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Pleural disease Flashcards

1
Q

What is a pleural effusion?

A

Accumulation of fluid in the pleural space

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2
Q

What are causes of transudative pleural effusion

- due to increase in hydrostatic pressure? [4]

A

LVH
Constrictive pericarditis
Nephrotic syndrome
Peritoneal dialysis

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3
Q

Causes of transudative pleural effusion - due to reduced oncotic pressure [6]

A 
Hypoalbuminemia - Hepatic cirrhosis
Hypothyroidism
Mitral stenosis
Ovarian hyperstimulation syndrome
Meig's syndrome
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4
Q

Causes of exudative pleural effusion [8]

A 
Ca eg lung cancer 
Pneumonia, TB
RA (low glucose), SLE
Pancreatitis
Post-MI syndrome
Yellow nail syndrome
Asbestos-related pleural effusion
Drugs
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5
Q

Pathophysiology of pleural effusion: transudate [5]

A
  • 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.

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6
Q

Pathophysiology of pleural effusion: exudate [3]

A
  • increased permeability of pleural surface
  • local capillaries and effusion
  • Usually unilateral
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7
Q

What fluid would you see in pleural effusion secondary to PE?

A

Can be both transudative and exudative

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8
Q

Drugs that cause exudative pleural effusion [5]

A 
Nitrofurantoin
Amiodarone
Methotrexate
Pencillamine
Bromocriptine
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9
Q

Symptoms of pleural effusion [6]

A 
Asymtpomatic
Increasing SOB
Pleuritic chest pain
Dry cough (rapid accumulation)
Weight loss, Malaise, Fever
Night sweats
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10
Q

What does pleuritic chest pain that improves indicate?

Pleuritic chest pain that worsens?

A

Improving pleuritic chest pain = inflammation

Worsening pleuritic chest pain = malignancy

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11
Q

Signs of pleural effusion [6]

A

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)

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12
Q

Signs of underlying cause - signs to look out for [3]

A
  • peripheral oedema (RHF)
  • orthopnoea and PND (congestive cardiac failure)
  • tar staining, clubbing (lung cancer)
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13
Q

What is Meig syndrome [3]

A

Benign ovarian tumour
Ascites
Pleural effusion

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14
Q

Initial Investigations [3]

A
  1. CXR
  2. Contrast CT thorax
  3. Pleural aspiration
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15
Q

CXR of pleural effusion

A
  • Only visible once >200ml
  • Loss of costophrenic angle
  • Mediastinal shift
  • Trachea deviated away
  • Complete white out of lung
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16
Q

What can you see on Contrast CT thorax of pleural effusion? [2]

A
  • 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

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17
Q

Pleural aspiration methods [5]

A
  • 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
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18
Q

Pleural fluid sample - what do you do with it next?

A

1) Send it off!
- 5ml to biochemistry
- 5ml to microbiology
- 40ml to cytology
2) Assess appearance

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19
Q

Ward analysis of pleural fluid sample. State the clinical significance of each:

  • Foul smelling
  • Pus
  • Food particle
  • Milky
  • Blood stained
  • Frank blood [4]
A
  • 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
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20
Q

Describe the components of these investigations that you would need to order:

  • Biochemistry [5]
  • Microbiology [3]
  • Cytology [3]
A

Biochemistry: Light’s criteria, amylase, glucose, pH, immunology

Microbiology: MC&S, gram stain, AAFB

Cytology: lymphocytes in TB or lymphoma, malignant cells, eosinophils

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21
Q

What is Light’s criteria

A

Transudate if <30g protein/L
Exudate if >30g protein/L

Exudate if >=1 of:

  • Pleural/serum protein >0.5
  • Pleural/serum LDH >0.6
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22
Q

What does elevated amylase indicate? [4]
What does glucose <3.3mM indicate? [4]
What does pH <7.2 indicate? [5]

A

 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

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23
Q

Investigations not including blind chest drain insertion and pleural tap

A
  • 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.
24
Q

Management of malignant pleural effusions

A
  • 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
25
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
26
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
27
Post-pleural drain: 1. lung has not re-expanded 2. lung has re-expanded
1. Not re-expanded - Apply suction for 24h and remove the drain as it is an infection risk 2. Re-expanded - Proceed with chemical pleurodhesis
28
Chemical pleurodhesis
Can use talc, bleomycin or tetracycline can reduce recurrence
29
Pneumothorax Define Classification [5]
Gas in pleural space Classification: - Primary spontaneous - Secondary spontaneous - Iatrogenic - Traumatic - Tension
30
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
31
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
32
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
33
Causes of iatrogenic PTX [4]
Iatrogenic PTX: - Subclavian CVP line insertion - Pleural aspiration/biopsy - Transbronchial biopsy - Liver biopsy
34
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
35
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 ```
36
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
37
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
38
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
39
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
40
# 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.
41
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
42
``` 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
43
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)
44
What is the prognosis in bilateral pneumothorax?
Bilateral pneumothoraces are fatal
45
Safe triangle for chest drain insertion
* Latissimus dorsi * Pectoralis major * Line superior to nipple * Apex
46
Examination findings on pleural effusion [4]
Reduced chest expansion Stony dullness on percussion Bronchial breathing Mediastinal shift - away from effusion if large
47
What does straw colour pleural fluid means?
Transudates and exudates can both be straw coloured. TB can produce straw coloured, cloudy or bloody appearance.
48
What does a yellow/green pleural fluid point to?
Rheumatoid effusion
49
Complications of pneumothorax [2]
* Para-pneumonic effusions may progress to empyema * ± permanent pleural scarring and adhesions, loculations or trapped lung.
50
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
51
# 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.
52
# 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
53
# 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)
54
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
55

Respiratory (14 decks)

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