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Y4 Respiratory > Pleural disease > Flashcards

Pleural disease Flashcards

1
Q

Define what a pleural effusion is and state what it can be divided into

A

A pleural effusion is fluid in the pleural space. Effusions can be divided by their protein concentration into transudates (<30g/L) & exudates (>30g/L)

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2
Q

List the causes of transudative pleural effusions

A

Transudate (< 30g/L protein): Think CHARM

  • Cardiac failure (most common transudate cause)
  • hypoalbuminaemia (liver disease/cirrhosis, nephrotic syndrome, malabsorption)
  • Atelectasis (ITU or post surgery)
  • Hypothyroidism
  • Renal failure (Peritoneal dialysis)
  • Meigs’ syndrome
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3
Q

What is Meigs syndrome ?

A

This is the the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor.

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4
Q

List the causes of exudative pleural effusions

A

Exudate (> 30g/L protein):

  • Infection: pneumonia (most common exudate cause), TB, subphrenic abscess
  • Malignancy: lung cancer, mesothelioma, metastases
  • Pancreatitis
  • Pulmonary embolism
  • Asbestos
  • Dressler’s syndrome
  • Connective tissue disease: RA, SLE
  • Yellow nail syndrome

Think CAPTAIN

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5
Q

Which type of pleural effusions are always a sign of pathology ?

A
  • Exudative effusions are always a sign of serious pathology
  • Transudative effusions however are not always a sign of pathology
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6
Q

What are the signs/symptoms of a pleural effusion ?

A

Symptoms (not may be asymptomatic):

  • Dysponea
  • Non-productive cough
  • Pleuritic chest pain

Signs:

  • Stony dull percussion note
  • Reduced breath sounds on the affected side
  • Reduced chest expansion
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7
Q

What are the 1st line investigations for someone presenting with a pleural effusion?

A

CXR + Pleural U/S + diagnostic aspiration (pleural tap/thoracocentesis)

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8
Q

What tests should the pleural aspirate obtained via thoracocentesis be sent off for ?

A
  1. Biochemistry - protein, glucose, pH, LDH, amylase
  2. Cytology
  3. Microbiology - culture, gram stain & microscopy, PCR, Acid-fast bacilli stain & liquid culture
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9
Q

What 2nd line imaging investigation may be done for someone with a suspected pleural effusion after CXR & pleural U/S and why?

A

CT chest - this is done if the CXR or US findings are ambiguous

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10
Q

What 2nd line additional investigations may be done for someone with a pleural effusion and why ?

A
  • If pleural fluid analysis is inconclusive consider parietal pleural biopsy (thorascopic or CT-guided)
  • OR repeat the pleural tap (thoracocentesis)
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11
Q

Why is pleural U/S now recommended prior pleural aspiration ?

A

It greatly reduces the risk of any complications e.g. organ puncture

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12
Q

What underlying cause of the pleural effusion does a straw-coloured aspirate suggest ?

A

Cardiac failure, hypoalbuminaemia

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13
Q

What underlying cause of the pleural effusion does a bloody aspirate suggest ?

A

Trauma, malignancy, infection, infarction

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14
Q

What underlying cause of the pleural effusion does a turbid/milky aspirate suggest ?

A

Empyema, chylothorax (lymph with fat)

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15
Q

What underlying cause of the pleural effusion does a foul-smelling aspirate suggest ?

A

Anaerobic empyema

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16
Q

What underlying cause of the pleural effusion does food particles in the aspirate suggest ?

A

Oesophageal rupture

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17
Q

What are the causes of bilateral pleural effusions ?

A

LVF, PE, drugs, systemic pathology

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18
Q

When interpreting the biochemistry results of the pleural aspirate what is the normal levels and what is abnormal ?

A
  • Normal = 7.6 (only valid if plasma pH normal)
  • < 7.3 suggests pleural inflammation (malignancy/ Rh A)
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19
Q

All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling. If the fluid is purulent or turbid/cloudy (i.e. pus) what should be done ?

A

A chest tube to allow drainage

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20
Q

If the fluid is clear but the pH is < 7.2 in patients with suspected pleural infection what should be done ?

A

Chest tube insertion and drainage

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21
Q

What does low glucose levels in the pleural aspirate suggest?

A

Infection, TB, rheumatoid arthritis, malignancy, oesophageal rupture, SLE

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22
Q

What is the main purpose of cytology on pleural aspirates ?

A

Mostly looking for malignant cells (2 samples will dx up to 2/3 of malignant effusions)

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23
Q

What are the 2 main causes you should think of if lymphocytes are seen on cytology of the pleural aspirate ?

A

TB or malignancy

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24
Q

If neutrophils are seen in the pleural aspirate on cytology what should you think of ?

A

An acute process

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25
Q

What do raised amylase levels on pleural aspirate suggest ?

A

Pancreatitis, oesophageal perforation

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26
Q

Iif the protein level is between 25-35 g/L, what criteria should be used to distinguish between transudates and exudates ?

A

Light’s criteria should be applied. An exudate is likely if at least one of the following criteria are met:

  1. pleural fluid protein divided by serum protein >0.5
  2. pleural fluid LDH divided by serum LDH >0.6
  3. pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
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27
Q

Define what a mesothelioma is

A

It is an uncommon malignant tumour of the mesothelial layer of the pleural cavity or very occasionally of other mesothelial layers such as those in theabdominal cavity.

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28
Q

What is the key risk factor for the development of mesothelioma ?

A

It is strongly associated with asbestos exposure

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29
Q

What are the signs/symptoms of mesothelioma ?

A
  • Dyspnoea
  • Weight loss, fever, sweating
  • Cough
  • Chest wall pain
  • Clubbing
  • 30% present as painless pleural effusion
30
Q

How long does mesothelioma take to develop since exposure to asbestos ?

A

Takes approx 30-40 years to develop since exposure to asbestos

31
Q

What imaging method usually results in the suspicion of mesothelioma being raised ?

A

On CXR when pleural effusion or thickening is seen

32
Q

What are the 1st and 2nd line investigations used to investigate for suspected mesothelioma ?

A
  • 1st line = CXR
  • 2nd line = contrast CT Thorax (done for those with CXR suggestive of mesothelioma i.e. pleural effusion or thickening seen OR for those with persistent symptoms and history of asbestos exposure despite normal CXR)
33
Q

If pleural effusion is present in someone with suspected mesothelioma then what should be done to analyse the effusion?

A

Aspiration of pleural fluid & sent off for all the normal tests (microbiology, biochemistry & cytology)

34
Q

What is done for a definitive histological diagnosis of mesothelioma ?

A

Biopsy (either thorascopy or CT-guided)

35
Q

What is the treatment of mesothelioma?

A
  • For those with good performance status (0-1) give pemetrexed + cisplatin chemotherapy
  • Consider giving palliative radiotherapy for localised pain
  • Offer either talc plurodesis or a indwelling pleural catheter for symptomatic pleural effusions
36
Q

What is the prognosis of mesothelioma ?

A

Prognosis poor, median survival 12 months

37
Q

For people whose mesothelioma could be due to work related asbestos exposure, what are they intitled to ?

A

They are able to claim compensation and other benefits.

38
Q

List the complications of talc plurodesis

A
  • Minor pleuritic pain and fever (Common).
  • Pneumonia (Rare).
  • Respiratory failure (Rare).
  • Talc pneumonitis/ARDS ( Rare)
  • Secondary empyema (Rare).
  • Local tumor implantation at port site in mesothelioma.
39
Q

List some of the complications of long term indwelling pleural catheters

A
  • Incorrect placement
  • Bleeding
  • Infection
40
Q

What are the clinical features suggestive of pleural infection ?

A
  • Patients may either present with sepsis and symptoms of pneumonia, such as fever, cough, sputum production and dyspnoea
  • Or may have a more indolent history with constitutional symptoms such as weight loss and night sweats, with parietal pleural inflammation causing pleuritic chest pain.
  • Physical examination commonly suggests a pleural effusion
41
Q

In what patients should there be a high clinical suspicion of pleural infection ?

A

Patients with non-resolving pneumonia should be suspected of having pleural infection. In particular, those with ongoing fevers or non-improving WCC/CRP counts after 2-3 days of antibiotic therapy

42
Q

How is pleural infection diagnosed ?

A

1st line = CXR + US + thoracocentesis (pleural fluid aspiration - sent off for the usual tests i.e. microbiology, cytology & biochemistry)

43
Q

List the risk factors for the development of pleural infections

A
  • Diabetes mellitus
  • Immunosuppression including corticosteroids
  • Gastro-oesophageal reflux
  • Alcohol misuse
  • IV drug abuse

Note - many patients have no apparent risk factors.

44
Q

What are the 3 types of pleural infection ?

A
  1. Complicated parapneumonic effusion = +ve G stain, pH <7.2, low glucose, septations, loculations.
  2. Simple parapneumonic effusion = none of the above may be treated with antibiotics alone but may need drainage later on if things change
  3. Empyema = complicated + development of frank pus.
45
Q

When should an empyema be suspected ?

A

It should be suspected if a patient with a resolving pneumonia develops a recurrent fever

46
Q

What CXR features are seen in somene with an empyema ?

A

CXR features suggest a pleural effusion (D-sign seen)

47
Q

What is the best investigation for empyema ?

A

USS - simple and can be done bedside (also needed for inserting chest drain)

48
Q

What is the treatment of pleural infections ?

A
  • Antibiotics (often for several weeks) + Chest drainage of effusion
  • Broad specturm - Amoxicillin and Metronidazole initially

Note - Very small (<1cm) effusions may be left untapped

49
Q

Go over this slide summarising treatment of pleural effusions:

  • LVF – diuretics
  • Infection – drain, antibiotics, may require surgery
  • Malignancy – drain, pleurodesis, long term pleural catheter
A
50
Q

Define what a pneumothorax is

A

It is a collection of air in the pleural cavity (between the lung and the chest wall) resulting in collapse of the lung on the affected side.

51
Q

What are the 2 main classifications of pneumothorax’s ?

A
  1. Primary spontaneous pneumothorax (PSP) = pneumothorax occurring in healthy people.
  2. Secondary pneumothorax (SSP) = pneumothorax occuing in someonewith underlying lung disease - eg, rupture of a congenital bulla or a cyst in COPD
52
Q

What is shown in the pic and what pathology could it result in ?

A

A large bullae is shown - rupture of this could result in a pneumothorax

53
Q

What are some of the ‘other’ classifications of pneumothorax’s

A
  • Traumatic pnuemothorax - follows a penetrating chest trauma such as a stab wound, gunshot injury or a fractured rib.
  • Iatrogenic pnuemothorax - may follow a number of procedures such as mechanical ventilation and interventional procedures such as central line placement, lung biopsy and percutaneous liver biopsy.
  • Catamenial pneumothorax is the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax
54
Q

List the risk factors for pneumothorax development

A
  • Tall thin men
  • Smokers
  • Cannabis
  • Underlying lung disease - COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia
  • Ventilation e.g. CPAP, IPPV & mechnical ventilation
  • Connective tissue disorders - marfans, ehler danlos
  • Menstruation
55
Q

Define what a tension pneumothorax is

A

It is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function

56
Q

What can a tension pneumothorax lead to ?

A

Cardiac arrest

57
Q

List some of the causes of tension pneumothoraces ?

A
  • Ventilated patient (invasive or not)
  • Trauma
  • CPR esp PEA
  • Blocked, kinked, misplaced drain
  • Pre existing airways disease
  • Patients undergoing hyperbaric treatment
58
Q

What are the clinical features of a pneumothorax

A
  • Sudden onset dysponea &/or pleuritic chest pain
  • Sweating
  • Tachycardia
  • Tachyponea
  • Hypoxia
  • Hyper-resonant percussion note
  • Reduced expansion
  • Diminished breath sounds on affected side
  • Hamman’s sign (‘Click’ on auscultation left side)

Note - esp in PSP that clincal features may be minimal or absent

59
Q

What additional clinical features would suggest a tension pneumothorax ?

A
  • ARDS
  • Trachea deviated to opposite side
  • Hypotension
  • Raised JVP
  • Reduced air entry on affected side
60
Q

How are pneumothorax’s diagnosed ?

A
  • 1st line = CXR (inspiratory)
  • 2nd line = CT chest for uncertain or complex cases esp small pneumothoraces
61
Q

How is the size of pneumothorax classified ?

A
  • Small = <2cm rim of air
  • Large = >2cm rim of air

Note - size measured at hilar level not apex

62
Q

What is the management of a primary spontaneous pneumothorax (PSP)?

A
  • 1st line = if the rim of air is < 2cm and the patient is not short of breath then discharge otherwise aspiration should be attempted
  • 2nd line = if this fails (still > 2 cm or still short of breath) then a chest drain should be inserted

Patients should be advised to avoid smoking to reduce the risk of further episodes

63
Q

What is the management of a secondary spontaneous pnuemothorax (SSP)?

A
  • 1st line = if aged > 50 & size > 2cm &/or the patient is SOB then insert a chest drain
  • 1st line = otherwise aspiration should be attempted if the rim of air is between 1-2cm.
  • 1st line = if the pneumothorax

2nd line = If aspiration fails (i.e. pneumothorax is still greater then 1cm) insert chest drain

64
Q

When should surgery be considered for someone with a spontaneous pneumothorax ?

A

Indications:

  • Second ipsilateral pneumothorax
  • First contralateral pneumothorax
  • Synchronous bilateral spontaneous pneumothorax
  • Persistent air leak (despite 5e7 days of chest tube drainage) or failure of lung re-expansion.
  • Spontaneous haemothorax.
  • Professions at risk (eg, pilots, divers).
  • Pregnancy.
65
Q

What should be given to someone with a spontaneous pneumothorax regardless of the treatment ?

A

Oxygen

66
Q

What follow-up should be given to someone who has had a pneumothorax ?

A
  • CXR until resolution
  • Discuss flying and diving after pneumothorax
  • Risk of recurrence
  • Smoking cessation
67
Q

If you suspect a tension pnuemothorax should you wait to get a CXR to confirm or treat immediately ?

A

Treat immediately

68
Q

What is the management of a tension pnuemothorax?

A
  • 1st line = oxygen + needle decompression with large bore (14-16G) needle with a syringe (usually a venflon)
  • 2nd line = then insert a chest drain
69
Q

What is the site for needle decompression of a pnuemothorax?

A

2nd intercostal space anteriorly midclavicular line

70
Q

What is the site for chest drainage of a pnuemothorax?

A

4th-6th intercostal space anterior-midaxillary line i.e. ‘the safe triangle’

Y4 Respiratory (27 decks)

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