pleural disease Flashcards
what are the types of pleural diseases? Name 6.
Pneumothorax = air in pleural cavity
pleural effusion = fluid in pleural cavity
empyema = infected fluid in pleural cavity
pleural tumours = benign Vs malignant
pleural plaques = discrete fibrous areas
pleural thickening = scarring/calcification causing thickening (benign vs malignant)
what are the types of pneumothorax?
- spontaneous
i. primary (no lung disease)
ii. secondary (lung disease) - traumatic
- tension = emergency.
- iatrogenic e.g post central line/pacemaker insertion.
what are the pneumothorax risk factors?
- pre existing lung disease
- height
- smoking/cannabis
- diving
- trauma/chest procedure
- association with other conditions e.g Marfans syndrome.
how is a tension pneumothorax drained?
Tension
- insert a large-bore (14–16g) needle with a syringe, partially filled with 0.9% saline, into the 2nd intercostal interspace in the midclavicular line on the side of the suspected pneumothora
how is a non tension pneumothorax drained?
mid axillary line
5th intercostal space, chest drain insertion.
what are the signs of a pneumothorax?
Reduced expansion, hyper-resonance to percussion, and diminished breath sounds on the affected side.
With a tension pneumothorax, the trachea will be deviated away from the affected side and the patient will be very unwell. Also will be in Respiratory distress, tachycardic, hypotensive, distended neck veins.
NB: Cxr shouldn’t be performed if tension is suspected. treat ASAP then do CXR after.
why is a tension pneumothorax an emergency?
Air drawn into the pleural space with each inspiration has no route of escape during expiration. The mediastinum is pushed over into the contralateral hemithorax, kinking and compressing the great veins. Unless the air is rapidly removed, cardiorespiratory arrest will occur.
what is the pneumothorax management guideline?
primary
- symptomatic and rim of air >2cm on CXR, give o2 and aspirate. if unsuccessful, consider re aspiration or intercostal drain. Remove drain after full re expansion. cessation of air leak
secondary
- above but lower threshold for ICD. if persistent air leak >5 days (bronchopulmonary fistula) refer to thoracic surgeons.
discharge advice - no flying or driving till resolved.
how would you approach a pleural effusion?
- history and examination
- CXR
- ECG
- bloods: FBC, U&E, LFTs, CRP, bone profile, LDH, clotting
- ECHO (if suspected heart failure)
- staging CT with contrast if suspected exudative cause
how is pleural effusion diagnosed?
- Ultrasound guided pleural aspiration
- biochemistry (protein, pH, LDH)
- cytology
- microbiology (including AAFB)
NB: dont insert chest drain unless diagnosis established as draining fluid may mean you can’t get pleural biopsies. Only indication for urgent chest drain for effusion = underlying empyema.
what can cause transudate effusions (pleural protein <30g/L)?
- heart failure
- cirrhosis
- hypoalbuminaemia nephrotic syndrome or peritoneal dialysis)
- PE
what is important in the treatment of transudate effusions?
treat underlying cause
if effusion resolves, stop/ reduce treatment but if it persists, then therapeutic aspiration/drainage is required.
what is the cause of exudate effusions (pleural protein >30g/L)?
- malignancy
- infections e.g parapneumonic, TB, HIV (kaposi’s)
- inflammatory e.g RA, pancreatitis, connective tissue diseases, lymphatic disorders.
what is lights criteria?
if pleural fluid protein level between 25-35 g/L aka borderline, its exudate if its one or more of the following
- pleural fluid. serum protein >0.5
- pleural fluid/serum LDH > 0.6
- pleural fluid LDH >2/3 upper limit of normal
what are the signs of a pleural effusion?
- Decreased expansion; stony dull percussion note; diminished breath sounds occur on the affected side. vocal resonance are
- may be bronchial breathing.
- may be tracheal deviation away from the effusion
