Pleural Disease Flashcards
What type of cells and tissue does the pleura contain?
Single layer of mesothelial cells and sub-pleural connective tissue
What are the two layers of the pleura called?
Visceral
paRIETAL
At what pressure is the pleura during the mechanics of breathing?
-0.66kPa
What is the surface anatomy of the pleura?
Extends over the 1st rib and extends over the kidneys, liver and spleen
What is a pleural effusion?
An abnormal collection of fluid in the pleural space
What nerves innervate the parietal pleura?
Phrenic nerves and intercostal nerves
What nerves innervate the visceral pleura?
Vagus nerve and sympathetic fibres
What do the symptoms of pleural effusion depend on?
On cause and volume of fluid
When would pleural effusion present as asymptomatic?
If the volume is small and accumulates slowly
What are symptoms of pleural effusion?
Increasing SOB
Pleuritic chest pain
Dull ache
Dry cough (if rapid)
Weight loss, malaise, fevers, night sweats
What are the causes of pleuritic chest pain in pleural effusion?
Inflammatory - may improve as fluid accumulates
Malignancy - progressively worsens
What other symptoms should you enquire about for pleural effusion?
Peripheral oedema
Liver disease
Orthopnoea
PND
What are the signs of pleural effusion on the affected side?
Decrease chest expansion
Stony dullness to percuss
Decrease breath sounds (band of bronchial breathing)
Decrease vocal resonance
What are the other signs of pleural effusion?
Clubbing Tar staining Cervical lymphadenopathy Elevated JVP Trachea deviation AWAY
Peripheral oedema
What are the two different types of fluid in pleural effusion?
Transudate
Exudates
What causes transudate fluid?
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
What causes exudates fluid?
Increase permeability of pleural surface and/or local capillaries due to inflammation, allowing fluid and protein to leak out
Normal hydrostatic forces
Usually unilateral
How are transudates and exudates distinguishes?
Pleural fluid protein:
Trans < 30g/L
Exudates > 30g/L
What are common causes for transudate pleural effusion?
LVF
Liver cirrhosis
Hypoalbuminaemia
Pertitoneal dialysis
How does liver cirrhosis cause pleural effusion?
Cirrhosis slows the normal flow of blood through the liver, thus increasing pressure in the vein, pushing fluid out (transudate)
How does hypoalbuminaemia cause pleural effusion?
Less protein in blood, pushing fluid out (transudate)
How does peritoneal dialysis cause a pleural effusion?
Leak of fluid from peritoneal cavity to pleural space
What are less common causes of transudate pleural effusion?
Hypothyoidism
Nephrotic syndrome
Mitral stenosis
Pulmonary embolism
What are common causes of exudate pleural effusion?
Malignancy (lung, breast, mesothelioma, metastatic)
Parapneumonic
What is parapneumonic pleural effusion?
Pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis
What are less common causes of exudate pleural effusion?
Pulmonary embolism Rheumatoid arthritis Autoimmune diseases Benign asbestos effusion Pancreatitis Post-MI
When should investigations be carried out for pleural effusion?
Unusual features
Failure to respond to appropriate treatment
What test confirms the presence of a pleural effusion?
CXR (200ml in pleura minimum)
What test can differentiate between malignant or benign disease for pleural effusion?
CT of thorax
Looks at areas of pleura and the thickening
What other investigations are used for pleural effusion?
Pleural aspiration and biopsy
If still no diagnosis: thoracoscopy
If pleural aspiration glucose < 3mM, what might be the cause of?
Empyema
Rheumatoid arthritis
TB
Malignancy
What investigations are carried out for pleural aspiration?
Protein, LDH Amylase increase - pancreatitis Glucose Culture Gram stain Cytology: lymphocytes, eosinophils, malignant cells
How many biopsies should be taken in a pleural effusion?
4
What is the treatment of pleural effusion?
Directed at the cause:
Chemo -> cancer
Anti-TB chemo -> TB
Corticosteroids -> infection
What is the palliative management of pleural effusion?
Cause by malignancy
Repeat pleural aspiration 1-1.5L at a time
What is the radical treatment of pleural effusion?
Pleurodhesis
How is the pleurodhesis performed?
Patient 45 on bed, arm above head
Thoracostomy tube entered to 4th IC mid-axillary
Drain 500ml/hr
Check with CXR
What to do if lung not re-expanded after pleurodhesis?
Apply suction 24hrs
After 24hrs, if lungs didn’t expand then remove drain due to infection risk
What to do if lung re-expanded?
Chemical pleurodhesis:
3mg/kg lignocaine and talc slurry
Clamp drain 1 hr
What is a pneumothorax?
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
What are two types of pneumothorax?
Spontaneous
Traumatic
What are the different types of spontaneous penumothorax?
Primary - no underlying condition
Secondary - underlying lung disease
What are the different types of traumatic pneumothorax?
Non-iatrogenic
Iatrogenic - cause by medical procedures
What is a tension pneumothorax?
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
What types of people are more likely to cause a spontaneous pneumothorax?
Younger and tall, thin
Due to weight of lung inducing development of apical blebs that rupture
What are the pre-existing lung diseases that can cause spontaneous secondary pneumothorax?
COPD Asthma Penumonia TB CF Fibrosing alveoli's Sarcoidosis
What can cause a non-iatrogenic traumatic pneumothorax?
Penetrating chest injury
Blunt chest injury
What can cause a iatrogenic traumatic pneumothorax?
Pleural aspiration/biopsy
Subclavian vein cannulation
Lung, liver, breast, renal biopsy
Acupunture
What are the symptoms of pneumothorax?
Asymptomatic
Acute breathlessness
Pleuritic chest pain
What are the signs of pneumothorax?
Non if small
Surgical emphysema if significant air leak
What are the signs of non-tension pneumothorax?
Trachea deviated TO affected side
Decreased expansion
Hyperresonant
Absent or decreased breath sounds
What are the signs of tension pneumothorax?
Trachea deviated AWAY from affected side (trapped air during expiration pushes it)
Haemodynamic compromise (obstructs venous return)
Elevated JVP
What are the boundaries for a large or small pneumothorax?
Small: < 2cm
Large rim of air >= 2cm
What is the treatment for pneumothorax based on?
If it is tension
Small or large
If breathless
If primary or secondary
What is the treatment for tension pneumothorax?
Chest drain:
Cannula entered into 2nd IC space mid-clav line
What is the management for a small primary pneumothorax, no SOB?
- Observe overnight, repeat CXR, if no change then hole has healed
- Discharge - no vigorous activity and CXR in 2 weeks
What is the management for a primary pneumothorax with SOB?
Aspirate pneumothorax:
- Lignocaine to 2nd IC space midclav to numb area
- 50ml syringe, cannula, 3 way tap and tube to water
- 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
What is the management for breathless secondary pneumothorax?
Chest drain:
4th IC space mid-axil and use small syringe
What is the ideal outcome of chest drains for pneumothorax?
Lung inflates in 1-2 days
Drain stops bubbling
CXR confirms lung inflated
What are the two choices after lung reinflation after a chest drain?
Clamp drain for 24hrs, CXR, no change then remove drain
Do CXR after 24hrs, no change, remove drain
What is the bad outcome of chest drains for pneumothorax?
Lung fails to reinflate after 48hrs
Drain continues bubbling
What to do if the lung does not reinflate with chest drain after 48hr?
Apply suction to drain
If still failing, thoracoscopic inspection of visceral pleura by surgeons for blebs, tears, clipping etc
What kinds of peumothoraxes are referred for surgical pleurodhesis?
Secondary ipsilateral
First contralateral
Bilateral spontaneous
What surgical options are there for pneumothorax?
Talc poudrage (chemical pleurodhesis)
Surgical pleurodhesis
Pleurectomy
What is asbestos?
Highly fibrous naturally occurring mineral
What are the 3 different types of asbestos?
Chrysotile (white)
Amosite (brown)
Crocodilite (blue) - most dangerous to health
What are the properties of asbestos?
High tensile strength
Fire resistance
Insulation to electrical damage
Resistant to chemical attack
How long after exposure to asbestos can disease occurs?
20-40yrs
What condition can asbestos exposure cause?
Mesothelioma
What is mesothelioma?
Pleural malignancy caused most commonly by asbestos
Who are most at risk of developing mesothelioma?
Mesothelioma is most common in men who have:
Worked in manufacturing using asbestos
Used asbestos products, particularly in construction or engineering
How does asbestos cause mesothelioma?
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.
What are the symptoms of mesothelioma?
Breathlessness
Chest wall pain
What does a CXR of mesothelioma show?
Usually unilateral
Diffuse or localised pleural thickening
What is the next step if the lung has re-expanded after pleurodhesis?
Lignocaine (anaesthetic)
Chemical pleurodhesis: instill talc slurry to ensure surfaces stick together and clamp drain 1 hour
What observations of the pleural aspiration can indicate the cause in pleural effusion?
Foul smelling -> anaerobic empyema Pus -> empyema Food particles -> oesophageal rupture Milky -> lymphoma Blood stained -> malignancy Blood -> haemothorax or trauma
