for TB tests and microbiology?
How do you treat pleural effusions?
Chemo - cancer or infection e.g. TB
Corticosteroids - inflammation
Repeat pleural aspirations
Pleurodhesis if recurrent or patient at risk
How much fluid can be removed at one time during pleural aspiration?
1-1.5L
What is a pneumothorax?
Presence of air in the pleural cavity due to a breach in either the parietal or visceral pleura, causing an uncoupling of the lungs to the chest wall
What is a tension pneumothorax?
When a pneumothorax of any cause leads to significant impairment of respiration and/or circulation
What are the signs and symptoms of a tension pneumothorax?
Chest pain Respiratory distress Tachycardia Tachypnoea Low O2 sats Low blood pressure Cyanosis Hyperresonant percussion of chest Reduced expansion and movement Altered levels of consciousness Displacement of apex beat Displacement of the trachea Reduced breath sounds
In what population are primary pneumothorax usually seen?
Young tall thin men - thought to be due to weight go lung inducing development of apical pleural blebs that rupture, possibly due to a congenital defect of the connective tissue in the alveolar wall
What diseases can cause secondary pneumothorax?
COPD Asthma Pneumonia TB CF Fibrosing alveolitis Sarcoidosis
What is the cut off between a small and a large pneumothorax?
Small - air rim <2cm
Large - air rim >2cm
How do you treat pneumothorax?
Normally insert cannula in 2nd intercostal pace in mid-clavicular line and insert chest drain
When do you refer patients with pneumothorax for surgery?
Second ipsilateral penumothorax
First contralateral pneumothorax
Bilateral spontaneous pneumothorax
First pneumothorax in high risk professions
