Pleural Disease Flashcards
What is the normal volume of fluid in the pleura?
10-20ml
What is pleural effusion?
When the pleural fluid increases
Does fluid always sink to the bottom in the pleura?
Mostly, but not always
What does TVF stand for?
Vocal fremitus
What does VR stand for?
Vocal resonance
What does TVF and VR show?
Presence of fluid → sound waves are poorly conducted through fluid
What are symptoms of pleural effusion?
- Productive cough
- Fever
- Crackles
- Percussion is stony (bc fluid) and dull
- Tracheal deviation (if large)
- Reduced breath sounds (can get bronchial breath sounds at level of effusion)
What are signs on a CXR of pleural effusion?
1) Can’t see hemidiaphragm
2) Dense white shadowing
3) Shadowing creeps up side of chest wall
What scan would you do after a CXR?
Ultrasound (black = fluid)
What is a thoracocentesis?
A pleural tap to get a sample of the fluid in the effusion
Where do you do the thoracocentesis and why?
Above the rib to avoid the neuromuscular bundle below the rib
What are the different types of samples from a thoracocentesis sent off?
- AFB (TB cultures), MCS (normal cultures, microscopy culture sensitivity)
- Protein, LDH
- Cytology
- Glucose
What are the two types of effusion fluid?
Transudate and exudate
How do you define a transudate?
< 25 g/L of protein
How do you define an exudate?
> 35 g/L (thick fluid with lots of protein and LDH)
What do you do if the pleural fluid has between 25-35 g/L of protein?
You use Light’s criteria
What is Light’s criteria?
Exudate if one or more is true:
1) Pleural protein divided by serum protein is >0.5
2) Pleural LDH divided by serum LDH is <0.6
3) Pleural LDH > ⅔ upper limit of lab normal LDH
What are transudates generally caused by?
Systemic problems i.e. failures - heart, liver, renal
What are v common causes of transudates?
- LV failure (most common)
- Liver cirrhosis/failure
What are less common causes of transudates?
- Hypoalbuminaemia
- Peritoneal dialysis
- Hypothyroidism
- Nephrotic syndrome
- Mitral stenosis
What are rare causes of transudates?
- Constrictive pericarditis
- Urinothorax
- Meigs’ syndrome
- Superior vena cava obstruction
What are exudates generally caused by?
Local problems e.g. infection, lung cancer
What are common causes of exudates?
- Infection
- Malignancy
- Parapneumonic effusions
- TB
What are less common causes of exudates?
- Pulmonary
- Rheumatoid arthritis
- Other autoimmune pleuritic
- Benign asbestos effusion
- Pancreatitis
- MI
- Post-coronary artery bypass graft
What are rare causes of exudates?
- Yellow nail syndrome
- Other lymphatic disorders
- Lymphangioleiomyomatosis
- Drugs
What is the glucose level like in pleural fluid?
Either normal or low (not really high)
What are causes of low pleural glucose in pleural fluid?
Something is using up the glucose
- Infection
- Malignancy
- RA
- TB
- Oesophageal rupture
- SLE
What is the normal level of pleural glucose?
3-5
How can you measure pleural pH on the spot?
Putting the fluid through a blood gas analyser
What does pleural pH mirror?
Pleural glucose (low pH = low glucose)
What does a pleural pH of <7.2 indicate?
There is a complicated parapneumonic effusion which needs to be drained
What does parapneumonic mean?
Next to pneumonia
How would you treat a simple parapneumonic effusion (exudate)?
Drain if there is so much that it is making pt breathless otherwise leave it alone and it will go away when she gets better (pneumonia clears up)
What does confusion indicate in the presence of pneumonia?
Bad pneumonia
What are signs of pneumonia/empyema?
- Unwell, febrile
- Cough, green sputum
- Dull
- High CRP
What do you do if there is (a large volume) of pus in the chest wall and why?
- Need to drain it and get it out
- Like an abscess → it is a walled off collection of infection and if you don’t drain it the infection will get worse
What do you use to drain pus?
A chest drain
What do you not need not do with fluid that looks like cheese and why?
Put it in a blood gas analyser
- Might clog it up
- Already know that pH is low due to lots of anaerobic bacterial metabolism occurring in the fluid
What is the normal pH of pleural fluid?
Same as blood
Describe strep milleri
- Terrible smell as soon as chest drain goes in
- Viridans group streptococci
- Gets in through teeth
What types of cells are know as pus cells?
Neutrophils
What is a chest drain?
A tube (not needle) that goes between the ribs into the pleural space
What is the most common chest drain?
Seldinger chest drain
What is the Seldinger technique?
Way to put the tube safely into the body → wire goes in first and tube follows wire
What else do you need when using a chest drain?
An underwater seal bottle
How does a chest drain + underwater seal bottle used?
1) When the drain is in, attach to the underwater seal bottle/bucket
2) The tube that comes from the patient is submerged in water → there is an outlet further up so that air that comes out of the pleural space can bubble out and fluid will just join water and increase volume in the bucket (one way valve)
3) This stops things going in but allows things to come out
4) Bottle needs to stay lower than patient
What is empyema?
When pus collects int eh pleural cavity (associated with pneumonia) → mortality of 20% (high)
How do you treat empyema?
- Recognise and treat early with a chest drain
- Some patients may need to have an operation to clean things up
Where does the chest drain usually enter the body?
On the side (unusual to be anteriorly)
What is haemoptysis?
Coughing up blood
What is cachexia?
Weakness and wasting of the body due to severe illness?
What is clubbing?
When the ends of the fingers become bulbous
What is one important cause of clubbing?
Lung cancer
What happens to breath sounds where a malignancy is present?
Reduced BS
What happens to CRP in lung cancer?
Might increase a bit
What sign on a CXR indicates fluid?
A meniscus
What indicates hyperinflation on a CXR?
Lowered hemidiaphragm
What indicates cancer on a CXR?
White blob in lung
What would you do if you saw a white blob on a CXR?
Also do a CT scan where you can see the lump in the same location more clearly
What type of effusion results from lung cancer?
Malignant pleural effusion
What test results would you see from a malignant pleural effusion?
Exudate, normal glucose, LDH increased
What is a malignant pleural effusion?
Pleural effusion caused by the spread of cancer to the pleural lining which then increases the rate of pleural fluid production and causes problems
What common cancers go to the pleura?
Lung, breast, ovarian (can also see it in lymphoma)
Why do you need to get fluid out in a pleural effusion?
- In patients (esp. with malignant pleural effusions), fluid can squash the lung so using less lung and weight the diaphragm down
- This can lead to breathlessness and other significant symptoms
- Taking fluid out allows lung to re-expand and takes weight off of the diaphragm so the patient feels better
Why can’t you drain all the fluid in one go when doing a thoracocentesis and so how much do you drain in a go?
- Bc can’t drain a large amount of fluid at once without causing problems
- So typically do up to 1.5L in one go (pt likely has much more)
Describe the process of talcum powder pleurodesis
1) Once fluid is out using a chest drain, can try and stick pleural space together using talcum powder which you mix into a paste a squirt into the chest drain
2) The talc slurry spreads around the outside of the lung and coats the lung and parietal surface, causing an inflammatory reaction
3) This causes the surfaces to stick together and fuse, meaning the pleural space goes → therefore there is nowhere for fluid to accumulate so it stops (not always successful)
4) Patients who have this no longer have the sliding of two surfaces when they breathe and can survive fine without this
What is thoracoscopy?
Another option to manage pleural effusion
Describe the two types of thoracoscopy
1) VATS (video assisted thoracoscopic surgery) → keyhole surgery in lung involving camera and two grabbers (general anaesthetic)
2) Medical thoracoscopy → usually done with one hole, local anaesthetic and bit of sedation (for people not fit for general anaesthetic)
Describe the management method of pleural effusions called a tunnel drain or indwelling pleural catheter (IPC)
1) Drain is put into pleural space, then tunnels under the skin for 10cm and comes out a distant point
2) Tunnel section forms an anchor, stopping it from being pulled out and forms and infection barrier
3) Patients have drain put in and can attach bottle which sucks fluid into it
4) Can do it at home → when finished draining, nurse takes bottle off and then wind tube up under dressing and done
What are the benefits of IPC (pleurex)?
- Don’t need to keep patient in hospital
- Quick procedure and then can go home → good for patient with poor prognosis with lung cancer
- V effective way of managing malignant pleural effusion
What type of pleural effusion tends to be bilateral?
Transudate (don’t tend to tap as know it will be transudate)
What do sternal wires indicate?
- Patient has had chest opened (sternum sewed with wires) → midline sternotomy
- Most common reasons is a coronary artery bypass graft (CABG) or valve operation
- So know that she has heart problems and upper lobe blood diversion
What are signs of heart failure?
- Increased SOB
- Orthopnoea
- Hypoxia?
- Increased JVP
- Sacral and ankle oedema (pitting)
How do you treat bilateral pleural effusion related to HF?
Can drain effusion off but unless fix the cause, it will just fill up again
What is a classic case of someone with a PTX?
Tall, skinny male who is a smoker (+ if have had one on one side before, chance of having another one is increased
What are signs and symptoms of a PTX?
- Sudden pain in the PTX side of chest (stabbing pain)
- Minor breathlessness
- Feels a bit weird
- Reduced BS and expansion, increased percussion note on PTX side
- Can’t normally feel tracheal tug
- Lung is away from chest wall
What is a typical appearance of a PTX on a CXR?
- Can’t see white feathery lines coming from centre (bronchi)
- Can maybe see lung squashed down (white outline of lung)
- Around squashed lung is v black
What is a PTX not the same as?
A collapsed lung (say deflated lung instead)
How do you treat a PTX?
Wide-bore chest drain
What do you need to do when treating a PTX with a wide-bore chest drain?
Need to have the same set up as for the other chest drain bc as the drain is put in, air will bubble down the tube, through the water and out into the atmosphere and the lung slowly comes up
What is the difference between a primary and secondary spontaneous PTX?
Primary = pt without lung disease Secondary = pt with lung disease
What is the significance of having a secondary PTX?
If e.g. have emphysema with lots of bubbles in the lung and one of these pops, likely to tolerate PTX much worse
What treatment can be given if someone keeps getting PTX on same side (or even just twice)?
Can have operation to stick things together → puff talcum powder into lung which coats surface of lung and chest wall = pleurodesis (like talcum powder pleurodesis before?)
Describe what you can see on a CXR of something with a tension PTX?
- Side of PTX hemidiaphragm much lower (goes backwards)
- Heart is completely on left side of the chest
- Tracheal deviation
- So much air on right side of chest that is squashing everything over to LHS
What happens in a tension PTX?
- Comes about bc there is a flap valve so whenever the pt breathes out, the air gets pushed into the pleural space but when they breathe in the air can’t escape
- So with each breath, volume of air on that side of the chest is increasing and will continue until the situation is relieved
- If you keep squashing, this will lead to cardiac arrest
- More common in trauma cases e.g. stabbing
What are causes of pulseless electrical activity (PEA) arrest (when the heart is doing its job but not managing to beat or generate an output?
1) Hypoxia
2) Hypovolaemia
3) Hypo/hyperkalaemia (metabolic)
4) Hypothermia
5) Thrombosis - coronary or pulmonary
6) Tension PTX
7) Tamponade (cardiac)
8) Toxins
How do you treat a tension PTX (normally managed by surgeons)?
- Immediate treatment is to put a cannula into the second intercostal space (mid-clavicular) → releases air, slowly pressure normalises, heart comes back and patient can un-arrest if lucky
- This is just a temporary measure → then need to put in normal chest drain to allow lung to fully expand and situation to be save
(Should really be able to diagnose and do this before CXR)
