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Respiratory Pathology > Pleural Disease > Flashcards

Pleural Disease Flashcards

1
Q

What is the pleura?

A

Single layer of mesothelial cells

Also sub pleural connective tissue

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2
Q

Layers of the pleura

A

Visceral

Parietal

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3
Q

What is the pleura lubricated by?

A

2-3ml of pleural fluid

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4
Q

Systemic arterial pressure vs pleural pressure

A

AP > pleural pressure

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5
Q

What is a pleural effusion?

A

Abnormal collection of fluid in the pleural space

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6
Q

What do the symptoms of pleural effusion depend on?

A

Cause

Volume of fluid

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7
Q

Presentation of pleural effusion

A 
Asymptomatic 
Increasing SOB
Pleuritic chest pain 
- inflammatory (early, may improve as fluid accumulates)
- malignancy (progressively worsening)
Dull ache
Dry cough 
Weight loss
Malaise
Fever
Night sweats
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8
Q

What causes pleuritic chest pain?

A

Surface of pleura inflamed and rub against each other

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9
Q

Signs of pleural effusion

A 
Chest affected on ONE side
Decreased expansion 
Stony dullness to percussion 
Decreased breath sounds (band of bronchial breathing)
Decreased vocal resonance
Clubbing
Tar staining
Cervical lymphadenopathy 
Increased JVP
Trachea deviated away from large effusion 
Peripheral oedema
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10
Q

If the trachea is NOT deviated away from a large effusion, what may this indicate?

A

Possible collapse

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11
Q

Two classifications of causes of pleural effusion

A

Transudates

Exudates

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12
Q

What causes transudates?

A

An imbalance of hydrostatic forces influencing the formation and absorption of pleural fluid

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13
Q

Features of transudates

A

Normal capillary permeability

Usually (not always) bilateral

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14
Q

What causes exudates?

A

Increased permeability of pleural surface and/or local capillaries into lesions or areas of inflammation

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15
Q

Are exudates usually bilateral or unilateral?

A

Unilateral

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16
Q

What is the exam cut off for pleural fluid protein for transudates?

A

< 30g/l

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17
Q

What is the exam cut off for pleural fluid protein for exudates?

A

> 30g/l

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18
Q

Which of transudates and exudates have more protein?

A

Exudates

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19
Q

Causes of transudates

A 
LVF
Liver cirrhosis
Hypoalbumineamia 
Peritoneal dialysis 
Hypothyroidism 
Nephrotic syndrome
MS
PE
Constrictive pericarditis
Ovarian hyperstimulation syndrome
Meigs syndrome
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20
Q

What is meigs syndrome?

A

Benign ovarian fibroma, ascites and R sided effusion

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21
Q

Causes of exudates

A 
Malignancy 
Parapneumonic
PE/Infarction 
RA
Autoimmune diseases (SLE)
Benign asbestos effusion 
Pancreatitis 
Post MI/cardiotomy syndrome
Yellow nail syndrome
Drugs
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22
Q

What is a parapneumonic

A

Pleural effusion that results from pneumonia, lung abscess or bronchiectasis (consider sub phrenic)

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23
Q

What drugs can cause exudates?

A 
Amoidarone
Nitrofurantoin 
Phenytoin 
Methotrexate
Carbamazepine
Penicillamine
Bromocriptin 
Pergolide
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24
Q

What is the name of the pleural malignancy?

A

Mesothelioma

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25
Q

80% of mesotheliomas are due to what?

A

Asbestos

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26
Q

Where can mesothelioma also occur?

A

Peritoneum

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27
Q

Presentation of mesothelioma

A

SOB

Chest wall pain

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28
Q

What does a mesothelioma look like on imaging?

A

Unilateral

Diffuse or localised pleural thickening

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29
Q

Investigation for pleural effusion

A

Investigation not usually required for transudates (clincial picture characteristic)
1. to confirm presence - CXR
2. Contrast enhanced CT thorax
3. Pleural aspiration and biopsy - ward analysis of fluid and blood gas analysis
4. Labs - protein, LDH, amylase, glucose, MC+S, gram stain, AAFB, culture, cytology
5. Interpret fluid protein
6. Pleural biopsy (4x)
7 If still no diagnosis - (video assisted) thoracoscopy

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30
Q

How much fluid is required to detect pleural effusion on CXR?

A

200ml

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31
Q

What would a pleural effusion look like on CXR?

A

Diaphragm shadow lost

Meniscus would be present

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32
Q

What does a contrast enhanced CT thorax look at?

A

Differentiates between malignant and benign disease
Nodular pleural thickening
Parietal pleural thickening > 1cm
Circumferential pleural thickening
Other malignant manifestations in lung/liver

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33
Q

Complications of pleural aspiration and biopsy

A 
Pneumothorax
Empyema
Pulmonary oedema 
Vagal reflex if not enough anaesthesia 
Air embolism 
Tumour cell seeding (cells may track along needle)
Haemothorax
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34
Q

What could be found when looking at the fluid?

A 
Foul smelling
Pus
Food particles
Milky 
Blood stained
Blood
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35
Q

What would foul smelling fluid indicate?

A

Anaerobic empyema

36
Q

What would pus in fluid indicate?

A

Empyema

37
Q

What would food particles in the fluid indicate?

A

Oesophageal rupture

38
Q

What would milky fluid indicate and what would this usually be caused by?

A

CHYLOTHORAX - usually lymphoma

39
Q

What would blood stained fluid indicate?

A

Possible malignancy

40
Q

What would blood coming out the needle indicate?

A

Haemothorax

Trauma

41
Q

How to interpret pleural protein

A

Transudate < 25g/l
Exudate > 35g/l
For protein 25 - 35g/l, use lights criteria
Exudate if greater and including 1 of the following then the criteria are met
- pleural/serum protein > 0.5
- pleural/serum LDH >0.6
- pleural/LDH > 0.66 of upper limit of serum LDH

42
Q

Treatment of pleural effusion

A 
Treatment directed at cause e.g. 
- chemo
- anti TB therapy
- corticosteriods
Pleurodhesis
43
Q

Palliative treatment of pleural effusion

A

Repeated pleural aspiration 1-1.5 L per time

44
Q

How does pleurodhesis work?

A

Patient lies on bed at 45 degrees arm above head
4TH IC SPACE MID AXILLARY LINE
Drain all fluid using a chest drain
Hole in pleura and attached to underwater seal
Drained at 500ml/hr

45
Q

What is used to check if all the fluid has been drained off in Pleurodehesis?

A

CXR

46
Q

What is a pneumothorax?

A

Presence of air in the pleural cavity

47
Q

Pathology of pneumothorax

A

Breach of visceral or parietal pleura with entry of air, lung collapses away from the chest wall because of the elastic recoil of the lung

48
Q

Types of pneumothorax

A

Spontaneous
Traumatic
Tension

49
Q

Types of spontaneous pneumothorax

A

Primary

Secondary

50
Q

Types of traumatic pneumothorax

A

Non iatrogenic

Iatrogenic

51
Q

What is a primary pneumothorax?

A

A pneumothorax in normal lungs

52
Q

What is a secondary pneumothorax?

A

A pneumothorax in lungs with underlying disease

53
Q

Example of iatrogenic pneumothorax

A

Pleural aspiration / biopsy
Sub clavian vein cannulation
Lung, liver, breast, renal biopsy
Acupuncture

54
Q

Example of non iatrogenic pnuemothorax

A 
Penetrating chest injury 
- stab / gunshot
Blunt chest injury 
- rib fractures
- bronchial rupture
55
Q

What is a tension pneumothorax?

A

Lungs get smaller and pneumothorax gets bigger
Vena cava becomes stretched and so reduces venous blood to the heart
Shifts the mediastinum to one of the sides

56
Q

Who gets primary pneumothorax?

A

Young
20 - 30 years
Tall and thin

57
Q

Causes of secondary pneumothorax

A 
COPD (30-50%)
Asthma
Pneumonia
TB
CF
Fibrosing alveoli 
Sarcoidosis
Histiocytosis X
58
Q

Presentation of pneumothorax

A

Asymptomatic
Acute SOB, worsening, extreme
Pleuritic chest pain
SUDDEN ONSET OF SYMPTOMS

59
Q

Signs of pneumothorax

A

May be no signs if small
Surgical emphysema if significant air leak - feels like bubble wrap
Non tension
- trachea deviated to affected side
- at affected side decreased expansion, hyper resonant, absent/decreased breath sounds
Tension
- trachea deviated away from affected site
- haemodynamic compromise
- Increased JVP

60
Q

Treatment of pneumothorax

A

Tension
- cannula be inserted into 2nd IC SPACE MID CLAVICULAR LINE Then insert an intercostal chest drain
Is pneumothorax space or large?
- small rim of air <2cm. Observe overnight, repeat CXR, if no change hole has sealed. Advise no vigorous activity and to return if become breathless. Review with CXR clinic in 2 weeks
- large; rim of air greater or equal to 2cm.
Breathless primary pneumothorax
- aspirate pneumothorax
- if successful, CXR and observe for 24 hours, unsuccessful - chest drain
Breathless secondary pneumothorax
- may aspirate if small but less successful
- insert IC drain (4th IC space mid axillary line)
Talc poudrage
Pleurectomy

61
Q

What is used as a local anaesthetic to aspirate the pneumothorax?

A

Lignocaine

62
Q

How does an IC chest drain work?

A

Lung inflates in 1 - 2 days
Drain stops bubbling
CXR confirms lung inflated

63
Q

What are the options after a chest drain has worked?

A
  1. Clamp drain for 24 hrs, re CXR and if no change remove the drain
  2. Re CXR after 24 hours and if there is no change then remove the drain
64
Q

What should be done if the lung fails to inflate?

A

Contact thoracic surgeons at 3 days

65
Q

Is there a high or low risk of subsequent pneumothorax?

A

High (54% at 4 years, 10 - 25% in first 4 months)

66
Q

What % of patients get a subsequent contralateral pneumothorax?

A

10 - 15%

67
Q

What is a pleurectomy?

A

Surgery where part of the pleura is removed

68
Q

Who with pneumothorax gets refered for surgical pleurodesis?

A

Second ipsilateral pneumothorax
First contralateral pneumothorax
Bilateral spontaneous pneumothoraces
First pneumothorax in high risk professionals (pilots, drivers)

69
Q

3 main types of asbestos

A

Chrysotile (white)
Amosite (brown)
Crocidolite (blue)

70
Q

Who gets exposure to asbestos?

A 
Boiler men
Engineers
Electricians
Plumbers
Building trade
Ship building
Fathers or husbands work gear
71
Q

When does the asbestos disease occur after exposure?

A

20 - 40 years after exposure

72
Q

Investigation for mesothelioma

A

Thoracoscopy and histology

73
Q

What area of the lungs does asbestosis affect?

A

Lower zones

74
Q

What are the main indications for placing a chest tube in a pleural infection?

A

Patients with frank purulent or tubid/cloudy pleural fluid on sampling
The presence of organisms identified by gram stain and/or culture from a non purulent pleural fluid sample
Pleural fluid pH < 7.2 in suspected infection

75
Q

Are pleural plaques malignant?

A

NO - they are benign and DO NOT undergo malignant change

76
Q

Asbestos related lung diseases

A 
Pleural plaques
Pleural thickening 
Asbestosis
Mesothelioma
Lung cancer
77
Q

What is the most common form of asbestos related lung disease?

A

Pleural plaques

78
Q

How long is the latent period for pleural plaques?

A

20 - 40 years

79
Q

What is the severity of asbestosis related to?

A

Length of exposure

80
Q

How much exposure do you need to get a mesothelioma?

A

Very little

81
Q

What lobes are affected in asbestosis?

A

Lower

82
Q

What type of asbestos is the most dangerous form?

A

Crocidolite (blue)

83
Q

What is the most common cause of exudative pleural effusion?

A

Pneumonia

84
Q

What is the ‘safe triangle’ for chest drain insertion?

A

Lattismus dorsi
Pec major
Line superior to the nipple and apex at the axilla

85
Q

What features of a pleural aspirate would suggest an empyema?

A

Pus present
pH < 7.2
Low glucose
High LDH

86
Q

Sudden deterioration with ventilation suggests what?

A

Tension pneumothorax

87
Q

What is the most common cause of transudative pleural effusion?

A

Heart failure

Respiratory Pathology (16 decks)

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