Pleural Disease - CHANGES NEEDED FOR PNEUMOTHORAX Flashcards
Give exampels of pleural diseases.
Pneumothorax
Pleural effusion
Empyema
Pleural tumours
Pleural plaques
Pleural thickening
What is a pleural effusion?
An excessive accumulation of fluid in the pleural space.
It can be detected on X-ray when 300 ml or more fluid is present.
Clinically it can be detected when there is 500 ml or more.
Symptoms of pleural effusion.
Asymptomatic
Dyspnoea
Pleuritic chest pain
Physical signs of pleural effusion on chest examination.
Reduced expansion
Reduced percussion appearing stony dull
Reduced air entry
Reduced vocal resonance
Trachea and mediastinum remains central unless there is a massive effusion > 1000 ml.
Investigations to do in pleural effusion.
CXR
Needle aspiration or chest drain for sample of pleural fluid
ECG
Bloods - FBC, U&Es, LFTs, CRP, Bone profile, LDH, Clotting
ECHO if there is a suspicion of heart failure
Staging CT with contrast if there is a suspicion of exudative cause
Other signs of pleural effusion.
Look for aspiration marks.
Signs of associated disease such as cachexia, clubbing, lymphadenopathy and radiation marks in malignancy.
Stigmata of liver disease
Cardiac failure
Hypothyoidism
RA
Malar rash in SLE
CXR findings of pleural effusion.
Small effusions with blunt costophrenic angles.
Large are seen as water-dense shadows with concave upper borders.
Meniscus
Fluid within horizontal or oblique fissures.
What is the diagnostic test of pleural effusion?
Ultrasound guided pleural aspiration.
What is the aspirated fluid checked for?
Biochemistry - protein, pH and LDH
Cytology
Microbiology including AAFB
What types of pleural effusions are there?
Transudate
Exudate
Explain diagnostic aspiration procedure.
Percuss upper border of the pleural effusion.
Choose a site 1 or 2 intercostal spaces below it.
5-10 ml of 1% lidocaine into pleura.
Attach a 21g needle to a syringe and insert it just above the upper border of an appropriate rib.
Draw off 10-30 ml of pleural fluid and send it to the lab for clinical chemistry, bacteriology and if indicated also immunology.
If the pleural fluid analysis is inconclusive, what can be done?
Consider a parietal pleural biopsy.
Thoracoscopic or CT guided pleural biopsy increases diagnostic yield.
When can an exudate effusion be established?
When the pleural protein > 30 g/L (some sources say > 35 g/L)
When can a transudate effusion be established?
When pleural fluid protein is < 30 g/L.
Some sources say < 25 g/L
When should Light’s criteria be assessed?
When pleural fluid protein level is between 25 to 35 g/L i.e. borderline.
Explain Light’s criteria.
It is an exudate effusion if one or more of the following;
Pleural fluid/Serum protein >0.5
Pleural fluid/Serum LDH >0.6
Pleural fluid LDH > 2/3 of the upper limit of normal
Causes of transudate effusion.
Heart failure
Cirrhosis
Hypoalbuminaemia (nephrotic/peritoneal dialysis)
Hypothyroidism
Mitral stenosis
Pulmonary embolism (important to exclude)
Constrictive pericarditis
SVCO
Meig’s syndrome
Causes of exudative effusion.
Malignancy
Infections - parapneumonic, TB, HIV (Kaposi’s sarcoma)
Inflammatory like RA, pancreatitis, benign asbestos effusion, Dressler’s, pulmonary infarction/embolus
Lymphatic disorders
Connective tissue disease
Yellow nail syndrome
Fungal infections
Drugs
Management of pleural effusion.
Drainage if the effusion is symptomatic - nevere insert a chest drain unless the diagnosis is well established and malignancy ruled out. This is because draining all fluid off may hinder the opportunity to obtain pleural biopsies. Only indication for an urgent chest drain insertion for a new effusion would be an underlying empyema.
Pleurodesis may be helpful in recurrent effusions.
Intrapleural alteplase and dornase alfa may help with empyema
Surgery
What suggests an empyema?
pH of pleural fluid < 7.2 or visible pus on aspiration
Turbid and yellow aspiration fluid.
Glucose < 3.3. mmol/L
LDH pleural:serum > 0.6
Types of pneumothorax.
Spontaneous - primary or secondary
Traumatic
Tension pneumothorax
Iatrogenic
Cause of primary spontaneous pneumothorax.
Occurs predominantly in young males.
Tall and thin young males.
By rupture of a pleural bleb, usually apical. Thought to be due to congenital defects in the connective tissue of the alveolar walls.
Causes of secondary pneumothorax.
COPD
Infection - TB, pneumonia, lung abscess
CF
Lung fibrosis
Sarcoidosis
Malignancy
Connective tissue disorders that can cause pneumothorax.
Marfan’s syndrome
Ehlers-Danlos syndrome
Risk factors of pneumothorax
Pre-existing lung disease
Height
Smoking/Cannabis
Diving
Trauma/Chest procedure
Clinical features of pneumothorax
Sudden onset of pleuritic chest pain and dyspnoea.
In tension pneumothorax they may become shocked as well.
Signs of pneumothorax.
Reduced expansion
Increased percussion
Reduced breath sounds
Trachea and mediastinal shift away from the affected side if tension pneumothorax.
Trachea and mediastinal shift towards affected side if simples pneumothorax.
Investigations of pneumothorax.
Erect CXR to assess size of pneumothorax.
If a tension pneumothorax is suspected a CXR should no be performed.
Check ABG in dyspnoeic/hypoxic patients and those with chronic lung disease.
Management of pneumothorax.
If no SOB and there is a < 2cm rim of air on the CXR then no treatment required as it will spontaneously resolve. Follow up in 2-4 weeks is recommended.
If SOB and/or there is a > 2cm rim of air on the chest xray then it will require aspiration and reassessment.
If aspiration fails twice it will require a chest drain.
Unstable patients or bilateral or secondary pneumothoraces generally require a chest drain.
If this is unsuccessful consider re-aspiration or intercostal drain with underwater seal. Remove drain after full re-expansion / cessation of air leak.
If the pneumothorax still remains -> surgery VATS such as pleurectomy or tacl pleurodesis.
Management of simple secondary pneumothorax.
Same as single primary but the threshold for intercostal drainage is lowered.
Management of tension pneumothorax.
Large bore 14-16g cannula with a syringe into the 2nd intercostal space in the midclavicular line of the suspected side of the pneumothorax.
This should be done before requesting a CXR and insert a chest drain afterwards.
Advice to patients after a pneumothorax.
No flying for 1 week
No diving until resolved
Smoking cessation
30-50% chance of recurrence
As a future management surgery can be considered.
Where do you put a chest drain in pneumothorax?
Chest drains are inserted into the “triangle of safety”. This triangle is formed by:
The 5th intercostal space (or the inferior nipple line)
The mid axillary line (or the lateral edge of the latissimus dorsi)
The anterior axillary line (or the lateral edge of the pectoris major)
The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib. Once the chest drain is inserted obtain a chest xray to check the positioning.
How do you assess the size of a pneumothorax?
Measuring the size of the pneumothorax on a chest xray can be done according to the BTS guidelines from 2010.
This involves measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum.
Spontaneous pneumothorax algorithm
Where is aspiration done in spontaneous pneumothorax?
2nd intercostal mid clavicular line
