pleural disease Flashcards
what are the different types of pleural diseases?
pleural effusion
parapneumonic effusion/empyema
pneumothorax
mesothelioma
what is the pleura made of?
single layer of mesothelial cells
sub-pleural connective tissue
what are the two layers of the pleura?
visceral and parietal
how much of pleural fluid is there?
2-3 ml
what organs does the pleuraa lie over?
liver, spleen kidney?
where does the pleura start?
first rib
what is pleural effusion?
Abnormal collection of fluid in the pleural space
symptoms of pleural effusion?
depend on cause and volume of fluid
Asymptomatic – if small and accumulates slowly
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
Need to enquire about peripheral oedema, liver disease, orthopnoea, PND
what are signs of pleural effusion?
Chest on affected side Expansion Stony dullness to percussion Breathsounds (band of bronchial breathing) Vocal resonance
Other signs Clubbing, tar staining of fingers Cervical lymphadenopathy JVP Trachea away from large effusion (if unchanged ?collapse)
peripheral oedema
what are causes of pleural effusion?
Transudates:
An imbalance of hydostatic forces influencing the formation and absorption of pleural fluid.
Normal capillary permeability.
Usually (not always) bilateral
Exudates:
permeability of pleural surface and/or local capillaries
Usually unilateral
investigations of pleural effusions?
Confirm presence of effusion: Chest radiograph
At least 200ml required before detectable on CXR
Contrast enhanced CT of thorax
pleural aspiration and biopsy
blood cultures?
with a ct scan for PE, how is malignant and benign differentiated?
nodular pleural thickening
mediastinal pleural thickening
parietal pleural thickening >1cm
circumferential pleural thickening
other malignant manifestations in lung/liver
how many biopsys should you take for pleural effusion?
At least 4 biopsies
Send at least 3 in formaldehyde for histology
Send at least 1 in saline to microbiology if TB suspected
when investigating pleural effusion, what are you looking and sniffing for?
foul smelling – anaerobic empyema
pus - empyema
food particles – oesophageal rupture
milky – chylothorax (usually lymphoma)
blood stained - ?malignancy
blood – haemothorax, trauma
if there is still no results after miltiple examinations what should you do?
thoracoscopy
video assisted thoracoscopy
Direct inspection of pleura, directed biopsies, therapeutic
how do you manage pleural effusion?
chemotherapy
antituberculous chemotherapy
corticosteroids
what is pleurodhesis?
procedure that uses medicine to adhere your lung to your chest wall. It seals up the space between the outer lining of your lung and chest wall (pleural cavity) to prevent fluid or air from continually building up around your lungs.
how do you perform pleurodhesis
Patient lying on bed at 45o arm above head,
4th intercostal space mid-axillary line
what is pneumothorax?
Presence of air within the pleural cavity
Breach of visceral or parietal pleura with entry of air, lung collapses away from chest wall because of elastic recoil of the lung.
what is traumatic, non- iatrogenic?
Penetrating chest injury (stab, gunshot)
Blunt chest injury (rib fractures, bronchial rupture)
what is traumatic, iatrogenic?
Pleural aspiration/biopsy Sub-clavian vein cannulation Lung, liver, breast, renal biopsy Acupuncture In USA as common as spontaneous
what are symptoms of pneumothorax?
Assymptomatic (if small, good respiratory reserve)
Acute breathlessness, worsening breathlessness
Pleuritic chest pain
what are signs of pneumothorax?
Surgical emphysema if significant air leak
(air tracking in subcutaneous fat), bubble wrap
Non tension Trachea deviated to affected side Affected side: lower expansion hyper resonant absent, breath sounds
Tension
Trachea deviated away from affected side
Haemodynamic compromise
JVP
what questions would you ask yourself when deciding how to manage pneumothorax?
Is it tension?
Is pneumothorax small or large?
Small: rim of air <2cm
Large: rim of air ≥2cm
Is patient breathless?
Is pneumothorax likely to be primary or secondary?
if it is tension pneumothorax how would you manage?
Cannula (large grey venflon) 2nd intercostal space mid-clavicular line
Then insert intercostal chest drain
how do you manage a patient who has a small primary pneumothorax but isnt breathless?
Observe overnight, repeat CXR, if no change, hole has sealed
2. Discharge
Advise no vigorous activity, to return if becomes breathless
Pneumothorax will resolve at about 1.25% /day
Review with CXR clinic 2 weeks
how do you manage a patient that has breathless primary pneumothorax?
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)
how do you manage a patient with breathless secondary pneumothorax?
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
what is indications of a poor chest drain?
lung fails to re-inflate after 48 hours
drain continues bubbling
what is asbestos?
Highly fibrous naturally occurring mineral
what are the three main types of asbestos?
Chrysotile (white)
Amosite (brown)
Crocidolite (blue)
clinical presentation of mesothelioma?
breathlessness
chest wall pain
what is Mesothelioma
Mesothelioma is a type of cancer that develops in the lining that covers the outer surface of some of the body’s organs.
what is a main cause of mesothelioma?
asbestos
if the fluid comes out straw-like, what does this mean?
normal
if the fluid comes out cloudy, what does this mean?
exudate
infection
milky
if the fluid comes out blood, what does this mean?
malignancy
tb
trauma
infarct
if the fluid comes out pus, what does this mean?
empyema
what surface is the production of fluid
parietal surface
what surface is the absorption of fluid
visceral surface
whats the difference between exudate and transudate
exudate is the fluid that leaks out and transudate is the fluid that is pushed through the capillaries
what protein content does exudate and transudate
exudate- over 3.5
transudate- under 2.5
what are the 6 main reasons for transudate?
cardiac failure liver failure renal failure hypoalbuminemia hypothyroidism pulmonary embolis
what are the 6 main reasons for exudate?
infection malignancy pulmonary embolis rheumatoid arthiritis SLE pancreatitis
whats the difference between trapped lung and pneumothorax?
theres not actually a puncture
would draining pus give you a better control of sepsis?
yes
when should you drain an effusion?
large: breathless, raised RR, hypoxia, tachycardiac, CXR trachia deviated
why do you always go above the rib in chest tube placement
nerve neurocostal bundle below
what would the pH be if you want to drain ?
under 7.2
how many intercostal spaces would be showing if there was hyperinflation
5.5 or 6
whats the management of pneumothorax?
do nothing if you can
aspirati0on
oxygen and chest insertion
management of tension pneumothorax?
oxygen
aspirate in 2nd anterior intercostal space in the midclavicular line
CXR
US to confirm if trained
what are symptoms of malignant mesothelioma?
chest pain breathlessness fever weakness cough weight loss
what would you see in a patient CXR that has malignant mesothelioma?
pleural effusion, pleural based opacity/mass
where does secondary spontaneous pneumothorax happen?
bad lungs
