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