Pleural disease Flashcards
What is a pleural effusion?
Accumulation of fluid in the pleural space
What are causes of transudative pleural effusion
- due to increase in hydrostatic pressure? [4]
LVH
Constrictive pericarditis
Nephrotic syndrome
Peritoneal dialysis
Causes of transudative pleural effusion - due to reduced oncotic pressure [6]
Hypoalbuminemia - Hepatic cirrhosis Hypothyroidism Mitral stenosis Ovarian hyperstimulation syndrome Meig's syndrome
Causes of exudative pleural effusion [8]
Ca eg lung cancer Pneumonia, TB RA (low glucose), SLE Pancreatitis Post-MI syndrome Yellow nail syndrome Asbestos-related pleural effusion Drugs
Pathophysiology of pleural effusion: transudate [5]
- imbalance of hydrostatic forces
- with reduced oncotic pressure
- causing increased absorption of interstitial fluid into pleural fluid.
- Capillary permeability is normal
- Usually bilateral
Generally, transudate effusions are managed conservatively and will resolve with treatment of underlying cause. Pleural aspiration is only required if there are atypical featues or not responding to diuretics.
Pathophysiology of pleural effusion: exudate [3]
- increased permeability of pleural surface
- local capillaries and effusion
- Usually unilateral
What fluid would you see in pleural effusion secondary to PE?
Can be both transudative and exudative
Drugs that cause exudative pleural effusion [5]
Nitrofurantoin Amiodarone Methotrexate Pencillamine Bromocriptine
Symptoms of pleural effusion [6]
Asymtpomatic Increasing SOB Pleuritic chest pain Dry cough (rapid accumulation) Weight loss, Malaise, Fever Night sweats
What does pleuritic chest pain that improves indicate?
Pleuritic chest pain that worsens?
Improving pleuritic chest pain = inflammation
Worsening pleuritic chest pain = malignancy
Signs of pleural effusion [6]
Decreased expansion (on affected side)
Stony dullness
Decreased breath sounds
Bronchial breathing at upper fluid level (severe)
Decreased vocal resonance
Trachea and mediastinum shift (away from affected side)
Signs of underlying cause - signs to look out for [3]
- peripheral oedema (RHF)
- orthopnoea and PND (congestive cardiac failure)
- tar staining, clubbing (lung cancer)
What is Meig syndrome [3]
Benign ovarian tumour
Ascites
Pleural effusion
Initial Investigations [3]
- CXR
- Contrast CT thorax
- Pleural aspiration
CXR of pleural effusion
- Only visible once >200ml
- Loss of costophrenic angle
- Mediastinal shift
- Trachea deviated away
- Complete white out of lung
What can you see on Contrast CT thorax of pleural effusion? [2]
- Differentiates between benign and malignant
- split pleura sign indicates presence of empyema as there is thickening of visceral and parietal pleural layer.
- Characterisation of loculations
- Malignant if nodular, mediastinal pleural thickening >1cm
Pleural aspiration methods [5]
- Lignocaine, 50ml syringe inserted with 21G green needle
- Effusion located under US guidance
- Needle inserted 1-2 ribs below upper border of effusion
- Avoid the neuromuscular bundle
- Withdraw 50ml
Pleural fluid sample - what do you do with it next?
1) Send it off!
- 5ml to biochemistry
- 5ml to microbiology
- 40ml to cytology
2) Assess appearance
Ward analysis of pleural fluid sample. State the clinical significance of each:
- Foul smelling
- Pus
- Food particle
- Milky
- Blood stained
- Frank blood [4]
- Foul smelling = anaerobic empyema
- Pus = empyema
- Food particle = esophageal rupture
- Milky = chylothorax
- Blood stained = ?malignancy
- Frank blood = haemothorax, trauma, mesothelioma, pulmonary infarction, post cardiac surgery
Describe the components of these investigations that you would need to order:
- Biochemistry [5]
- Microbiology [3]
- Cytology [3]
Biochemistry: Light’s criteria, amylase, glucose, pH, immunology
Microbiology: MC&S, gram stain, AAFB
Cytology: lymphocytes in TB or lymphoma, malignant cells, eosinophils
What is Light’s criteria
Transudate if <30g protein/L
Exudate if >30g protein/L
Exudate if >=1 of:
- Pleural/serum protein >0.5
- Pleural/serum LDH >0.6
What does elevated amylase indicate? [4]
What does glucose <3.3mM indicate? [4]
What does pH <7.2 indicate? [5]
Amylase: elevated in pancreatitis, carcinoma, bacterial pneumonia, oesophageal rupture
Glucose: <3.3mM in empyema, RA, SLE, TB, malignancy
pH: <7.2 in empyema, RA, SLE, TB, malignancy
Investigations not including blind chest drain insertion and pleural tap
- CT guided percutaneous pleural biopsy - suitable for patients unfit for surgery
- Thoracoscopic pleural biopsy is best
- VATS pleural biopsy done by cardiothoracic surgeon is best for exudate
- Bronchoscopy for patients presenting with features of lung malignancy like haemoptysis, aspiration pneumonia, inhalation of FB.
Management of malignant pleural effusions
- Usually recur within weeks of drainage and repeated aspirations are NOT ideal.
- Asymptomatic from effusion > monitoring
- Poor PS, life expectancy few weeks > repeated aspirations or small bore chest drain on low suction with regular flushing, or PleurX catheter with tunnelled tube.
- Good PS with good prognosis > VATS pleurodesis +/- trapped lung management
- Pleuroperitoneal shunt if pleurodesis fails
Complications of pleural tap [6]
Injury to surrounding structures, lung, liver, diaphragm
Bleeding
Infection - Empyema
Pulmonary edema
Vagal reflex
Air embolism
Tumor cell seeding
Pneumothorax
Pleural drainage rules:
- Site of puncture
- How fast to drain and why
- Follow-up care
Site: 4th ICS, level of nipple, anterior axillary line
Rate: no faster than 500ml/h otherwise re-expansion pulmonary edema
Drain until dry and check with CXR to see if lung has re-expanded
Post-pleural drain:
- lung has not re-expanded
- lung has re-expanded
- Not re-expanded
- Apply suction for 24h and remove the drain as it is an infection risk - Re-expanded
- Proceed with chemical pleurodhesis
Chemical pleurodhesis
Can use talc, bleomycin or tetracycline can reduce recurrence
Pneumothorax
Define
Classification [5]
Gas in pleural space
Classification:
- Primary spontaneous
- Secondary spontaneous
- Iatrogenic
- Traumatic
- Tension
What is primary spontaneous PTX? [3]
Risk factors [4]
- rupture of sub pleural bullae
- without preceding trauma or precipitating event
- and no clinically apparent pulmonary disease
RF:
- Smokers
- Marfan syndrome
- Homocystinuria
- FHx
What is secondary spontaneous PTX?
Name 4 risk factors
Occuring as a complication of underlying pulmonary disease
RF:
Pre-existing lung disease - COPD, asthma, PJP, TB, CF
- Connective tissue diseases
- Catamenial pneumothorax
- Ventilation
- Lymphanioleiomyomatosis LAM
- Pulmonary langerhands cell histiocytosis
What is catamenial pneumothorax?
Catamenial pneumothorax is a condition of air leaking into the pleural space (pneumothorax) occurring in conjunction with menstrual periods (catamenial refers to menstruation), and or during ovulation, believed to be caused primarily by endometriosis of the pleura
Causes of iatrogenic PTX [4]
Iatrogenic PTX:
- Subclavian CVP line insertion
- Pleural aspiration/biopsy
- Transbronchial biopsy
- Liver biopsy
Pathophysiology: pneumothorax
Intrapleural pressure exceeds atmospheric pressure
Especially during expiration
Causes a one way valve mechanism promoting
inspiratory accumulation of pleural gases
Pressure builds up eventually causing right heart and vena canal compression
Reduced CO, hypoxemia and respiratory failure due to lung compression
Symptoms of pneumothorax [5]
Asymptomatic if small and large reserve Acute SOB worsening Pleuritic chest pain Sweating, Tachycardia Tachypnoea Sudden deterioration if underlying pulmonary disease
Pneumothorax signs [5]
Reduced breath sounds
Reduced expansion
Hyper-resonance on side of pneumothorax
Surgical emphysema if significant air leak
Left side clicking if cardiac produces friction
How can tracheal deviation ddx from tension and normal PTX?
Tracheal deviation TOWARDS affected side in normal PTX, AWAY from affected side in tension PTX
Pneumothorax
First line investigation
Immediate mx of tension pneumothorax [3]
Ix: CXR
Mx of tension:
- No CXR needed
- 14G cannula into 2nd ICS and MCL
- Check drain
Primary spontaneous PTX management
<50 year olds with small pneumothorax <2cm who are NOT breathless can be discharged.
Provide safety netting advice & smoking cessation advice
Review in respiratory clinic with repeat CXR to ensure resolved pneumothorax
Primary pneumothorax management
> 50 years old and small PTX and not breathless
> 50 years old and small PTX and not breathless
- Observation in hospital with high flow oxygen
- Repeat CXR to check for enlarging pneumothorax
Breathlessness warrants admission regardless of size with high flow oxygen and percutaneous aspiration. Aspirate until you feel resistance or until patient coughs/sob.
Procedure of percutaneous aspiration for primary spontaneous pneumothorax [3]
- 50ml syringe via large grey venflon
- 2nd ICS, MCL
- CXR to confirm success at 24h
- Chest drain if unsuccessful
Secondary spontaneous PTX management Indications for: - conservative mx [2] - Percutaneous aspiration [2] - Chest drain [3] - Thoracoscopy [2]
Conservative:
<1cm visible rim AND
No SOB
Percutaneous aspiration:
1-2cm visible rim AND
No SOB
Chest drain:
>50yo or
>2cm visible rim or
SOB
Thoracoscopy:
- if fails to reinflate after 3d
- when pleurodesis wants to be done simultaneously
Management of iatrogenic pneumothorax [2]
Indications for surgical pleurodesis [4]
Iatrogenic:
- most resolve with observation, aspiration if not
- chest drain indicated in COPD or ventilated pts (less likely to recur)
Pleurodesis indicated in:
- 2nd ipsilateral PTX
- 1st contralateral PTX
- bilateral spontaneous PTX
- 1st PTX in high risk professions (pilots etc)
What is the prognosis in bilateral pneumothorax?
Bilateral pneumothoraces are fatal
Safe triangle for chest drain insertion
- Latissimus dorsi
- Pectoralis major
- Line superior to nipple
- Apex
Examination findings on pleural effusion [4]
Reduced chest expansion
Stony dullness on percussion
Bronchial breathing
Mediastinal shift - away from effusion if large
What does straw colour pleural fluid means?
Transudates and exudates can both be straw coloured. TB can produce straw coloured, cloudy or bloody appearance.
What does a yellow/green pleural fluid point to?
Rheumatoid effusion
Complications of pneumothorax [2]
- Para-pneumonic effusions may progress to empyema
- ± permanent pleural scarring and adhesions, loculations or trapped lung.
Intercostal chest drain insertion for pneumothorax
* Swinging chest drain
* Bubbling with inspitation and coughing
The drain should be attached to an underwater sealed unit
Swinging of the drain indicates that it is in the pleural space
Bubbling of the drain on inspiration and coughing will confirm the drainage of air
Confirm position with CXR
Management of secondary pneumothorax
HRCT first to distinguish bulla from pneumothorax
Small pneumothorax
Large and persistent air leak
Small pneumothoraces can be managed first with percutaneous aspiration.
Mx of chest drains for pneumothorax
When would you suspect kinking or displacement of chest tube
- No swinging or bubbling but CXR showing persistent pneumothorax
Mx of chest drains for pneumothorax
When is suction indicated?
- Suction (high volume, low pressure -10 to -20) is recommended if there is continuied air leak 48h after chest drain insertion
- Removes air from pleural space helping the parietal and visceral pleural surfaces to come together
- Suctioning before 48h is not recommended as this may precipitate re-expansion pulmonary oedema (affects contralateral lung)
Complications of drain insertion and their management
Surgical emphysema - resolves with high flow oxygen and re-positioning
Severe cases can cause upper airway obstruction and rspiratory distress requiring skin incision decompression
Persistent air leak in pnemothorax may require surgical intervention
