Pleural disease Flashcards
What is a pleural effusion?
build-up of excess fluid between the layers of the pleura outside the lungs
What are the symptoms of a pleural effusion?
- Often asymptomatic
- Increasing dyspnoea
- Pleuritic chest pain
- Dull ache
- Dry cough
- Weight loss
- Malaise
- Fever
- Night sweats
What are the signs of a pleural effusion?
Chest exam gives:
- Reduced expansion, breath sounds and vocal resonance.
- Stony dull percussion
Clubbing Cervical lymphadenopathy Raised JVP Tracheal deviation Peripheral oedema
A suspected pleural effusion patient is sent for a CXR
What would a pleural effusion look like?
Cloudy consolidation of fluid at peripheral/base of lung
Concave or horizontal fluid level
Loss of costophrenic angle
What would a CT scan (with contrast) of a patient with a pleural effusion look like?
Grey areas in peripheries of lungs
Often with diffuse or nodular thickening, deposits
Asbestos patients often have thickened, bumpy looking pleura
What is the purpose of using US scanning on a patient with pleural effusion?
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)
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?
Colour:
- Straw
- Cloudy
Blood
Pus
What does straw coloured fluid show?
Nothing
This is normal
What does cloudy coloured fluid indicate?
Exudate
Infection
Chylothorax (milky)
What does bloody fluid mean?
Malignancy
TB
Trauma
Infarct
What does purulent (pus-ee) fluid mean?
Empyema
How is pleural fluid investigated?
Biochemistry: protein, LDH, glucose, triglyceride, cholesterol, amylase, rheumatoid factor
Microbiology:Gram stain, AAFB (for TB) and culture
Cytology
What is the difference between transudate and exudate?
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
What is the difference in protein levels between transudate and exudate?
Transudate is low protein (<2.5)
Exudate is high protein (>3.5)
How much LDH is in transudate and exudate?
LDH is transudate is normal
Exudate has high LDH
The levels of proteins and LDH in transudate and exudate is represented using ________
Lights criteria
What can exudate in pleural fluid indicate?
Infection
Malignancy
Pulmonary embolus
Rheumatoid arthritis
SLE
Pancreatitis
Benign asbestos effusions
Drug related effusions
Post MI
Yellow nail syndrome
What can transudate in pleural fluid indicate?
Cardiac failure
Liver failure
Renal failure
Hypoalbuminaemia
Hypothyroidism
Pulmonary embolus
Malignancy
Constrictive pericarditis
Meigs syndrome
For Abrams pleural biopsy procedure, describe the:
- location
- type of anaesthetic
- level of visualisation
- success rate
- diagnostic/pleurodesis
Bedside
Local anaesthetic
Blind
Low/moderate success rate (27-50%)
Can only be used for diagnosis
For Image guided biopsy, describe the:
- location
- type of anaesthetic
- level of visualisation
- success rate
- diagnostic/pleurodesis
Day case
Local anaesthetic
Image guided
87% success rate
Can only be used for diagnosis
For medical thoracoscopy, describe the:
- location
- type of anaesthetic
- level of visualisation
- success rate
- diagnostic/pleurodesis
Sterile procedure room
Local anaesthetic and sedation
Direct visualisation
High success rate 90%
Pleurodesis
For VATS pleural biopsy, describe the:
- location
- type of anaesthetic
- level of visualisation
- success rate
- diagnostic/pleurodesis
Theatre
General anaesthetic
Direct visualisation
Highest success rate 90-96%
Pleurodesis
When would you have to drain a pleural effusion?
how bad must it be
Large enough to make the patient:
breathless, raised RR, Hypoxia, Tachycardic, CXR trachea deviated
Parapneumonic, PH <7.2
Purulent (pus)
Trauma / post operative
Effusion is drained using a chest tube
Where is this inserted in relation to the rib?
In intercostal space, just above the rib to avoid the neurovascular bundle
