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Medicine Respiratory > Pleural Disease > Flashcards

Pleural Disease Flashcards

1
Q

What does the visceral pleura cover?

A

The lungs and forms interlobar fissures

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2
Q

What does the parietal pleura cover?

A

Mediastinum, diaphragm and inner surface of the thorax

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3
Q

Pleural effusion - what is it?

A

Abnormal collection of fluid in the pleural space

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4
Q

Which pleural effusions should raise concern?

A

Large unilateral pleural effusions

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5
Q

Pleural fluid appearance and what it indicates:

  • Straw-coloured
  • Bloody
  • Turbid/milky
  • Foul smelling
  • Food particles
A
  • Straw coloured = cardiac failure, hypoalbuminaemia
  • Bloody = trauma, malignancy, infection, infarction
  • Turbid/milky = empyema, chylothorax
  • Foul smelling = anaerobic empyema
  • Food particles = oesophageal rupture
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6
Q

What may a bilateral pleural effusion be caused by?

A

Left ventricular failure, pulmonary thromboendarterectomy, drugs, systemic path

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7
Q

Signs and symptoms of a pleural effusion (including clinical examination findings)

A
  • 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
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8
Q

Transudate pleural effusion:

  • Protein
  • Causes
  • Benign or pathological
A
  • <30g/L protein
  • Heart failure, liver cirrhosis, hypoalbuminaemia, atelectasis, peritoneal dialysis
  • Does not always have a benign aetiology but not always pathological
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9
Q

Exudate pleural effusion:

  • Protein
  • Causes
  • Benign or pathological
A
  • > 30g/L protein
  • Malignancy, infection (including TB), pulmonary infarct, asbestos
  • Always look for serious pathology
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10
Q

pH in pleural effusion - what do differences in pH mean?

A

<7.3 suggests pleural inflammation (malignancy, rheumatoid arthritis)
<7.2 requires drainage in the setting of infection

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11
Q

Glucose in pleural effusion:

- When is it low?

A

Glucose is low in infection, TB, rheumatoid arthritis, malignancy, oesophageal rupture, systemic lupus erythematosus

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12
Q

What may the presence of lymphocytes in a pleural effusion indicate?

A

TB or malignancy - although any long-standing effusion will become lymphocytic

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13
Q

What does the presence of neutrophils in pleural effusion indicate?

A

An acute process

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14
Q

Investigations for diagnosis of pleural effusion

A
  • History and examination
  • CXR
  • Ultrasound
  • Diagnostic aspiration
  • Pleural biopsy
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15
Q

What may a chest x-ray show in a pleural effusion?

A

Small effusions can show blunt costophrenic angles

Large effusions are shown as water-dense shadows with concave upper borders

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16
Q

What may an ultrasound show in a pleural effusion?

A

It will indicate the presence of pleural fluid

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17
Q

Process of diagnostic aspiration for pleural effusion

A
  • 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
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18
Q

Management options for pleural effusion

A
  • Drainage (if symptomatic)
  • Pleurodesis
  • Intra-pleural alteplase and and dornase alfa may help with empyema
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19
Q

Treatment options for malignant pleural effusion

A
  • Do nothing and palliate symptoms
  • Repeat pleural taps
  • Drain and/or pleurodesis
  • Long term pleural catheters
  • Surgical options
  • TALC - sclerosing agent
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20
Q

Complications of TALC - treatment of malignant pleural effusion

A
  • Minor pleuritic pain and fever
  • Pneumonia
  • Respiratory failure
  • Talc pneumonitis
  • Secondary empyema
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21
Q

Mesothelioma - what is it?

A

An uncommon tumour of the lining of the lung or very occasionally of the lining of the abdominal cavity

22
Q

Main risk factor for mesothelioma

A

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

23
Q

Signs and symptoms of mesothelioma

A

Chest pain, dyspnoea, weight loss, fever, sweating and cough

24
Q

Types of asbestos

A

Chrysotile - “white asbestos” - most common
Amosite - “brown asbestos”
Crocidolite - most dangerous

25
Q

Investigations for mesothelioma

A

Imaging, pleural fluid aspiration, biopsy

26
Q

What does imaging show in mesothelioma?

A
  • Pleural nodularity
  • Circumferential pleural thickening
  • Local invasion
  • Lung entrapment
27
Q

Treatment for mesothelioma

A

Pleurodese effusions, radiotherapy, surgery, chemotherapy, palliative care

28
Q

Long term pleural catheters:

  • How often do they need drained?
  • Maximum fluid drainage per day
A
  • Every day for a week or so initially then two or three times a week
  • No more than 1L per day
29
Q

Complications of long term pleural catheters

A

Incorrect placement, bleeding, infection

30
Q

What is pneumothorax?

A

The presence of air or gas in the cavity between the lungs and the chest wall

31
Q

Risk factors for pneumothorax

A
  • Tall, thin men
  • Cannabis users
  • Smokers
  • Underlying lung disease
32
Q

Primary vs secondary pneumothorax

A

Primary - normal lungs, apical bullae rupture

Secondary - underlying lung disease (e.g. COPD)

33
Q

Symptoms of pneumothorax

A
  • Acute onset pleuritic chest pain
  • Shortness of breath
  • Hypoxia
34
Q

Signs of pneumothorax

A
  • Tachycardia
  • Hyper-resonant percussion note
  • Reduced chest expansion
  • Quiet breath sounds on auscultation
  • Hamman’s sign
35
Q

Hamman’s sign

A

‘Click’ on auscultation left side

36
Q

Investigations for pneumothorax

A

Chest x-ray - usually sufficient

CT scan of chest

37
Q

Small vs large pleural effusion size on chest x-ray

A

Small - <2cm rim of air on CXR

Large - >2cm rim of air on CXR

38
Q

Why may a CT scan of chest be useful in pneumothorax?

A

Useful to differentiate bullous lung disease or small pneumothoraces

39
Q

Management of pneumothorax

A
  • Oxygen
  • No treatment if asymptomatic and small
  • Aspiration 1st line in primary spontaneous pneumothorax
  • Chest drain
  • May need suction
  • Surgical intervention
40
Q

Indications for surgical intervention

A
  • Second ipsilateral pneumothorax
  • First contralateral pneumothorax
  • Persistent air leak
  • Risk professions after first pneumothorax
41
Q

Follow-up after pneumothorax

A
  • CXR until resolution
  • Discuss flying and diving after pneumothorax
  • Risk of recurrence
  • Smoking cessation
42
Q

Aspiration technique

A
  • Explain procedure and gain consent
  • Infiltrate 2% lidocaine down to pleura in 2nd intercostal space, mid-clavicular line
  • Push 3-4cm gauge cannula through pleura
  • Connect cannula to a three-way tap and 50ml syringe
  • Aspirate up to 2.5L of air. Stop if resistance to suction is felt or patient is coughing excessively
43
Q

Tension pneumothorax

A

Occurs when a one-way valve causes progressively increasing pressure in the pleural space and effectively pushes other chest organs to the opposite side of the affected side, as well as causing acute respiratory distress

44
Q

Signs and symptoms of tension pneumothorax

A

Symptoms - sudden onset of pleuritic chest pain, shortness of breath, hypoxia
Signs - trachea deviated to opposite side, hypotension, raised JVP, reduced air entry on affected side, hyper-resonant percussion note and reduced breath sounds on auscultation

45
Q

At risk patients for tension pneumothorax

A
  • Ventilated patients
  • Trauma
  • CPR
  • Blocked, kinked or misplaced drain
  • Pre-existing airway disease
  • Patients undergoing hyperbaric treatment
46
Q

Treatment for tension pneumothorax

A

Needle decompression:

  • usually with large bore venflon
  • second intercostal space anteriorly, mid-clavicular line
  • should hear a long hissssss
47
Q

Pleural infection

A

Infection in the pleural space, often associated with pleural effusion.
Can be simple parapneumonic effusion, complicated parapneumonic effusion or empyema

48
Q

Risk factors for pleural infection

A
  • Diabetes mellitus
  • Immunosuppression (incl. corticosteroids)
  • GORD
  • Alcohol misuse
  • PWID
49
Q

Empyema

A

Pus in pleural space

50
Q

Complicated effusion

A

+ve gram stain, pH <7.2, low glucose, septations, loculations

51
Q

Management of pleural infection

A
  • Antibiotics
  • Drain effusion as needed
  • Early discussion with surgeons if persistent sepsis
  • Nutrition
  • VTE prophylaxis

Medicine Respiratory (12 decks)

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