Pleural Disease Flashcards
What are the pleura?
Single layers of mesothelial cells and subpleural connective tissue
What are the two layers of the pleura?
Visceral
Parietal
What lies between the two layers of the pleura?
Pleural cavity
What does the pleural cavity contain?
2-3ml of pleural fluid
What is a pleural effusion?
Abnormal collection of fluid in the pleural cavity
What are clinical features of pleural effusion?
SoB, non-productive cough or chest pain (pleuritic)
Dry cough (esp if rapid accumulation)
Wt loss, fever, malaise, night sweats
Classic Ex findings - dullness to percussion, reduced breath sounds, reduced chest expansion
Trachea may be away from large effusion
How are the causes of pleural effusion categorised?
Transudate (<30g/L protein)
Exudate (>30g/L protein)
What are exudative causes of pleural effusion due to?
Inflammation –> protein leaking out of the tissue into the pleural space
What are exudative causes of pleural effusion?
Infection - pneumonia most common cause, TB, subphrenic abscess
Connective tissue dx - RA, SLE
Neoplasia: lung cancer, mesothelioma, mets
Pancreatitis
PE
Dressler’s syndrome
Yellow nail syndrome
What are transudative causes of pleural effusions due to?
Fluid moving across into the lungs
What are transudative causes of pleural effusions?
Heart failure (most common)
Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
Hypothyroidism
Meig’s syndrome
What investigations should be done in suspected pleural effusion?
PA CXR
US recommended
Contrast CT to investigate underlying cause
Pleural aspiration
What needle and syringe should be used to perform a pleural aspiration?
21G needle, 50ml syringe
What fluid from pleural aspiration be sent for?
pH Protein Lactate dehydrogenase (LDH) Cytology (check for malignancy) Microbiology (MCS)
What is Light’s criteria?
Criteria used to distinguish between transudates and exudates if protein level between 25-35g/L
An exudate is more likely if 1+ of the following are met:
Pleural fluid protein divided by serum protein >0.5
Pleural fluid LDH divided by serum LDH >0.6
Pleural fluid LDH more than 2/3rds the upper limits of normal serum LDH
When is low glucose in pleural effusion commonly see?
RA, TB
When is raised amylase in pleural effusion usually seen?
Pancreatitis, oesophageal peforation
When is heavy blood staining in pleural effusion usually seen?
Mesothelioma, PE, TB
What are treatment options for recurrent pleural effusion?
Recurrent aspiration
Pleurodesis
Indwelling pleural catheter
Drug management to alleviate symptoms, e.g. opiates to relieve dyspnoea
All patients with a pleural effusion in association with sepsis/pneumonic illness require what?
Diagnostic pleural fluid sampling
Fluid purulent/cloudy or pH <7.2 insert chest tube
What are complications of pleural aspiration?
Pneumothorax Empyema Pulmonary oedema Vagal reflex Air embolism Tumour cell seeding Haemothorax
Pleural fluid should be drained no faster than what?
500mls/min
After a lung has reexpanded following chest drainage what should be done?
Chemical pleurodesis
What is used for pleurodesis?
Talc
What is a pneumothorax?
Presence of air in the pleural cavity (breach of visceral/parietal pleura) –> lung collapse away from chest wall
What are RFs for pneumothorax?
Pre-existing lung dx - COPD, asthma, CF, lung cancer, PJP
Connective tissue dx - Marfans, RA
Ventilation (incl. NIV)
Catamenial pneumothorax (endometriosis within thorax)
What are features of pneumothorax?
Sudden onset - SoB Chest pain (often pleuritic) Sweating Tachypnoea Tachycardia Trachea may deviate to affected side Hyperresonance, decreased chest expansion and decreased breath noises on affected side
What are the types of pneumothoraces?
Spontaneous (primary/secondary)
Traumatic (iatrogenic/non-iatrogenic)
What is a tension pneumothorax?
A medical emergency occurring when intrapleural pressure exceeds atmospheric pressure due to a valve mechanism that promotes inspiratory accumulation of pleural gasses
Build up of pressure –> hypoxaemia and resp failure due to lung compression
How can thoracic trauma lead to a tension pneumothorax?
When a lung parenchymal flap is created
What are clinical signs of tension pneumothorax?
Trachea shifts away from affected side
Hyperexpanded chest
Hyperresonance on affected side
How is tension pneumothorax treated?
Needle decompression
Chest tube insertion
Who most commonly gets a spontaneous primary pneumothorax?
Young (20-30yos) who are tall and thin
Thought to be due to weight of lung inducing development of apical blebs that rupture
What kind of trauma may cause a traumatic pneumothorax?
Penetrating chest injury and blunt chest injury, e.g. rib fracture
What may cause iatrogenic pneumothorax?
Pleural aspiration/biopsy
Subclavian v cannulation
Lung, liver, breast biopsy
Acupuncture
How might small pneumothoraces with no SoB be managed?
Conservatively, observe over night and repeat CXR (if no change, the hole is sealed and they can go home)
Advise to avoid vigorous activity and return in 2 weeks for CXR
What is the criteria for a patient with primary pneumothorax being discharged?
Rim of air <2cm + no SoB
What is the management of primary pneumothorax >2cm?
Aspirate If failed (still >2cm or SoB) insert chest drain
What advise should be given to those after primary pneumothorax to reduce their risk of it happening again?
Avoid smoking
How is secondary pneumothorax managed?
> 50y + rim of air >2cm/SoB –> insert chest drain
Aspirate if rim of air 1-2cm (if this fails –> insert chest drain)
If rim of air <1cm - give oxygen and admit for 24h
What is the advice re diving in someone who has had a pneumothorax?
Avoid diving unless bilateral surgical pleurectomy has been done + pt has normal lung function and chest CT scan post-op
How should iatrogenic pneumothoraces be managed?
Majority resolve with observation
If req treatment use aspiration
Where is the needle inserted in aspiration for pneumothorax?
2 ic space mid clav
Where should chest drains be inserted for pneumothorax?
4th ic space mid axillary line
How do you check if the chest drain can come out? I.e. the lung has reinflated in pneumothorax?
Drain stops bubbling
CXR will confirm
Reclamp for 24h and if no change/no change on CXR, remove drain (avoids reinsertion of chest drain)
Who should be referred for surgical pleurodesis?
Second ipsilateral pneumothorax
First contralateral pneumothorax
Bilateral spontaneous pneumothorax
First pneumothorax in high risk progressions, e.g. drivers, pilots etc.
What are the three types of asbestos?
Chrysotile (white)
Amosite (brown)
Cociodoite (blue)
When does disease due to asbestos present?
20-40 years post-exposure
What is mesothelioma?
Cancer of the mesothelial layer of the pleural cavity that is strongly associated with asbestos exposure
What are features of mesothelioma?
SoB, wt loss, chest wall pain
Clubbing
30% present as painless pleural effusion
Where does mesothelioma tend to metastasise to?
Contralateral lung and peritoneum
What raises suspicion of mesothelioma on CXR?
Pleural effusion or pleural thickening
After CXR what is the next step in suspected mesothelioma?
CT
Pleural effusion should be sent for MCS, biochem and cytology
LA thoracoscopy used to investigate cytology neative exudative effusions
If pleural nodularity seen on CT then image guided pleural biopsy may be used
How is mesothelioma managed?
Symptomatic
Chemo, surgery if operable
Poor prognosis
