pleural disease Flashcards
what is pleural effusion?
- abnormal collection of fluid in the pleural space
- common presentation on many diseases
- does not always require drainage or sampling
- large unilateral effusions should raise concern
what should you do when suspecting pleural effusion?
- history and examination
- PA CXR
- pleural aspirate (if not convincingly cardiac failure)
- biochemistry
- cytology
- culture
what does the appearance of the pleural fluid tell us?
- straw coloured e.g. cardiac failure, hypoalbuminaemia etc
- bloody e.g trauma, malignancy, infaction, infarction
- turbid/milky e.g. empyema
- foul smelling e.g anaerobic empyema
- food particles e.g oesophageal rupture
- bilateral - drugs, systemic path
what does the biochemistry test tell us?
transudates = protein <30 g/l»_space; heart failure, liver cirrhosis, hypoalbuminaemia, atelectasis, peritoneal dialysis
exudates = protein >30g/l»_space; malignancy, infection, pulmonary infarction, asbestos
(look for serious pathology)
fluid pH <7.3 suggests pleural inflammation (malignancy/ rheumatoid A). <7.2 requires drainage in infection
glucose = low in infection, TB, rheumatoid arthritis, malignancy, oesophageal rupture)
what does cytology and cell counts tell you?
- mostly looking for malignant cells
- lymphocytes - think TB and malignancy although any long standing effusion will eventually become lymphocytic
- neutrophils suggest acute process
why might biopsies be negative so often?
- wrong technique (don’t contain pleura)
- the involvement of pleural disease is discontinuous
- the effusion is ancilliary with malignancy but not malignant.
what is the advantage of a image (CT) guided cutting needle pleural biopsy?
- increases diagnostic sensitivity significantly
- no complications
what is mesothelioma?
- uncommon malignant tumour of the lining of the lung or very occasionally of the lining of the abdominal cavity
- likelihood of development increases with degree and length of time exposed to asbestos
- often takes 30-40 years to develop
- may cause breathlessness, chest pain, weight loss, fever, sweating and cough.
what are the treatments for mesothelioma?
- Pleurodese effusions
- Radiotherapy
- Surgery
- Chemotherapy
- Palliative care
- Report deaths to fiscal
Describe malignant pleural effusion.
- virtually all cancers may metastasise to the pleura especially lung, breast, upper GI, lymphoma, melanoma, ovary
- treatment; palliative care, pleural taps, drain, pleural catheters long term, surgical options
what are pleural catheters?
- allow patients to control their effusion and therefore symptoms
- inserted when malignant effusions
- may need overnight stay
- drain is designed to remain for life though some people will stop producing fluid.
- vacuum in drainage bottle that suctions pleural fluid
- complications include incorrect placement, bleeding, infection.
how do we predict survival time in malignant pleural effusion?
L - LDH (lactate dehydrogenase)
E - ECOG PS (eastern cooperative oncology group performance score)
N - neutrophil to lymphocyte ratio
T -tumour type
what is the treatment for malignant pleural effusion?
- dependant on underlying cause
- LVF -diuretics
- if infection then drain, antibiotics, possible surgery
- malignancy - drain, pleurodesis, long term pleural catheter
- unilateral effusions watched carefully
who is most likely to get a pneumothorax?
- tall thin men
- smokers’-cannabis smokers
- those with underlying lung disease
what is a primary pneumothorax?
- in normal lungs
- apical bullae rupture
- may be asymptomatic if moderately sized
what is a secondary pneumothorax?
- due to underlying lung disease e.g COPD
- usually symptomatic even if small
what are signs and symptoms of pneumothorax?
- acute onset pleuritic chest pain
- shortness of breath
- hypoxia
- tachycardia
- hyper resonant percussion note
- reduced expansion
- quiet breath sounds on auscultation
- hammans sing (click on auscultation of left side)
how are pneumothorax managed?
- oxygen even if no drain
- no treatment is asymptomatic and small
- aspiration 1st line in primary pneumothorax (avoids chest pain, time consuming, fail fail if older than 50 or SSP)
- chest drain
- suction
- surgical intervention
what is a tension pneumothorax?
- emergency can lead to cardiac arrest
- one way valve leads to progressively increasing pressure in the pleural space.
- this pushes other chest organs to opposite side
- acute respiratory distress
- signs; deviated trachea, hypotension, raised JVP, reduced air entry on affected side.
what can cause tension pneumothorax?
- ventilated patients
- trauma
- CPR
- blocked, kimked or misplaced drains
- pre existing airway disease
- patients undergoing hyperbaric treatment
what is the treatment for a tension pneumothorax?
- needle decompression
- usually with a large bore venflon
- second intercostal space anteriorly, mid clavicular line
- should hear a hiss sound
what are risk factors for pleural infection?
- diabetes mellitus
- immunesuppression including corticosteroids
- gastro-oesophageal reflux
- alcohol missuse
- IV drug abuse
what are the types of pleural effusion?
- simple parapneumonic effusion
- complicated parapneumonic effusion
- empyema
pleural fluid should be sampled to determine effusions that require urgent tube drainage
How can a complicated and simple effusion be distinguished?
- complicated = +ve gram stain, pH <7.2, low glucose, septations (material floating in the pleura), loculations (fluid, pus)
- simple effusions have none of the above and can be treated with antibiotics
