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RESP - 1 > Pleural Disease > Flashcards

Pleural Disease Flashcards

1
Q

What are the pleura?

A

Single layers of mesothelial cells and subpleural connective tissue

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2
Q

What are the two layers of the pleura?

A

Visceral

Parietal

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3
Q

What lies between the two layers of the pleura?

A

Pleural cavity

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4
Q

What does the pleural cavity contain?

A

2-3ml of pleural fluid

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5
Q

What is a pleural effusion?

A

Abnormal collection of fluid in the pleural cavity

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6
Q

What are clinical features of pleural effusion?

A

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

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7
Q

How are the causes of pleural effusion categorised?

A

Transudate (<30g/L protein)

Exudate (>30g/L protein)

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8
Q

What are exudative causes of pleural effusion due to?

A

Inflammation –> protein leaking out of the tissue into the pleural space

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9
Q

What are exudative causes of pleural effusion?

A

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

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10
Q

What are transudative causes of pleural effusions due to?

A

Fluid moving across into the lungs

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11
Q

What are transudative causes of pleural effusions?

A

Heart failure (most common)
Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
Hypothyroidism
Meig’s syndrome

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12
Q

What investigations should be done in suspected pleural effusion?

A

PA CXR
US recommended
Contrast CT to investigate underlying cause
Pleural aspiration

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13
Q

What needle and syringe should be used to perform a pleural aspiration?

A

21G needle, 50ml syringe

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14
Q

What fluid from pleural aspiration be sent for?

A 
pH
Protein
Lactate dehydrogenase (LDH)
Cytology (check for malignancy)
Microbiology (MCS)
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15
Q

What is Light’s criteria?

A

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

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16
Q

When is low glucose in pleural effusion commonly see?

A

RA, TB

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17
Q

When is raised amylase in pleural effusion usually seen?

A

Pancreatitis, oesophageal peforation

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18
Q

When is heavy blood staining in pleural effusion usually seen?

A

Mesothelioma, PE, TB

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19
Q

What are treatment options for recurrent pleural effusion?

A

Recurrent aspiration
Pleurodesis
Indwelling pleural catheter
Drug management to alleviate symptoms, e.g. opiates to relieve dyspnoea

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20
Q

All patients with a pleural effusion in association with sepsis/pneumonic illness require what?

A

Diagnostic pleural fluid sampling

Fluid purulent/cloudy or pH <7.2 insert chest tube

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21
Q

What are complications of pleural aspiration?

A 
Pneumothorax
Empyema 
Pulmonary oedema
Vagal reflex
Air embolism
Tumour cell seeding
Haemothorax
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22
Q

Pleural fluid should be drained no faster than what?

A

500mls/min

23
Q

After a lung has reexpanded following chest drainage what should be done?

A

Chemical pleurodesis

24
Q

What is used for pleurodesis?

A

Talc

25
Q

What is a pneumothorax?

A

Presence of air in the pleural cavity (breach of visceral/parietal pleura) –> lung collapse away from chest wall

26
Q

What are RFs for pneumothorax?

A

Pre-existing lung dx - COPD, asthma, CF, lung cancer, PJP
Connective tissue dx - Marfans, RA
Ventilation (incl. NIV)
Catamenial pneumothorax (endometriosis within thorax)

27
Q

What are features of pneumothorax?

A 
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
28
Q

What are the types of pneumothoraces?

A

Spontaneous (primary/secondary)

Traumatic (iatrogenic/non-iatrogenic)

29
Q

What is a tension pneumothorax?

A

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

30
Q

How can thoracic trauma lead to a tension pneumothorax?

A

When a lung parenchymal flap is created

31
Q

What are clinical signs of tension pneumothorax?

A

Trachea shifts away from affected side
Hyperexpanded chest
Hyperresonance on affected side

32
Q

How is tension pneumothorax treated?

A

Needle decompression

Chest tube insertion

33
Q

Who most commonly gets a spontaneous primary pneumothorax?

A

Young (20-30yos) who are tall and thin

Thought to be due to weight of lung inducing development of apical blebs that rupture

34
Q

What kind of trauma may cause a traumatic pneumothorax?

A

Penetrating chest injury and blunt chest injury, e.g. rib fracture

35
Q

What may cause iatrogenic pneumothorax?

A

Pleural aspiration/biopsy
Subclavian v cannulation
Lung, liver, breast biopsy
Acupuncture

36
Q

How might small pneumothoraces with no SoB be managed?

A

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

37
Q

What is the criteria for a patient with primary pneumothorax being discharged?

A

Rim of air <2cm + no SoB

38
Q

What is the management of primary pneumothorax >2cm?

A 
Aspirate
If failed (still >2cm or SoB) insert chest drain
39
Q

What advise should be given to those after primary pneumothorax to reduce their risk of it happening again?

A

Avoid smoking

40
Q

How is secondary pneumothorax managed?

A

> 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

41
Q

What is the advice re diving in someone who has had a pneumothorax?

A

Avoid diving unless bilateral surgical pleurectomy has been done + pt has normal lung function and chest CT scan post-op

42
Q

How should iatrogenic pneumothoraces be managed?

A

Majority resolve with observation

If req treatment use aspiration

43
Q

Where is the needle inserted in aspiration for pneumothorax?

A

2 ic space mid clav

44
Q

Where should chest drains be inserted for pneumothorax?

A

4th ic space mid axillary line

45
Q

How do you check if the chest drain can come out? I.e. the lung has reinflated in pneumothorax?

A

Drain stops bubbling
CXR will confirm

Reclamp for 24h and if no change/no change on CXR, remove drain (avoids reinsertion of chest drain)

46
Q

Who should be referred for surgical pleurodesis?

A

Second ipsilateral pneumothorax
First contralateral pneumothorax
Bilateral spontaneous pneumothorax
First pneumothorax in high risk progressions, e.g. drivers, pilots etc.

47
Q

What are the three types of asbestos?

A

Chrysotile (white)
Amosite (brown)
Cociodoite (blue)

48
Q

When does disease due to asbestos present?

A

20-40 years post-exposure

49
Q

What is mesothelioma?

A

Cancer of the mesothelial layer of the pleural cavity that is strongly associated with asbestos exposure

50
Q

What are features of mesothelioma?

A

SoB, wt loss, chest wall pain
Clubbing
30% present as painless pleural effusion

51
Q

Where does mesothelioma tend to metastasise to?

A

Contralateral lung and peritoneum

52
Q

What raises suspicion of mesothelioma on CXR?

A

Pleural effusion or pleural thickening

53
Q

After CXR what is the next step in suspected mesothelioma?

A

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

54
Q

How is mesothelioma managed?

A

Symptomatic
Chemo, surgery if operable
Poor prognosis

RESP - 1 (27 decks)

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