Pleural Disease Flashcards
What are the 2 types of pleura found in the lung and what structures do they cover?
visceral pleura
- covers lungs and forms fissures
parietal pleura
- covers mediastinum, diaphragm, inner surface of thorax
The most inferior part of the pleura extends down to below the inferior lung border. TRUE/FALSE?
TRUE
How much fluid is usually found in the pleural cavity?
4mls
need >200mls for it to be detected on a CXR
How does the inferior part of the pleura (which extends beyond the lung) attach to the diaphragm?
- pleural layers combine to form the pulmonary ligament
- this attaches the root of the lung to the diaphragm.
What is a pleural effusion?
Abnormal collection of fluid in pleural space
Pleural effusions do not always need drained. TRUE/FALSE?
TRUE
- e.g. in cardiac failure this may be the new “normal” for the patient
When should a pleural effusion raise concern?
Large unilateral collection of fluid
How can a pleural effusion be investigated?
- PA CXR
- Pleural aspirate
- Biochemistry (is it a transudate or an exudate?)
- Cytology and culture
Bilateral pleural effusions point towards what diagnoses?
Bilateral – LVF, PTE, drugs, systemic path
The colour of a pleural effusion can point towards a diagnosis. Give examples of this.
Straw-coloured => cardiac failure, hypoalbuminaemia
Bloody => trauma, malignancy, infection, infarction
Turbid/Milky => empyema
Foul smelling => Anaerobic empyema
Food particles => oesophageal rupture
What is the difference between a transudate and exudate pleural effusion?
Transudate - Protein <30g/L
Exudate - Protein >30g/L (should point towards more serious pathology)
What are the main causes of a transudate pleural effusion?
- Heart failure
- Liver cirrhosis
- Hypoalbuminaemia
- Lung Collapse (ITU or post surgery)
- Peritoneal dialysis
CAUSES AREN’T ALWAYS BENIGN
What are the main causes of an exudate pleural effusion?
- Malignancy
- Infection inc TB
- Pulmonary infarct
- Asbestos
Why is checking the pH of pleural fluid useful?
- Normal 7.6
- <7.3 suggests pleural inflammation (malignancy/ RhA)
- < 7.2 NEEDS DRAINED (if infection suspected)
- Do not check pH if frank pus! **
What is the relevance of measuring glucose in pleural fluid?
- LOW in many cases (being used up by organism/ tumour)
- infection/TB
- rheumatoid arthritis/SLE
- malignancy
- oesophageal rupture
Often pleural protein is not expressed as an amount, instead it is compared to serum protein. Over what ratio would pleural protein be considered abnormal?
Pleural protein: serum protein ratio >0.5
What other component of pleural fluid is compared to the level in serum to differentiate between transudate/exudate?
LDH
if Pleural LDH: Serum LDH ratio > 0.6
=> exudate
How can cytology on pleural fluid aid diagnosis?
- Malignant cells present indicating cancer?
- Lymphocytes present?– TB, malignancy, or just longstanding effusion
- Neutrophils = acute process
Why is thoracocentesis often repeated?
- Pleural aspiration diagnoses malignancy in 60% with malignant pleural effusion
- 2nd sample increases yield slightly,
- No further samples increase yield
It is difficult to diagnose mesothelioma from pleural fluid aspiration. TRUE/FALSE?
TRUE
- positive result obtained < 1/3 of cases.
How can a malignant lung tumour cause a pleural effusion through “systemic” means?
- Pulmonary embolism
- hypoalbuminaemia
How can a malignant lung tumour cause a pleural effusion locally?
- postobstructive infection
- ymphatic obstruction
- atelectasis (collapsed lung)
What type of biopsy is taken to aid diagnostic sensitivity when looking for pleural disease?
Image (CT) guided cutting needle pleural biopsy
increases diagnostic sensitivity to 87%
What is mesothelioma?
- malignant tumour of the lining of the lung
- occasionally of the lining of the abdominal cavity
- takes 30–40 years to develop
- associated with asbestos exposure => patients can gain compensation
Only those who have come into contact with asbestos can get mesothelioma. TRUE/FALSE?
FALSE
- More at risk with increased asbestos exposure
- Occasionally occurs in people who have not worked with asbestos but have been associated with people who have.
What are the main symptoms of mesothelioma?
- breathlessness
- chest pain
- weight loss
- fever
- sweating
- cough
What are the various types of asbestos and which of these is the most dangerous?
Chrysotile ( WHITE - most common)
Amosite (BROWN)
Crocidolite (BLUE - most dangerous)
How does mesothelioma appear on imaging?
- Pleural nodules
- Pleural thickening
- Local invasion
- Lung entrapment
Mesothelioma does not produce a good volume of fluid aspiration and repeat aspiration should be avoided. TRUE/FALSE?
TRUE
How is mesothelioma treated if it is diagnosed?
Pleurodesis - used to remove pleural effusions Radiotherapy Surgery Chemotherapy Palliative care Report deaths to Procurator fiscal
What other types of cancer can metastasise to the pleura?
COMMON
- lung
- breast
OTHERS
- Upper GI
- lymphoma
- melanoma
- ovary
How long do patient’s survive on average after a cancer metastasises to the pleura?
Median survival 3-12 months
How is pleurodesis (using TALC) carried out to prevent effusions returning?
- fluid removed
- seals space between tissues by using sterile talc
- makes them inflamed so they stick together
=> no space for the fluid to collect
What is a common complication of pleurodesis with TALC?
Minor pleuritic pain and fever
What long term solution can be used to prevent pleural effusions building up?
Long term Pleural catheter
- Vacuum in drainage bottle provides suction to drain pleural fluid
- Initially people drain daily for 1 week
- Eventually drain 2-3 times a week
- Never drain > 1 litre a day
What are the main complications of Long term pleural catheters?
- incorrect placement
- bleeding
- infection
What are some advantages and disadvantages of long term pleural catheters?
- Patients can shower with catheter in
- Flying can be tricky
How is prognosis calculated when a patient has a malignant pleural effusion?
LENT SCORE:
- LDH
- ECOG PS (patients ability to withstand therapies/ procedures)
- Neutrophil to lymphocyte ratio (serum)
- Tumour type
LOW risk 0-1
MOD risk 2-4
HIGH risk 5-7
How are bilateral pleural effusions due to heart failure treated?
- diuretics
How are infected pleural effusions treated?
- drain
- antibiotics
- may require surgery
A pneumothorax is more common in what type of patients?
- Tall thin men
- Smokers (esp. Cannabis)
- Underlying lung disease
- connective tissue diseases (Marfan’s, Ehler’s Danlos)
Describe the difference between a Primary and Secondary Pneumothroax
Primary
- Normal lungs
- Apical bullae rupture
- Patients may be asymptomatic even if moderately sized
Secondary
- Due to underlying lung disease (e.g. COPD)
- Patients usually symptomatic even if air leak is small
Patients who have a pneumothorax present with what symptoms and signs?
- Acute onset pleuritic chest pain
- SOB
- Hypoxia
Signs:
- increased HR
- Hyper-resonant percussion note
- Reduced expansion
- Quiet breath sounds on auscultation
What is used to investigate and measure a pneumothorax?
CXR
- <2cm = small pneumothorax
- > 2cm = large pneumothorax
- *measured from hilum not apex**
How is a pneumothroax treated?
- O2 even if no drain
- No Tx if asymptomatic and small
IF PRIMARY
- Aspiration 1st line
- Avoid chest drain (Time consuming)
May fail esp if age >50 or SECONDARY
=> Chest drain
=> May need suction (air leak >48 hours)
=> Surgical intervention
When is surgical intervention recommended for pneumothorax?
- 2nd ipsilateral ptx
- 1st contralateral ptx
- Bilateral spontaneous ptx
- Persistent air leak
- Risk professions (pilots, divers) after 1st ptx
How should patients with a pneumothorax be followed up?
- CXR until resolution
- Discuss flying and diving after pneumothorax
- Risk of recurrence
- Smoking cessation
How do patients present with a tension pneumothorax?
- Acute respiratory distress Signs: - Trachea deviated to opposite side - Hypotension - Raised JVP - Reduced air entry on affected side
Who is at risk of a tension pneumothorax?
- Ventilated patient (invasive or not)
- Trauma
- CPR
- Blocked/kinked/misplaced drain
- Pre existing airways disease
- Patients undergoing hyperbaric treatment (O2)
How is a tension pneumothorax treated?
- Needle decompression
- Large Bore 14G
- 2nd intercostal space, mid-clavicular line
Pleural infections always follow a penumonia. TRUE/FALSE?
FALSE
- Does not necessarily follow pneumonia
- Can rapidly coagulate to form fibrous peels even with antibiotics
=> DON’T IGNORE IT
What risk factors can make a pleural infection more likely?
- diabetes mellitus
- immunosuppression (inc. steroids)
- GORD
- alcohol misuse
- intravenous drug abuse
What are the different types of pleural infection?
- Simple parapneumonic effusion
- Complicated parapneumonic effusion
- Empyema
Which type of pleural infection requires urgent tube drainage?
parapneumonic effusions require urgent tube drainage
=> sample pleural fluid quickly!
Describe the features of a complicated pleural effusion
+ve G stain
pH <7.2
low glucose
septations + loculations.
Describe the difference in treatment between a simple and a large pleural effusion due to infection
V small (<1cm) effusions may be left untapped
Simple effusion = treated with antibiotics but may need drainage later on if things change
Large effusion = chest drainage
Other than antibiotics and drainage, what should be considered in management of an infected pleural effusion?
- Early discussion with surgeons if persistent sepsis
- Nutrition
- VTE prophylaxis
