Pleural disease Flashcards
What types of pneumothorax exist?
- Spontaneous pneumothorax
- Primary: no lung disease
- Secondary: pre-existing lung disease eg. COPD
- Traumatic
- Tension*
- Iatrogenic eg. Central line insertion
Name two risk factors for pneumothorax
- Young males (6:1), often tall and thin
- Over 40s: most commonly due to COPD
- Connective tissue diseases
What sign can occur following rib fractures
Flail chest occurs if 2+ fractures occur in the same rib.
Paradoxical movement of flail segment during respiration
Define tension pneumothorax
Medical emergency
Pneumothorax + haemodynamic instability
Describe the presentation of pneumothorax
- Sudden onset unilateral pleuritic pain
- Progressive dyspnoea
- May develop pallor and tachycardia
- Tension: additional tachycardia and hypotension
What signs may be seen with tension pneumothorax?
- Respiratory distress:
- Increased work of breathing
- Tachypneoa
- Low oxygen saturations
- Tachycardia
- Hypotension
- On affected side:
- Absent breath sounds
- Tracheal deviation away
- Hyper-resonant on percussion
What should be done if tension pneumothorax is clinically diagnosed?
Immediate decompression of the affected side to establish haemodynamic stability
- Large bore needle (14/16 gauge)
- Inserted into 2nd intercostal space
- Mid-clavicular line
What anatomical landmark is used for chest drain insertion?
‘Triangle of safety’:
- Superior: Base of axilla
- Anterior: Pectoralis major (lateral aspect)
- Posterior: Latissimus dorsi (lateral aspect)
- Base: 5th intercostal space
What are the clinical examination findings in pneumothorax? What are the radiological findings?
- Clinical:
- Tachypnoea
- Low oxygen saturations
- Hyperresonance on percussion
- Reduced or absent breath sounds
- Radiological:
- Rim of air: visible visceral pleural edge
- Loss of lung markings
Outline the management of non-tension pneumothorax
- Smoking cessation
- Diving and flying advice
- Primary:
- Asymptomatic small rim (<2cm): no treatment, avoid strenuous exercise, follow-up imaging to confirm resolution.
- Symptomatic small rim (<2cm): needle aspiration and admission
- Symptomatic after aspiration or >2cm: intercostal drain
- Secondary: Intercostal drain and discharge. Recurrent: pleurodesis
Describe the presentation of pleural effusion
What are the findings on clinical examination?
- May be asymptomatic
- Dyspnoea, pleuritic chest pain, reduces exercise tolerance
- History of pneumonia, which may not be resolving
- On examination:
- Reduced chest expansion
- Stony dull percussion
- Reduced breath sounds
- Reduced vocal and tactile fremitus
- Trachial deviation away (if very large)
What are the radiological findings in pleural effusion
- Lower zone opacification
- Meniscus sign if fluid alone
- Air fluid level if hydropneumothorax
- Blunting of costophrenic angles
What are the different types of pleural effusion?
- Serous fluid:
- Exudate: protein >30 g/L
- Transudate: protein <30 g/L
- Haemothorax
- Empyema: purulent, may be complication of pneumonia
- Chylothorax: lymph usually due to leakage from thoracic duct after trauma or infiltration by carcinoma
What investigations are needed in suspected pleural effusion?
- Chest X-ray
-
US guided aspiration
- pH, protein, LDH, microbiology, cytology
- CT chest
Give 3 causes of transudate effusion
Give 3 causes of exudate effusion
Transudate: <30 g/L due to increased capillary hydrostatic pressure
- Heart failure
- Liver failure (unable to produce albumin)
- Renal failure (loss of proteins in glomerulus)
Exudate: >35 g/L due to increased capillary permeability and protein leakage
- Infection: pneumonia, TB
- Inflammation: RA
- Maligancy: primary lung, mesothelioma
What is the Light’s criteria?
A tool used to categorise borderline effusions (25-35 g/L of protein) into transudate or exudate.
Exudate if one or more of the following:
- Pleural fluid:serum ratio of protein >0.5
- Pleural fluid:serum ratio of LDH >0.6
- Pleural fluid LDH >2/3 of upper limit of normal
Outline the management of pleural effusions
- General: aspiration and drainage (chest drain)
- Repeat imaging
- Specific treatment of underlying cause
What is the cause of pleural plaques and pleural thickening?
Asbestos exposure. Pleural plaques are the commonest physical manifestation of asbestos exposure.
Describe the presentation of pleural plaques
Plaques are nearly always asymptomatic, further investigation is not indicated.
Define pleural plaques
Discrete areas of fibrosis usually occurring in the parietal pleura. Overtime can calcify. Benign and not pre-malignant.
Define pleural thickening
Widespread pleural thickening usually affecting the visceral pleura. Occurs due to scarring, calcification, and/or thickening. Benign and not pre-malignant.
List 2 types of primary pleural tumors
Mesothelioma: benign or malignant Pleural fibroma: benign Primary pleural lymphoma
Where do secondary pleural tumours more commonly originate from?
Lung Breast Stomach Lymphoma
How does mesothelioma present?
Pleural effusion Persistent pleuritic pain Increasing dyspnoea Mesothelioma can occur with light asbestos exposure
What is the prognosis of mesothelioma
Median survival of 2 years
