Pleural Disease Flashcards
imaging used to see pleural effusion
- CRX
- ultrasound
- CT
loculation define
fluid in the pleural cavity that prevents the full expansion of lungs, making it difficult to breathe.
loculated pleural effusion define
when there is scarring and fibrosis as well as fluid, the fluid then gets trapped in pockets, preventing natural drainage. This type usually stays there for a long time.
what does granular or cloudy fluid in scan indicate?
it means that it could be pus = means that there is likely an infection
blood is also not a good sign
5 things to consider when looking at the effusion:
- cloudy?
- pH
- biochem (LDH, cholesterol, glucose, proteins, amylase, rheumatoid factor)
- microbiology (what stain of bacteria?)
- cytology (the study of cells - malignancy?)
transudate vs exudate
TRANSUDATE:
- fluid that leaks out from the capillaries due to high arterial pressure and therefore has low protein content
- protein <2.5
- LDH normal
- associated with cardiac/liver/renal failure, hypothyroidism, hypoalbuminemia, malignancy, constrictive pericarditis
- has to do with organ failure or things that drop plasma protein content and therefore even if you drain the fluid, it would return unless you solve the underlying cause.
EXUDATE:
- fluid that comes out of the capillaries due to impaired permeability, either due to damage or inflammatory response, and therefore has high plasma protein content
- protein >3.5
- LDH high
- associated with infection, malignancy, pulmonary embolus, rheumatoid arthritis, pancreatitis, drug related effusions, post MI, systemic lupus erythematosus
- you also need to figure out the cause and then take things further
define lung trap
when the fluids have already been drained but the lung has not quite rebounded back to position due to fibrosis, will normally resolve itself in a few days
define blind sampling and its use
when we suspect something about the effusion, we take a blind sample by sticking a needle inside. Here we would not know which part of the effusion we are actually taking from and there are some inaccuracies
when to drain a pleural effusion?
* you don’t drain when the patient is very frail and instead rely on PMH
- when it is a large effusion (can lead to breathlessness, tachypnoea, tachycardia, hypoxia, tracheal deviation)
- when it is parapneumonic effusion (pH<7.2), this type of effusion arises from pneumonic infection. It is basically a collection of pus that if left for a long time can lead to another infection and therefore needs to be drained.
- drain when there is pus
- drain if this is post-trauma or post-operative
Why can’t you drain more than 1L of effusion at a time
the lung expanding too fast will cause it to be filled with fluid, resulting pulmonary effusion.
what is surface anatomy the safe triangle
bounded at the sides by the lateral edge of pectoris major and lateral edge of lastissimus dorsi and at the bottom by the 5th intercostal space.
symptoms of parapneumonic effusions
- pus in the cavity
- dull percussion note
- reduced breath tone
- poor prognosis
2 causes of parapneumonic effusions
(usually from infections like pneumonia)
- poor hygiene
- prior dental procedure–> oral bacteria goes and infects the lungs
treatment of parapneumonic effusions
- IV antibiotics (a lot needed, and takes a long time to heal)
- chest drain (need this if the pH<7.2 and if the effusion is too big for antibiotics to handle by itsef)
- also make sure to make blood culture of the drained fluid to determine the strain
- surgery if there is uncontrolled sepsis or established effusion
symptoms of pneumonthorax
- gas in the pleural cavity and collapsed lungs
- tracheal deviation (drain the air if there is tracheal deviation)
- bulla
- quite simple to manage
bulla define
permanent, air filled space in the lung parenchyma that is >1cm and is bordered with remnants of the alveolar septa of the pleura.
formed from damaged alveoli
3 management of pneumothorax
(quite simple to manage unless the person is very unwell)
- aspiration
- chest drain (if they are unable to reduce the cannula with aspiration)
- O2 given afterwards
4 types of pneumothorax
- primary spontaneous pneumothorax
- secondary spontaneous pneumothorax
- trauma pneumothorax (iatrogenic or non-iatrogenic)
- tension pneumothorax (fatal)
primary spontaneous pnuemothorax
- affects men 15-30 yrs, especially if they are tall and thin (pleural pressure makes them more susceptible)
- recurrence 25%
symptoms: - reduced chest expansion
- cardiac arrest
causes:
- no pre-existing lung disesase
- subpleural blebs (weak areas of the lung fill with air that is likely to rupture and leak into the pleural cav)
secondary spontaneous pneumothorax
- affects men >55 yrs
- associated with COPD, asthma, CF, lung cancer, interstitial lung disease, sarcoid, lymphagioleiomyomatosis, pneumonia, catamenial
- higher recurrence rate than primary
treatment: consider pleurodesis
traumatic pneumothorax
- blunt penetrating force
- iatrogenic is when it is caused by the physician
lymphagioleiomyomatosis (LAM) define
abnormal multiplication of muscle cells in the lungs airways and blood vessels
catamenial define
pneumothorax along with menstruation, is recurrent in women or reproductive age
symptoms of tension pnuemothorax
- large pneumothorax that presses on the mediastinal and results in cardiorespiratory failure and cardiac arrest
- fatal, medical emergency
- tracheal deviation
- subcutaneous emphysema
- reduced chest expansion
- hypoxia
- tachycardia
- hypotension
treatments of tension pneumothorax
- aspirate or chest drain (at the second intercostal space at the midclavicular line)
- O2
- CXR and USS to confirm
3 asbestos related pleural diseases
- pleural plaques
- benign asbestos effusion
- malignant mesothelioma
3 main types of asbestos - latent period of 20-40 yrs
- chrysotile (white) - 90%, the most common
- amolite (brown)
- crocidolite (blue) - most dangerous
pleural plaques
- area of hyalinized collagen fibers that form in the pleura
- benign
- incidentally found
- evidence of past exposure to asbestos
benign asbestos effusion
- blood stained exudate
- chronic
- can normally resolve spontaneously
- associated with diffuse pleural thickening and therefore may have worsening symptoms
malignant mesothelioma
- asbestos-induced transformation of vascular endothelial growth factor (VEGF)
- chest pain
- breathlessness
- cough
- fever, weakness
- weight loss
- median survival < 1 year
treatment:
- CXR
- CT
- aspirate blood stained effusion
- tissue sample for confirmation of diagnosis
- image guided biopsy/thoracoscopy/ video-associated thoracoscopic surgery
- chemo
- palliative care: pleurodesis and long term drain insertion
