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RESPIRATORY > Pleural Disease > Flashcards

Pleural Disease Flashcards

1
Q

What are the 2 types of pleura found in the lung and what structures do they cover?

A

visceral pleura
- covers lungs and forms fissures

parietal pleura
- covers mediastinum, diaphragm, inner surface of thorax

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2
Q

The most inferior part of the pleura extends down to below the inferior lung border. TRUE/FALSE?

A

TRUE

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3
Q

How much fluid is usually found in the pleural cavity?

A

4mls

need >200mls for it to be detected on a CXR

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4
Q

How does the inferior part of the pleura (which extends beyond the lung) attach to the diaphragm?

A
  • pleural layers combine to form the pulmonary ligament

- this attaches the root of the lung to the diaphragm.

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5
Q

What is a pleural effusion?

A

Abnormal collection of fluid in pleural space

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6
Q

Pleural effusions do not always need drained. TRUE/FALSE?

A

TRUE

- e.g. in cardiac failure this may be the new “normal” for the patient

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7
Q

When should a pleural effusion raise concern?

A

Large unilateral collection of fluid

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8
Q

How can a pleural effusion be investigated?

A
  • PA CXR
  • Pleural aspirate
  • Biochemistry (is it a transudate or an exudate?)
  • Cytology and culture
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9
Q

Bilateral pleural effusions point towards what diagnoses?

A

Bilateral – LVF, PTE, drugs, systemic path

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10
Q

The colour of a pleural effusion can point towards a diagnosis. Give examples of this.

A

Straw-coloured => cardiac failure, hypoalbuminaemia
Bloody => trauma, malignancy, infection, infarction
Turbid/Milky => empyema
Foul smelling => Anaerobic empyema
Food particles => oesophageal rupture

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11
Q

What is the difference between a transudate and exudate pleural effusion?

A

Transudate - Protein <30g/L

Exudate - Protein >30g/L (should point towards more serious pathology)

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12
Q

What are the main causes of a transudate pleural effusion?

A
  • Heart failure
  • Liver cirrhosis
  • Hypoalbuminaemia
  • Lung Collapse (ITU or post surgery)
  • Peritoneal dialysis

CAUSES AREN’T ALWAYS BENIGN

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13
Q

What are the main causes of an exudate pleural effusion?

A
  • Malignancy
  • Infection inc TB
  • Pulmonary infarct
  • Asbestos
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14
Q

Why is checking the pH of pleural fluid useful?

A
  • Normal 7.6
  • <7.3 suggests pleural inflammation (malignancy/ RhA)
  • < 7.2 NEEDS DRAINED (if infection suspected)
    • Do not check pH if frank pus! **
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15
Q

What is the relevance of measuring glucose in pleural fluid?

A
  • LOW in many cases (being used up by organism/ tumour)
  • infection/TB
  • rheumatoid arthritis/SLE
  • malignancy
  • oesophageal rupture
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16
Q

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?

A

Pleural protein: serum protein ratio >0.5

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17
Q

What other component of pleural fluid is compared to the level in serum to differentiate between transudate/exudate?

A

LDH
if Pleural LDH: Serum LDH ratio > 0.6
=> exudate

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18
Q

How can cytology on pleural fluid aid diagnosis?

A
  • Malignant cells present indicating cancer?
  • Lymphocytes present?– TB, malignancy, or just longstanding effusion
  • Neutrophils = acute process
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19
Q

Why is thoracocentesis often repeated?

A
  • Pleural aspiration diagnoses malignancy in 60% with malignant pleural effusion
  • 2nd sample increases yield slightly,
  • No further samples increase yield
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20
Q

It is difficult to diagnose mesothelioma from pleural fluid aspiration. TRUE/FALSE?

A

TRUE

- positive result obtained < 1/3 of cases.

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21
Q

How can a malignant lung tumour cause a pleural effusion through “systemic” means?

A
  • Pulmonary embolism

- hypoalbuminaemia

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22
Q

How can a malignant lung tumour cause a pleural effusion locally?

A
  • postobstructive infection
  • ymphatic obstruction
  • atelectasis (collapsed lung)
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23
Q

What type of biopsy is taken to aid diagnostic sensitivity when looking for pleural disease?

A

Image (CT) guided cutting needle pleural biopsy

increases diagnostic sensitivity to 87%

24
Q

What is mesothelioma?

A
  • 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
25
Q

Only those who have come into contact with asbestos can get mesothelioma. TRUE/FALSE?

A

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.
26
Q

What are the main symptoms of mesothelioma?

A
  • breathlessness
  • chest pain
  • weight loss
  • fever
  • sweating
  • cough
27
Q

What are the various types of asbestos and which of these is the most dangerous?

A

Chrysotile ( WHITE - most common)
Amosite (BROWN)
Crocidolite (BLUE - most dangerous)

28
Q

How does mesothelioma appear on imaging?

A
  • Pleural nodules
  • Pleural thickening
  • Local invasion
  • Lung entrapment
29
Q

Mesothelioma does not produce a good volume of fluid aspiration and repeat aspiration should be avoided. TRUE/FALSE?

A

TRUE

30
Q

How is mesothelioma treated if it is diagnosed?

A 
Pleurodesis - used to remove pleural effusions
Radiotherapy
Surgery
Chemotherapy
Palliative care
Report deaths to Procurator fiscal
31
Q

What other types of cancer can metastasise to the pleura?

A

COMMON

  • lung
  • breast

OTHERS

  • Upper GI
  • lymphoma
  • melanoma
  • ovary
32
Q

How long do patient’s survive on average after a cancer metastasises to the pleura?

A

Median survival 3-12 months

33
Q

How is pleurodesis (using TALC) carried out to prevent effusions returning?

A
  • fluid removed
  • seals space between tissues by using sterile talc
  • makes them inflamed so they stick together
    => no space for the fluid to collect
34
Q

What is a common complication of pleurodesis with TALC?

A

Minor pleuritic pain and fever

35
Q

What long term solution can be used to prevent pleural effusions building up?

A

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
36
Q

What are the main complications of Long term pleural catheters?

A
  • incorrect placement
  • bleeding
  • infection
37
Q

What are some advantages and disadvantages of long term pleural catheters?

A
  • Patients can shower with catheter in

- Flying can be tricky

38
Q

How is prognosis calculated when a patient has a malignant pleural effusion?

A

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

39
Q

How are bilateral pleural effusions due to heart failure treated?

A
  • diuretics
40
Q

How are infected pleural effusions treated?

A
  • drain
  • antibiotics
  • may require surgery
41
Q

A pneumothorax is more common in what type of patients?

A
  • Tall thin men
  • Smokers (esp. Cannabis)
  • Underlying lung disease
  • connective tissue diseases (Marfan’s, Ehler’s Danlos)
42
Q

Describe the difference between a Primary and Secondary Pneumothroax

A

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
43
Q

Patients who have a pneumothorax present with what symptoms and signs?

A
  • Acute onset pleuritic chest pain
  • SOB
  • Hypoxia

Signs:

  • increased HR
  • Hyper-resonant percussion note
  • Reduced expansion
  • Quiet breath sounds on auscultation
44
Q

What is used to investigate and measure a pneumothorax?

A

CXR

  • <2cm = small pneumothorax
  • > 2cm = large pneumothorax
  • *measured from hilum not apex**
45
Q

How is a pneumothroax treated?

A
  • 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

46
Q

When is surgical intervention recommended for pneumothorax?

A
  • 2nd ipsilateral ptx
  • 1st contralateral ptx
  • Bilateral spontaneous ptx
  • Persistent air leak
  • Risk professions (pilots, divers) after 1st ptx
47
Q

How should patients with a pneumothorax be followed up?

A
  • CXR until resolution
  • Discuss flying and diving after pneumothorax
  • Risk of recurrence
  • Smoking cessation
48
Q

How do patients present with a tension pneumothorax?

A 
- Acute respiratory distress
Signs: 
- Trachea deviated to opposite side
- Hypotension
- Raised JVP
- Reduced air entry on affected side
49
Q

Who is at risk of a tension pneumothorax?

A
  • Ventilated patient (invasive or not)
  • Trauma
  • CPR
  • Blocked/kinked/misplaced drain
  • Pre existing airways disease
  • Patients undergoing hyperbaric treatment (O2)
50
Q

How is a tension pneumothorax treated?

A
  • Needle decompression
  • Large Bore 14G
  • 2nd intercostal space, mid-clavicular line
51
Q

Pleural infections always follow a penumonia. TRUE/FALSE?

A

FALSE
- Does not necessarily follow pneumonia
- Can rapidly coagulate to form fibrous peels even with antibiotics
=> DON’T IGNORE IT

52
Q

What risk factors can make a pleural infection more likely?

A
  • diabetes mellitus
  • immunosuppression (inc. steroids)
  • GORD
  • alcohol misuse
  • intravenous drug abuse
53
Q

What are the different types of pleural infection?

A
  • Simple parapneumonic effusion
  • Complicated parapneumonic effusion
  • Empyema
54
Q

Which type of pleural infection requires urgent tube drainage?

A

parapneumonic effusions require urgent tube drainage

=> sample pleural fluid quickly!

55
Q

Describe the features of a complicated pleural effusion

A

+ve G stain
pH <7.2
low glucose
septations + loculations.

56
Q

Describe the difference in treatment between a simple and a large pleural effusion due to infection

A

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

57
Q

Other than antibiotics and drainage, what should be considered in management of an infected pleural effusion?

A
  • Early discussion with surgeons if persistent sepsis
  • Nutrition
  • VTE prophylaxis

RESPIRATORY (9 decks)

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