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
