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Respiratory > Pleural disease > Flashcards

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
Q

Complications of pleural tap [6]

A

Injury to surrounding structures, lung, liver, diaphragm
Bleeding
Infection - Empyema
Pulmonary edema
Vagal reflex
Air embolism
Tumor cell seeding
Pneumothorax

26
Q

Pleural drainage rules:

  • Site of puncture
  • How fast to drain and why
  • Follow-up care
A

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
Q

Post-pleural drain:

  1. lung has not re-expanded
  2. lung has re-expanded
A
  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
Q

Chemical pleurodhesis

A

Can use talc, bleomycin or tetracycline can reduce recurrence

29
Q

Pneumothorax
Define
Classification [5]

A

Gas in pleural space

Classification:

  • Primary spontaneous
  • Secondary spontaneous
  • Iatrogenic
  • Traumatic
  • Tension
30
Q

What is primary spontaneous PTX? [3]

Risk factors [4]

A
  • rupture of sub pleural bullae
  • without preceding trauma or precipitating event
  • and no clinically apparent pulmonary disease

RF:

  • Smokers
  • Marfan syndrome
  • Homocystinuria
  • FHx
31
Q

What is secondary spontaneous PTX?

Name 4 risk factors

A

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
Q

What is catamenial pneumothorax?

A

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
Q

Causes of iatrogenic PTX [4]

A

Iatrogenic PTX:

  • Subclavian CVP line insertion
  • Pleural aspiration/biopsy
  • Transbronchial biopsy
  • Liver biopsy
34
Q

Pathophysiology: pneumothorax

A

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
Q

Symptoms of pneumothorax [5]

A 
Asymptomatic if small and large reserve
Acute SOB worsening
Pleuritic chest pain
Sweating, Tachycardia
Tachypnoea
Sudden deterioration if underlying pulmonary disease
36
Q

Pneumothorax signs [5]

A

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
Q

How can tracheal deviation ddx from tension and normal PTX?

A

Tracheal deviation TOWARDS affected side in normal PTX, AWAY from affected side in tension PTX

38
Q

Pneumothorax
First line investigation
Immediate mx of tension pneumothorax [3]

A

Ix: CXR
Mx of tension:
- No CXR needed
- 14G cannula into 2nd ICS and MCL
- Check drain

39
Q

Primary spontaneous PTX management

A

<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
Q

Primary pneumothorax management

> 50 years old and small PTX and not breathless

A

> 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
Q

Procedure of percutaneous aspiration for primary spontaneous pneumothorax [3]

A
  • 50ml syringe via large grey venflon
  • 2nd ICS, MCL
  • CXR to confirm success at 24h
  • Chest drain if unsuccessful
42
Q 
Secondary spontaneous PTX management
Indications for:
- conservative mx [2]
- Percutaneous aspiration [2]
- Chest drain [3]
- Thoracoscopy [2]
A

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
Q

Management of iatrogenic pneumothorax [2]

Indications for surgical pleurodesis [4]

A

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
Q

What is the prognosis in bilateral pneumothorax?

A

Bilateral pneumothoraces are fatal

45
Q

Safe triangle for chest drain insertion

A
  • Latissimus dorsi
  • Pectoralis major
  • Line superior to nipple
  • Apex
46
Q

Examination findings on pleural effusion [4]

A

Reduced chest expansion
Stony dullness on percussion
Bronchial breathing
Mediastinal shift - away from effusion if large

47
Q

What does straw colour pleural fluid means?

A

Transudates and exudates can both be straw coloured. TB can produce straw coloured, cloudy or bloody appearance.

48
Q

What does a yellow/green pleural fluid point to?

A

Rheumatoid effusion

49
Q

Complications of pneumothorax [2]

A
  • Para-pneumonic effusions may progress to empyema
  • ± permanent pleural scarring and adhesions, loculations or trapped lung.
50
Q

Intercostal chest drain insertion for pneumothorax
* Swinging chest drain
* Bubbling with inspitation and coughing

A

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
Q

Management of secondary pneumothorax

HRCT first to distinguish bulla from pneumothorax
Small pneumothorax
Large and persistent air leak

A

Small pneumothoraces can be managed first with percutaneous aspiration.

52
Q

Mx of chest drains for pneumothorax

When would you suspect kinking or displacement of chest tube

A
  • No swinging or bubbling but CXR showing persistent pneumothorax
53
Q

Mx of chest drains for pneumothorax

When is suction indicated?

A
  • 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
Q

Complications of drain insertion and their management

A

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
Q
A

Respiratory (14 decks)

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