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Respiratory > Pleural disease > Flashcards

Pleural disease Flashcards

1
Q

What is a pleural effusion?

A

build-up of excess fluid between the layers of the pleura outside the lungs

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2
Q

What are the symptoms of a pleural effusion?

A
  • Often asymptomatic
  • Increasing dyspnoea
  • Pleuritic chest pain
  • Dull ache
  • Dry cough
  • Weight loss
  • Malaise
  • Fever
  • Night sweats
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3
Q

What are the signs of a pleural effusion?

A

Chest exam gives:

  • Reduced expansion, breath sounds and vocal resonance.
  • Stony dull percussion
Clubbing
Cervical lymphadenopathy
Raised JVP
Tracheal deviation
Peripheral oedema
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4
Q

A suspected pleural effusion patient is sent for a CXR

What would a pleural effusion look like?

A

Cloudy consolidation of fluid at peripheral/base of lung

Concave or horizontal fluid level

Loss of costophrenic angle

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5
Q

What would a CT scan (with contrast) of a patient with a pleural effusion look like?

A

Grey areas in peripheries of lungs

Often with diffuse or nodular thickening, deposits

Asbestos patients often have thickened, bumpy looking pleura

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6
Q

What is the purpose of using US scanning on a patient with pleural effusion?

A

Real time site marking of the effusion

Done at bedside

Marks out where to put the needle/drain in for the aspiration

It can also identify if the effusion is loculated (split into little pools of fluid)

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7
Q

The colour of drained effusion can identify what is wrong with the patient (if the effusion is secondary to something else)

What should you look for when inspecting the fluid?

A

Colour:

  • Straw
  • Cloudy

Blood

Pus

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8
Q

What does straw coloured fluid show?

A

Nothing

This is normal

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9
Q

What does cloudy coloured fluid indicate?

A

Exudate
Infection
Chylothorax (milky)

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10
Q

What does bloody fluid mean?

A

Malignancy
TB
Trauma
Infarct

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11
Q

What does purulent (pus-ee) fluid mean?

A

Empyema

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12
Q

How is pleural fluid investigated?

A

Biochemistry: protein, LDH, glucose, triglyceride, cholesterol, amylase, rheumatoid factor

Microbiology:Gram stain, AAFB (for TB) and culture

Cytology

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13
Q

What is the difference between transudate and exudate?

A

Transudate is fluid pushed out the capillary into the effusion due to high pressure within the capillary.

Exudate is fluid that leaks around the cells of the capillaries caused by inflammation

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14
Q

What is the difference in protein levels between transudate and exudate?

A

Transudate is low protein (<2.5)

Exudate is high protein (>3.5)

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15
Q

How much LDH is in transudate and exudate?

A

LDH is transudate is normal

Exudate has high LDH

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16
Q

The levels of proteins and LDH in transudate and exudate is represented using ________

A

Lights criteria

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17
Q

What can exudate in pleural fluid indicate?

A

Infection
Malignancy

Pulmonary embolus
Rheumatoid arthritis
SLE

Pancreatitis
Benign asbestos effusions
Drug related effusions

Post MI
Yellow nail syndrome

18
Q

What can transudate in pleural fluid indicate?

A

Cardiac failure
Liver failure
Renal failure

Hypoalbuminaemia
Hypothyroidism
Pulmonary embolus

Malignancy
Constrictive pericarditis
Meigs syndrome

19
Q

For Abrams pleural biopsy procedure, describe the:

  • location
  • type of anaesthetic
  • level of visualisation
  • success rate
  • diagnostic/pleurodesis
A

Bedside

Local anaesthetic

Blind

Low/moderate success rate (27-50%)

Can only be used for diagnosis

20
Q

For Image guided biopsy, describe the:

  • location
  • type of anaesthetic
  • level of visualisation
  • success rate
  • diagnostic/pleurodesis
A

Day case

Local anaesthetic

Image guided

87% success rate

Can only be used for diagnosis

21
Q

For medical thoracoscopy, describe the:

  • location
  • type of anaesthetic
  • level of visualisation
  • success rate
  • diagnostic/pleurodesis
A

Sterile procedure room

Local anaesthetic and sedation

Direct visualisation

High success rate 90%

Pleurodesis

22
Q

For VATS pleural biopsy, describe the:

  • location
  • type of anaesthetic
  • level of visualisation
  • success rate
  • diagnostic/pleurodesis
A

Theatre

General anaesthetic

Direct visualisation

Highest success rate 90-96%

Pleurodesis

23
Q

When would you have to drain a pleural effusion?

how bad must it be

A

Large enough to make the patient:
breathless, raised RR, Hypoxia, Tachycardic, CXR trachea deviated

Parapneumonic, PH <7.2

Purulent (pus)

Trauma / post operative

24
Q

Effusion is drained using a chest tube

Where is this inserted in relation to the rib?

A

In intercostal space, just above the rib to avoid the neurovascular bundle

25
Q

What is the procedure for parapneumonic effusions?

A

Drain if PH <7.2

If loculated, then drain the largest locule(s)

Inoculate blood culture bottles at time of sampling

IV antibiotics

Refer for surgery early if poor control of sepsis and effusion established

26
Q

What are the main types of pneumothorax?

A

Primary spontaneous
Secondary spontaneous

Iatrogenic
Non-iatrogenic

Any of these^ can be tension pneumothorax

27
Q

What is a spontaneous pneumothorax?

A

Spontaneous means the pneumothorax was not caused by an injury such as a rib fracture

28
Q

What is the difference between a primary and secondary pneumothorax?

A

Primary spontaneous = without apparent lung disease

Secondary spontaneous = in presence of existing lung disease

29
Q

What is an iatrogenic pneumothorax?

A

Pneumothorax caused through a medical procedure/treatment

30
Q

What are the short term treatment options for a pneumothorax?

A

Do nothing

Aspiration

Oxygen and chest drain insertion

31
Q

What are the long term management plans for a pneumothorax?

A

Permanent chest drain for patient to have at home

Medical pleurodeisis

Cardiothoracic referral

32
Q

What is a tension pneumothorax?

A

Large pneumothorax causing cardiorespiratory compromise

33
Q

What proportion of tension pneumothorax patients are ventilated?

A

Equal numbers

34
Q

What are the signs/symptoms of a tension pneumothorax?

A

Non ventilated patients insidious ( hours )

Ventilated Dramatic, emergency

Distressed

Trachea deviated, subcutaneous emphysema

Reduced chest excursion

Hyperresonance

Hypoxia, tachycardia and hypotension

Cardiac arrest

35
Q

What is the short term management procedure for a tension pneumothorax?

A

Oxygen

Aspirate - 2nd anterior intercostal space in midclavicular line

CXR

36
Q

After a patient has been discharged after a pneumothorax

Why should they not go on holiday to anywhere far away?

A

They should not fly

Pressure changes can cause a pneumothorax to re-occur

37
Q

What is the main cause of pleural plaques?

A

Asbestos

38
Q

Where do pleural plaques form?

A

Parietal pleura

39
Q

What is malignant mesothelioma?

A

Cancer of the thin tissue (mesothelium) that lines the lung, chest wall, and abdomen

40
Q

What are the symptoms of malignant mosothelioma?

A 
Chest Pain
Breathlessness
Fever
Weakness
Cough
Weight loss
41
Q

What other pleural disease is caused by malignant mesothelioma, that can easily be seen on a CXR

A

Pleural effusion

42
Q

What is the treatment route for malignant mesothelioma?

A

Chemotherapy

Survival generally less than a year so mainly palliative care:

  • Pleurodeisis
  • Long term drain insertion

Respiratory (32 decks)

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