Pleural Disease

Question 1

Pleura

Answer 1

Single layer of mesothelial cells

Sub-pleural connective tissue

Question 2

Pleural effusion

Answer 2

Abnormal collection of fluid in the pleural space

Question 3

Symptoms of a pleural effusion

Answer 3

Depend on cause and volume of fluid
Asymptomatic - small and accumulates slowly

Increasing breathlessness
Pleuritic chest pain => inflammatory: early, may improve as fluid accumulates; malignancy => progressively worsening
Dull ache
Dry cough - especially with rapid accumulation
Weight loss, malaise, fevers, night sweats

Question 4

Signs of pleural effusion

Answer 4

Chest on affected side - decreased expansion, stony dullness to percussion, decreased breath sounds, decreased vocal resonance

Question 5

Causes of pleural effusion

Answer 5

Convenient to classify into transudates and exudates

Question 6

Investigation of pleural effusion

Answer 6

Confirm with chest radiograph - at least 200ml required to see on CXR
Enhanced CT of thorax - usually differentiates between benign and malignant disease
Pleural aspiration and biopsy

Question 7

Pleural aspiration - ward analysis

Answer 7

Look and sniff:
Foul smelling - anaerobic empyema
Pus - empyema
Food particles - oesophogeal rupture
Milky - chylothorax (usually lymphoma)
Bloodstained - malignancy?
Blood - haemothorax, trauma

Question 8

Transudate

Answer 8

If less than 25g/l

Question 9

Exudate

Answer 9

If greater than 35g/l

Question 10

Pleurodhesis

Answer 10

Management of pleural effusion
4th intercostal space at midaxilliary line
Drain to dryness, check with CXR,
If lung not re-expanded (trapped), apply suction 24 hours
If lung not re-expanded remove drain (infection risk)

If lung re-expanded, chemical pleurodhesis
Instill 3mg/kg lignocaine
Instill talc slurry (2-5g), clamp drain 1hour
Chemical pleurisy, pleurodhesis (90% success)
Remove drain after 12-72hours if lung remains re-expanded

Question 11

Pneumothorax

Answer 11

Presence of air within the pleural cavity
Breach of visceral or parietal pleura with entry of air, lung collapses away from the chest wall because of elastic recoil of lung
Spontaneous/traumatic

Question 12

Spontaneous pneumothorax

Answer 12

Primary - no clinically apparent disease

Secondary - pre-existing lung disease

Question 13

Traumatic pneumothorax

Answer 13

Non-iatrogenic - penetrating/blunt chest injury (stabbing/rib fracture etc)
Iatrogenic - Pleural aspiration/biopsy, cannulation, acupuncture

Question 14

Symptoms of pneumothorax

Answer 14

Acute breathlessness, worsening
Pleuritic chest pain
Extreme dyspnoea

Question 15

Signs of pneumothorax

Answer 15

Trachea deviated to affected side - decreased expansion/breath sounds, hyper resonant

Question 16

Size of pneumothorax

Answer 16

Small - less than 2cm

Large - greater than or equal to 2cm

Question 17

Pneumothorax management

Answer 17

Cannula in 2nd intercostal space, mid-clavicular line then insert intercostal chest drain

Question 18

Management of small, primary pneumothorax

Answer 18

Observe overnight, repeat CXR, if no change, hole has sealed. Review CXR clinic in 2 weeks

Question 19

Management of breathless primary pneumothorax

Answer 19

Aspirate pneumothorax
Patient at 45o
Lignocaine to second intercostal space, midclavicular line
50ml syringe, venflon, 3 way tap, tube to water
Aspirate until:
Feel lung surface on tip of venflon just beneath surface of chest wall
Aspirated >3 litres (persistent air leak)
If successful, CXR observe 24 hours, unsuccessful - chest drain

Question 20

Breathless secondary pneumothorax

Answer 20

May try to aspirate if small but less successful
Insert intercostal chest drain
4th intercostal space mid-axillary line
Small bore 10-14F
If surgical emphysema I tend to use large 24-32F, large air leak
Underwater seal

Question 21

Mesothelioma

Answer 21

Pleural malignancy (mostly due to asbestos)
Can also occur in peritoneum
Clinical presentation - breathlessness, chest wall pain
Usually unilateral
Diffuse or localised pleural thickening