Pleural Disease Flashcards
What does the visceral pleura cover?
The lungs and forms interlobar fissures
What does the parietal pleura cover?
Mediastinum, diaphragm and inner surface of the thorax
Pleural effusion - what is it?
Abnormal collection of fluid in the pleural space
Which pleural effusions should raise concern?
Large unilateral pleural effusions
Pleural fluid appearance and what it indicates:
- Straw-coloured
- Bloody
- Turbid/milky
- Foul smelling
- Food particles
- Straw coloured = cardiac failure, hypoalbuminaemia
- Bloody = trauma, malignancy, infection, infarction
- Turbid/milky = empyema, chylothorax
- Foul smelling = anaerobic empyema
- Food particles = oesophageal rupture
What may a bilateral pleural effusion be caused by?
Left ventricular failure, pulmonary thromboendarterectomy, drugs, systemic path
Signs and symptoms of a pleural effusion (including clinical examination findings)
- Can be asymptomatic (esp small pleural effusions)
- May present with dyspnoea
- Pleuritic chest pain
- Decreased expansion
- Stony dull percussion
- Diminished breath sounds on affected side
- May be bronchial breathing above the effusion
- Trachea may be deviated away if effusion is large
Transudate pleural effusion:
- Protein
- Causes
- Benign or pathological
- <30g/L protein
- Heart failure, liver cirrhosis, hypoalbuminaemia, atelectasis, peritoneal dialysis
- Does not always have a benign aetiology but not always pathological
Exudate pleural effusion:
- Protein
- Causes
- Benign or pathological
- > 30g/L protein
- Malignancy, infection (including TB), pulmonary infarct, asbestos
- Always look for serious pathology
pH in pleural effusion - what do differences in pH mean?
<7.3 suggests pleural inflammation (malignancy, rheumatoid arthritis)
<7.2 requires drainage in the setting of infection
Glucose in pleural effusion:
- When is it low?
Glucose is low in infection, TB, rheumatoid arthritis, malignancy, oesophageal rupture, systemic lupus erythematosus
What may the presence of lymphocytes in a pleural effusion indicate?
TB or malignancy - although any long-standing effusion will become lymphocytic
What does the presence of neutrophils in pleural effusion indicate?
An acute process
Investigations for diagnosis of pleural effusion
- History and examination
- CXR
- Ultrasound
- Diagnostic aspiration
- Pleural biopsy
What may a chest x-ray show in a pleural effusion?
Small effusions can show blunt costophrenic angles
Large effusions are shown as water-dense shadows with concave upper borders
What may an ultrasound show in a pleural effusion?
It will indicate the presence of pleural fluid
Process of diagnostic aspiration for pleural effusion
- Percuss upper border of effusion and choose an intercostal space 1 or 2 below it
- Infiltrate down to the pleura with 5-10ml of lidocaine
- Attach 21G needle to syringe and insert it just above the upper border of the appropriate rib
- Draw 10-30ml of pleural fluid and send it to the lab for clinical chemistry, bacteriology, cytology, and if indicated, immunology
Management options for pleural effusion
- Drainage (if symptomatic)
- Pleurodesis
- Intra-pleural alteplase and and dornase alfa may help with empyema
Treatment options for malignant pleural effusion
- Do nothing and palliate symptoms
- Repeat pleural taps
- Drain and/or pleurodesis
- Long term pleural catheters
- Surgical options
- TALC - sclerosing agent
Complications of TALC - treatment of malignant pleural effusion
- Minor pleuritic pain and fever
- Pneumonia
- Respiratory failure
- Talc pneumonitis
- Secondary empyema
Mesothelioma - what is it?
An uncommon tumour of the lining of the lung or very occasionally of the lining of the abdominal cavity
Main risk factor for mesothelioma
Asbestos exposure. Likelihood increases with degree and length of time exposed to asbestos. Occasionally can occur in people who have not worked with asbestos but have been associated with those who have
Signs and symptoms of mesothelioma
Chest pain, dyspnoea, weight loss, fever, sweating and cough
Types of asbestos
Chrysotile - “white asbestos” - most common
Amosite - “brown asbestos”
Crocidolite - most dangerous
