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1st year systems > pleural disease > Flashcards

pleural disease Flashcards

1
Q

what are the different types of pleural diseases?

A

pleural effusion
parapneumonic effusion/empyema
pneumothorax
mesothelioma

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2
Q

what is the pleura made of?

A

single layer of mesothelial cells

sub-pleural connective tissue

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3
Q

what are the two layers of the pleura?

A

visceral and parietal

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4
Q

how much of pleural fluid is there?

A

2-3 ml

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5
Q

what organs does the pleuraa lie over?

A

liver, spleen kidney?

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6
Q

where does the pleura start?

A

first rib

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7
Q

what is pleural effusion?

A

Abnormal collection of fluid in the pleural space

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8
Q

symptoms of pleural effusion?

A

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

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9
Q

what are signs of pleural effusion?

A 
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

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10
Q

what are causes of pleural effusion?

A

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

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11
Q

investigations of pleural effusions?

A

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?

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12
Q

with a ct scan for PE, how is malignant and benign differentiated?

A

nodular pleural thickening

mediastinal pleural thickening

parietal pleural thickening >1cm

circumferential pleural thickening

other malignant manifestations in lung/liver

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13
Q

how many biopsys should you take for pleural effusion?

A

At least 4 biopsies

Send at least 3 in formaldehyde for histology
Send at least 1 in saline to microbiology if TB suspected

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14
Q

when investigating pleural effusion, what are you looking and sniffing for?

A

foul smelling – anaerobic empyema

pus - empyema

food particles – oesophageal rupture

milky – chylothorax (usually lymphoma)

blood stained - ?malignancy

blood – haemothorax, trauma

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15
Q

if there is still no results after miltiple examinations what should you do?

A

thoracoscopy

video assisted thoracoscopy

Direct inspection of pleura, directed biopsies, therapeutic

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16
Q

how do you manage pleural effusion?

A

chemotherapy

antituberculous chemotherapy

corticosteroids

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17
Q

what is pleurodhesis?

A

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.

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18
Q

how do you perform pleurodhesis

A

Patient lying on bed at 45o arm above head,

4th intercostal space mid-axillary line

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19
Q

what is pneumothorax?

A

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.

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20
Q

what is traumatic, non- iatrogenic?

A

Penetrating chest injury (stab, gunshot)

Blunt chest injury (rib fractures, bronchial rupture)

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21
Q

what is traumatic, iatrogenic?

A 
Pleural aspiration/biopsy
	Sub-clavian vein cannulation
	Lung, liver, breast, renal biopsy
	Acupuncture	
	In USA as common as spontaneous
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22
Q

what are symptoms of pneumothorax?

A

Assymptomatic (if small, good respiratory reserve)

Acute breathlessness, worsening breathlessness
Pleuritic chest pain

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23
Q

what are signs of pneumothorax?

A

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

24
Q

what questions would you ask yourself when deciding how to manage pneumothorax?

A

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?

25
Q

if it is tension pneumothorax how would you manage?

A

Cannula (large grey venflon) 2nd intercostal space mid-clavicular line

Then insert intercostal chest drain

26
Q

how do you manage a patient who has a small primary pneumothorax but isnt breathless?

A

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

27
Q

how do you manage a patient that has breathless primary pneumothorax?

A

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)

28
Q

how do you manage a patient with breathless secondary pneumothorax?

A

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
29
Q

what is indications of a poor chest drain?

A

lung fails to re-inflate after 48 hours

drain continues bubbling

30
Q

what is asbestos?

A

Highly fibrous naturally occurring mineral

31
Q

what are the three main types of asbestos?

A

Chrysotile (white)
Amosite (brown)
Crocidolite (blue)

32
Q

clinical presentation of mesothelioma?

A

breathlessness

chest wall pain

33
Q

what is Mesothelioma

A

Mesothelioma is a type of cancer that develops in the lining that covers the outer surface of some of the body’s organs.

34
Q

what is a main cause of mesothelioma?

A

asbestos

35
Q

if the fluid comes out straw-like, what does this mean?

A

normal

36
Q

if the fluid comes out cloudy, what does this mean?

A

exudate
infection
milky

37
Q

if the fluid comes out blood, what does this mean?

A

malignancy
tb
trauma
infarct

38
Q

if the fluid comes out pus, what does this mean?

A

empyema

39
Q

what surface is the production of fluid

A

parietal surface

40
Q

what surface is the absorption of fluid

A

visceral surface

41
Q

whats the difference between exudate and transudate

A

exudate is the fluid that leaks out and transudate is the fluid that is pushed through the capillaries

42
Q

what protein content does exudate and transudate

A

exudate- over 3.5

transudate- under 2.5

43
Q

what are the 6 main reasons for transudate?

A 
cardiac failure
liver failure
renal failure
hypoalbuminemia
hypothyroidism
pulmonary embolis
44
Q

what are the 6 main reasons for exudate?

A 
infection
malignancy
pulmonary embolis
rheumatoid arthiritis
SLE
pancreatitis
45
Q

whats the difference between trapped lung and pneumothorax?

A

theres not actually a puncture

46
Q

would draining pus give you a better control of sepsis?

A

yes

47
Q

when should you drain an effusion?

A

large: breathless, raised RR, hypoxia, tachycardiac, CXR trachia deviated

48
Q

why do you always go above the rib in chest tube placement

A

nerve neurocostal bundle below

49
Q

what would the pH be if you want to drain ?

A

under 7.2

50
Q

how many intercostal spaces would be showing if there was hyperinflation

A

5.5 or 6

51
Q

whats the management of pneumothorax?

A

do nothing if you can
aspirati0on
oxygen and chest insertion

52
Q

management of tension pneumothorax?

A

oxygen
aspirate in 2nd anterior intercostal space in the midclavicular line
CXR
US to confirm if trained

53
Q

what are symptoms of malignant mesothelioma?

A 
chest pain
breathlessness
fever
weakness
cough
weight loss
54
Q

what would you see in a patient CXR that has malignant mesothelioma?

A

pleural effusion, pleural based opacity/mass

55
Q

where does secondary spontaneous pneumothorax happen?

A

bad lungs

1st year systems (74 decks)

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