Pleural disease Flashcards
what is a pleural effusion
collection of fluid between two pleural layers of lung (in the pleural space)
what are you looking for when you inspect pleural fluid
cloudy
blood
pus
pus in pleural fluid can mean what?
empyema
Cloudy pleural fluid can mean what?
exudate - protein
infection
milky (chylothorax- rare)
Blood in pleural fluid can mean what?
malignancy
TB
trauma
infarct
which microbiology tests are always used to inspect pleural fluid?
gram stain
AAFB - Alcohol and acid fast bacilli (continuous automated bacterial culture - can take up to 8 weeks) - mainly checking for AFB for TB diagnosis
culture
when should you drain an effusion?
when it is large : breathless, raised RR, Hypoxia, Tachycardic, CXR trachea deviated
Parapneumonic , PH < 7.2 (caused by pneumonia)
Pus
Trauma/Post operative
when should you drain an effusion?
when it is large : breathless, raised RR, Hypoxia, Tachycardic, CXR trachea deviated
Parapneumonic , PH < 7.2
Pus
Trauma/Post operative
what does ‘the pleura’; consist of
single layer of mesothelial cells - line serous cavities and internal organs. Primary function - provides a slippery, non-adhesive and protective surface.
sub-pleural connective tissue
how many ml of pleural fluid usually found in the layers between pleura
2-3 ml
symptoms of a pleural effusion depend on what
cause and volume of fluid
a pleural effusion can be asymptomatic if…?
it is small and accumulates slowly
name some common symptoms associated with a pleural effusion
Increasing breathless (days, weeks, months)
Pleuritic chest pain
inflammatory: early, may improve as fluid accumulates
malignancy: progressively worsening
Dull ache
Dry cough – especially if rapid accumulation
Weight loss, malaise, fevers, night sweats
what are some clinical signs, in the chest area, of a pleural effusion?
on the effected side…
the chest should have fallen in (hear a stony dullness to percussion)
decreased breathsounds
decreased vocal resonance
what are some more general signs of a pleural effusion?
Clubbing
Chest examination - reduced expansion, breath sounds and vocal resonance. Stony, dull percussion
Cervical lymphadenopathy -enlarged nodes
increased jugular venous pulse JVP
Trachea away from large effusion (if unchanged? collapse)
Peripheral oedema
what can is a pleural effusion classified into by its protein concentration?
transudate or exudate
causes of transudate?
An imbalance of hydrostatic forces influencing the formation and absorption of pleural fluid.
Normal capillary permeability.
Usually (not always) BILATERAL
increase in venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
causes of exudates
increased permeability of pleural surface and/ or local capillaries
basically leakiness of pleural capillaries secondary to infection, inflammation or malignancy ie pneumonia, TB, pulmonary infarction
usually UNILATERAL
what is a transudate?
filtrate of blood
caused by increased pressure in the veins and capillaries that forces fluid through the vessel walls
what is an exudate?
a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation
classically, a pleural fluid protein level >30g/l is…
an exudate
classically, a pleural fluid protein level <30g/l is…
a transudate (proteins not pushed out as can’t fit between endothelial cells)
a transudate can very commonly come about from which health problems
anything that changes pressure in vessels
left ventricular failure - blood flowing back to pulmonary arteries - increase in pressure - fluid forced out due to this
liver problems
Peritoneal dialysis
an exudate can very commonly come about from which health problems
usually inflammatory - endothelial cells more spaced out due to inflammation - more proteins can be forced out with the fluid
Malignancy (lung, breast, mesothelioma, metastatic) Parapneumonic effusion (as a result of pneumonia)
an exudate rarely comes about from which health problems/ drugs
Yellow nail syndrome
Drugs :
amiodarone
nitrofurantoin phenytoin penicillamine
how man ml of effusion is required before an effusion is detected on CXR
at least 200 ml
example of investigations carried out for pleural effusion
CXR - to confirm the presence of effusion
contrast enhanced CT of thorax - usually differentiates between malignant and benign disease
pleural aspiration - small needle or tube is inserted to remove sample of pleural fluid
biopsy
pleural aspiration technique
50 ml syringe 21 G needle
lignocaine anaesthesia
blood culture bottles
complications with a pleural aspiration (7)
pneumothorax
Empyema
Pulmonary oedema
Vagal reflex - feeling faint, warm, nauseous
Air embolism - air bubble entering artery
Tumour cell seeding - local spread of viable tumour cells due to intervention
Haemothorax
analysis of pleural aspiration done on the ward?
look and sniff
foul smelling - anaerobic empyema
pus - empyema
food particles - oesophageal rupture
milky - chylothorax
blood stained - malignancy?
blood - haemothorax, trauma
what results are required from a blood gas analyser before a chest drain is on the cards
if it is infected
and pH is <7.2
what lab analysis is done on a pleural aspiration?
microscopy, gram stain, AAFB- alcohol and acid fast bacilli, culture
what things are biochemists looking for in pleural aspiration sample
protein, LDH
increased amylase levels
glucose <3.3mM
where is a biopsy done?
immediately above a rib
difference between abram’s needle and tru-cut in pleural biopsy?
abram’s needle - blind biopsies
tru-cut CT guided
how many pleural biopsies are done at once
at least 4 biopsies
3 sent in formaldehyde for histology
1 sent to microbiology if TB is suspected
if after a pleural aspiration there is still no diagnosis what is done?
a thoracoscopy
or video assisted thoracoscopy
which allows for direct inspection of pleura and directed biopsies
treatment of pleural disease
directed at the cause:
chemotherapy
antituberculous chemotherapy
corticosteroids
how is malignancy detected in pleural disease and what does that mean for treatment
repeated pleural aspiration 1-1.5 litres at any one time
hospitalised, very limited life expectancy
palliative care treatment usually
what is pleurodhesis
procedure performed to obliterate the pleural space to prevent recurrent pleural effusion or pneumothorax or to a treat persistent pneumothorax
chest tube is fixed in place through chest and this drains fluid
rate of fluid drainage using pleurodhesis
no faster than 500 ml/hr
what are asbestos
Highly fibrous naturally occurring mineral
most dangerous type- crocidolite- blue
who is exposed to asbestos
building trade
ship building
plumbers
what is malignant mesothelioma and what are some
type of cancer that develops in the lining that covers the outer surface of some of the body’s organs
What is malignant mesothelioma mostly caused by
exposure to asbestos
benign is not cancerous and not due to asbestos
what are pleural plaques
characterised by areas of fibrous thickening on the pleura and the outermost lining of the lungs or diaphragm.
- The condition typically arises 20 to 30 years after asbestos exposure.
- they’re benign
