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Respiratory System > Pleural Disease > Flashcards

Pleural Disease Flashcards

1
Q

What type of cells and tissue does the pleura contain?

A

Single layer of mesothelial cells and sub-pleural connective tissue

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2
Q

What are the two layers of the pleura called?

A

Visceral

paRIETAL

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3
Q

At what pressure is the pleura during the mechanics of breathing?

A

-0.66kPa

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4
Q

What is the surface anatomy of the pleura?

A

Extends over the 1st rib and extends over the kidneys, liver and spleen

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5
Q

What is a pleural effusion?

A

An abnormal collection of fluid in the pleural space

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6
Q

What nerves innervate the parietal pleura?

A

Phrenic nerves and intercostal nerves

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7
Q

What nerves innervate the visceral pleura?

A

Vagus nerve and sympathetic fibres

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8
Q

What do the symptoms of pleural effusion depend on?

A

On cause and volume of fluid

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9
Q

When would pleural effusion present as asymptomatic?

A

If the volume is small and accumulates slowly

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10
Q

What are symptoms of pleural effusion?

A

Increasing SOB
Pleuritic chest pain
Dull ache
Dry cough (if rapid)

Weight loss, malaise, fevers, night sweats

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11
Q

What are the causes of pleuritic chest pain in pleural effusion?

A

Inflammatory - may improve as fluid accumulates

Malignancy - progressively worsens

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12
Q

What other symptoms should you enquire about for pleural effusion?

A

Peripheral oedema
Liver disease
Orthopnoea
PND

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13
Q

What are the signs of pleural effusion on the affected side?

A

Decrease chest expansion
Stony dullness to percuss
Decrease breath sounds (band of bronchial breathing)
Decrease vocal resonance

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14
Q

What are the other signs of pleural effusion?

A 
Clubbing
Tar staining 
Cervical lymphadenopathy 
Elevated JVP 
Trachea deviation AWAY

Peripheral oedema

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15
Q

What are the two different types of fluid in pleural effusion?

A

Transudate

Exudates

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16
Q

What causes transudate fluid?

A

An imbalance of hydrostatic forces - less protein or increased pressure in the pul. vessels (due to L HF) pushes fluid into pleural space

Normal permeability
Usually bilateral

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17
Q

What causes exudates fluid?

A

Increase permeability of pleural surface and/or local capillaries due to inflammation, allowing fluid and protein to leak out

Normal hydrostatic forces
Usually unilateral

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18
Q

How are transudates and exudates distinguishes?

A

Pleural fluid protein:
Trans < 30g/L
Exudates > 30g/L

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19
Q

What are common causes for transudate pleural effusion?

A

LVF
Liver cirrhosis
Hypoalbuminaemia
Pertitoneal dialysis

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20
Q

How does liver cirrhosis cause pleural effusion?

A

Cirrhosis slows the normal flow of blood through the liver, thus increasing pressure in the vein, pushing fluid out (transudate)

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21
Q

How does hypoalbuminaemia cause pleural effusion?

A

Less protein in blood, pushing fluid out (transudate)

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22
Q

How does peritoneal dialysis cause a pleural effusion?

A

Leak of fluid from peritoneal cavity to pleural space

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23
Q

What are less common causes of transudate pleural effusion?

A

Hypothyoidism
Nephrotic syndrome
Mitral stenosis
Pulmonary embolism

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24
Q

What are common causes of exudate pleural effusion?

A

Malignancy (lung, breast, mesothelioma, metastatic)

Parapneumonic

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25
Q

What is parapneumonic pleural effusion?

A

Pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis

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26
Q

What are less common causes of exudate pleural effusion?

A 
Pulmonary embolism 
Rheumatoid arthritis 
Autoimmune diseases 
Benign asbestos effusion 
Pancreatitis 
Post-MI
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27
Q

When should investigations be carried out for pleural effusion?

A

Unusual features

Failure to respond to appropriate treatment

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28
Q

What test confirms the presence of a pleural effusion?

A

CXR (200ml in pleura minimum)

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29
Q

What test can differentiate between malignant or benign disease for pleural effusion?

A

CT of thorax

Looks at areas of pleura and the thickening

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30
Q

What other investigations are used for pleural effusion?

A

Pleural aspiration and biopsy

If still no diagnosis: thoracoscopy

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31
Q

If pleural aspiration glucose < 3mM, what might be the cause of?

A

Empyema
Rheumatoid arthritis
TB
Malignancy

32
Q

What investigations are carried out for pleural aspiration?

A 
Protein, LDH 
Amylase increase - pancreatitis 
Glucose 
Culture 
Gram stain 
Cytology: lymphocytes, eosinophils, malignant cells
33
Q

How many biopsies should be taken in a pleural effusion?

A

4

34
Q

What is the treatment of pleural effusion?

A

Directed at the cause:
Chemo -> cancer
Anti-TB chemo -> TB
Corticosteroids -> infection

35
Q

What is the palliative management of pleural effusion?

A

Cause by malignancy

Repeat pleural aspiration 1-1.5L at a time

36
Q

What is the radical treatment of pleural effusion?

A

Pleurodhesis

37
Q

How is the pleurodhesis performed?

A

Patient 45 on bed, arm above head
Thoracostomy tube entered to 4th IC mid-axillary
Drain 500ml/hr
Check with CXR

38
Q

What to do if lung not re-expanded after pleurodhesis?

A

Apply suction 24hrs

After 24hrs, if lungs didn’t expand then remove drain due to infection risk

39
Q

What to do if lung re-expanded?

A

Chemical pleurodhesis:
3mg/kg lignocaine and talc slurry
Clamp drain 1 hr

40
Q

What is a pneumothorax?

A

Presence of air within the pleural cavity which causes the lung to collapse away from the chest wall due to elastic recoil of the lung

41
Q

What are two types of pneumothorax?

A

Spontaneous

Traumatic

42
Q

What are the different types of spontaneous penumothorax?

A

Primary - no underlying condition

Secondary - underlying lung disease

43
Q

What are the different types of traumatic pneumothorax?

A

Non-iatrogenic

Iatrogenic - cause by medical procedures

44
Q

What is a tension pneumothorax?

A

Hole in lung surface which acts as a one way valve which is open during inspiration, but closed during expiration causing a build up of air which puts pressure on vessels

45
Q

What types of people are more likely to cause a spontaneous pneumothorax?

A

Younger and tall, thin

Due to weight of lung inducing development of apical blebs that rupture

46
Q

What are the pre-existing lung diseases that can cause spontaneous secondary pneumothorax?

A 
COPD 
Asthma 
Penumonia 
TB 
CF
Fibrosing alveoli's 
Sarcoidosis
47
Q

What can cause a non-iatrogenic traumatic pneumothorax?

A

Penetrating chest injury

Blunt chest injury

48
Q

What can cause a iatrogenic traumatic pneumothorax?

A

Pleural aspiration/biopsy
Subclavian vein cannulation
Lung, liver, breast, renal biopsy
Acupunture

49
Q

What are the symptoms of pneumothorax?

A

Asymptomatic
Acute breathlessness
Pleuritic chest pain

50
Q

What are the signs of pneumothorax?

A

Non if small

Surgical emphysema if significant air leak

51
Q

What are the signs of non-tension pneumothorax?

A

Trachea deviated TO affected side
Decreased expansion
Hyperresonant
Absent or decreased breath sounds

52
Q

What are the signs of tension pneumothorax?

A

Trachea deviated AWAY from affected side (trapped air during expiration pushes it)
Haemodynamic compromise (obstructs venous return)
Elevated JVP

53
Q

What are the boundaries for a large or small pneumothorax?

A

Small: < 2cm

Large rim of air >= 2cm

54
Q

What is the treatment for pneumothorax based on?

A

If it is tension
Small or large
If breathless
If primary or secondary

55
Q

What is the treatment for tension pneumothorax?

A

Chest drain:

Cannula entered into 2nd IC space mid-clav line

56
Q

What is the management for a small primary pneumothorax, no SOB?

A
  1. Observe overnight, repeat CXR, if no change then hole has healed
  2. Discharge - no vigorous activity and CXR in 2 weeks
57
Q

What is the management for a primary pneumothorax with SOB?

A

Aspirate pneumothorax:

  1. Lignocaine to 2nd IC space midclav to numb area
  2. 50ml syringe, cannula, 3 way tap and tube to water
  3. Aspirate until you feel the lung surface on the tip on the venflon (cannula)

If successful - CXR and observes 24 hrs
If unsuccessful - chest drain

58
Q

What is the management for breathless secondary pneumothorax?

A

Chest drain:

4th IC space mid-axil and use small syringe

59
Q

What is the ideal outcome of chest drains for pneumothorax?

A

Lung inflates in 1-2 days
Drain stops bubbling
CXR confirms lung inflated

60
Q

What are the two choices after lung reinflation after a chest drain?

A

Clamp drain for 24hrs, CXR, no change then remove drain

Do CXR after 24hrs, no change, remove drain

61
Q

What is the bad outcome of chest drains for pneumothorax?

A

Lung fails to reinflate after 48hrs

Drain continues bubbling

62
Q

What to do if the lung does not reinflate with chest drain after 48hr?

A

Apply suction to drain

If still failing, thoracoscopic inspection of visceral pleura by surgeons for blebs, tears, clipping etc

63
Q

What kinds of peumothoraxes are referred for surgical pleurodhesis?

A

Secondary ipsilateral
First contralateral
Bilateral spontaneous

64
Q

What surgical options are there for pneumothorax?

A

Talc poudrage (chemical pleurodhesis)
Surgical pleurodhesis
Pleurectomy

65
Q

What is asbestos?

A

Highly fibrous naturally occurring mineral

66
Q

What are the 3 different types of asbestos?

A

Chrysotile (white)
Amosite (brown)
Crocodilite (blue) - most dangerous to health

67
Q

What are the properties of asbestos?

A

High tensile strength
Fire resistance
Insulation to electrical damage
Resistant to chemical attack

68
Q

How long after exposure to asbestos can disease occurs?

A

20-40yrs

69
Q

What condition can asbestos exposure cause?

A

Mesothelioma

70
Q

What is mesothelioma?

A

Pleural malignancy caused most commonly by asbestos

71
Q

Who are most at risk of developing mesothelioma?

A

Mesothelioma is most common in men who have:
Worked in manufacturing using asbestos
Used asbestos products, particularly in construction or engineering

72
Q

How does asbestos cause mesothelioma?

A

The fibres work their way into the pleura and irritate the pleura and may cause mutations that lead to the growth of cancer
Some of the fibres can be coughed up and swallowed - cause of peritoneal mesothelioma.

73
Q

What are the symptoms of mesothelioma?

A

Breathlessness

Chest wall pain

74
Q

What does a CXR of mesothelioma show?

A

Usually unilateral

Diffuse or localised pleural thickening

75
Q

What is the next step if the lung has re-expanded after pleurodhesis?

A

Lignocaine (anaesthetic)

Chemical pleurodhesis: instill talc slurry to ensure surfaces stick together and clamp drain 1 hour

76
Q

What observations of the pleural aspiration can indicate the cause in pleural effusion?

A 
Foul smelling -> anaerobic empyema
Pus -> empyema 
Food particles -> oesophageal rupture 
Milky -> lymphoma 
Blood stained -> malignancy
Blood -> haemothorax or trauma

Respiratory System (29 decks)

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