Pleural Disease Flashcards
What is pleural effusion?
excessive accumulation of fluid in the pleural space
what levels of fluid need to present for pleural effusion to be detected?
> 300mL on Xray
>500mL clinically
What may be seen on X-ray in a patient with pleural effusion?
- obliteration of costophrenic angle
- dense homogoneus shadows occupying part of hemithorax
- fluid below the lung can simulate a raised hemidiaphragm
- fluid in fissures-may resemble intrapulmonary mass
How is a diagnosis of pleural effusion made?
pleural aspiration with ultrasound guidance
what are the categories of effusion?
transudate
exudate
where are transudates usually found?
can be bilateral but are often larger on right side
what are the causes of transudate?
heart failure hypoproteinaemia constrictive pericarditis hypothyroidism ovarian tumours
what is the protein, lactic dehydrogenase content and fluid to serum LDH ratio of transudate?
protein <30g/L
lactic dehydrogenase<200IU/L
fluid to serum LDH ratio is <0.6
what is the protein, lactic dehydrogenase content of exudate?
protein >30g/L
lactic dehydrogenase >200IU/L
What are the causes of exudates?
bacterial pneumonia carcinoma of bronchus TB autoimmune rheumatic diseases post MI infarction acute pancreatitis mesothelioma sarcoidosis yellow nail syndrome familial mediterranean fever
what are the features of a history of a patient with pleural effusion?
dyspnea pleuritic chest pain cough fever hemoptysis weight loss trauma history of cancer cardiac surgery
what are the physical examination findings for a patient with pleural effusion?
dullness to percussion decreased breath sounds absent tactle fremitus ascites JVP peripheral oedema friction rub unilateral leg swelling
what is pneumothorax?
air in the pleural space
what are the types of pneumothorax?
spontaneous
or due to trauma
spontaneous pneumothorax
- who gets it?
- what causes it?
1.common in young men. often in tall and thin patients
2. caused by rupture of a pleural bleb. usually apical and due to congenital defects in connective tissue of alveolar walls
underlying cause in patients over 40 is usually COPD
when is a pneumothorax localied?
if the visceral pleura has previously become adherent to parietal pleura
when is a pneumothorax generalised?
if there are no pleural adhesions
how does a bronchopleural fistula occur?
pressure in pleural space is usually negative and this is lost once a communication is made with atmospheric pressure, the elastic recoil pressure of the lung causes it to partially deflate. bronchopleural fistula occurs if communication between airways and pleural space remains open
what are the features of pneumothorax?
sudden onset of unilateral pleuritic pain or progressively increasing breathlessness.
if pneumothorax enlarges, the patient becomes more breathless and may develop pallor and tachycardia
few physical signs if pneumothorax is small
a third of patients have recurrence
what are the signs and symptoms of pneumothorax?
P-THORAX Pleuritic pain Trachea deviation Hyper resonance Onset sudden Reduced breath sounds (and dyspnea) Absent fremitus X-ray showing collapse
what is the presentation of a tension pneumothorax?
distended neck veins
tracheal deviation
cardiac arrest
death
what is the difference between primary spontaneous and secondary spontaneous pneumothorax?
primary - pleuritic chest pain, dyspnoea mild or moderate
secondary - no pleuritic chest pain, dyspnoea usually severe
what is a primary spontaneous pneumothorax?
occurs in patient with no known underlying lung disease
tall and thin people
familial component
associations to marfan syndrome. ehlers-danlos syndrome, alpha-1-antitrypsin deficiency, homocystinuria
what is a secondary pneumothorax
when the underlying lung is abnormal
what diseases can lead to secondary pneumothorax?
- cystic lung disease, emphysema, asthma, pneumocystis jiroveci pneumonia, end stage ILD,
- parenchymal necrosis, lung abscess, necrotic pneumonia, septic emboli, fungal disease, TB, cavitating neoplasm, radiation necrosis, pulmonary infarct
what is usually seen on CXR in a patient with a pneumothorax?`
- visible visceral pleural edge (very thin sharp white line)
- no lung markings are seen peripheral to this line
- peripheral space is radiolucent compared to the adjacent lung
- lung may completely collapse
- no mediastinum shift unless tension pneumothorax
- subcutaneous emphysema and pneumomediastinum
What is a small pneumothorax?
small rim of air
best seen on expiratory X-ray
<20% of radiographic volume
what is a medium pneumothorax?
definite 20-50% of radiographic volume
what is a large pneumothorax?
obvious >50% of radiographic volume
some shift of trachea and mediastinum
what is tension pneumothorax?
lung grossly deflated
marked deviation of trachea and mediastinum
what is recurrent pneumothorax?
recurs more than twice (1 in 5 recur in first year)
what is the management of small pneumothorax?
minimal symptoms
resume normal activity but avoid strenuous exercise
observe at 2 weekly intervals until air is reabsorbed
what is the initial management of medium, large and tension pneumothorax?
aspirate air (if no recurrence follow management of small pneumothorax)
what is the management for medium, large and tension pneumothorax if there is a recurrence following aspiration?
insert intercostal drainage with underwater seal for 2-3 days.
NEXT
-re-expansion / tube not bubbling=remove tube and re-Xray to exclude recurrence
OR
-pneumothorax remains/tube bubbling = surgery VATS
what is the management for recurrent pneumothorax?
surgery VATS
describe the options for surgery VATS for patients with pneumothorax?
- pleurectomy (no recurrence)
- talc pleurodesis (some recurrence)
