Pleural Disease - CHANGES NEEDED FOR PNEUMOTHORAX

Question 1

Give exampels of pleural diseases.

Answer 1

Pneumothorax

Pleural effusion

Empyema

Pleural tumours

Pleural plaques

Pleural thickening

Question 2

What is a pleural effusion?

Answer 2

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.

Question 3

Symptoms of pleural effusion.

Answer 3

Asymptomatic

Dyspnoea

Pleuritic chest pain

Question 4

Physical signs of pleural effusion on chest examination.

Answer 4

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.

Question 5

Investigations to do in pleural effusion.

Answer 5

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

Question 6

Other signs of pleural effusion.

Answer 6

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

Question 7

CXR findings of pleural effusion.

Answer 7

Small effusions with blunt costophrenic angles.

Large are seen as water-dense shadows with concave upper borders.

Meniscus

Fluid within horizontal or oblique fissures.

Question 8

What is the diagnostic test of pleural effusion?

Answer 8

Ultrasound guided pleural aspiration.

Question 9

What is the aspirated fluid checked for?

Answer 9

Biochemistry - protein, pH and LDH

Cytology

Microbiology including AAFB

Question 10

What types of pleural effusions are there?

Answer 10

Transudate

Exudate

Question 11

Explain diagnostic aspiration procedure.

Answer 11

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.

Question 12

If the pleural fluid analysis is inconclusive, what can be done?

Answer 12

Consider a parietal pleural biopsy.

Thoracoscopic or CT guided pleural biopsy increases diagnostic yield.

Question 13

When can an exudate effusion be established?

Answer 13

When the pleural protein > 30 g/L (some sources say > 35 g/L)

Question 14

When can a transudate effusion be established?

Answer 14

When pleural fluid protein is < 30 g/L.

Some sources say < 25 g/L

Question 15

When should Light’s criteria be assessed?

Answer 15

When pleural fluid protein level is between 25 to 35 g/L i.e. borderline.

Question 16

Explain Light’s criteria.

Answer 16

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

Question 17

Causes of transudate effusion.

Answer 17

Heart failure

Cirrhosis

Hypoalbuminaemia (nephrotic/peritoneal dialysis)

Hypothyroidism

Mitral stenosis

Pulmonary embolism (important to exclude)

Constrictive pericarditis

SVCO

Meig’s syndrome

Question 18

Causes of exudative effusion.

Answer 18

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

Question 19

Management of pleural effusion.

Answer 19

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

Question 20

What suggests an empyema?

Answer 20

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

Question 21

Types of pneumothorax.

Answer 21

Spontaneous - primary or secondary

Traumatic

Tension pneumothorax

Iatrogenic

Question 22

Cause of primary spontaneous pneumothorax.

Answer 22

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.

Question 23

Causes of secondary pneumothorax.

Answer 23

COPD

Infection - TB, pneumonia, lung abscess

CF

Lung fibrosis

Sarcoidosis

Malignancy

Question 24

Connective tissue disorders that can cause pneumothorax.

Answer 24

Marfan’s syndrome

Ehlers-Danlos syndrome

Question 25

Risk factors of pneumothorax

Answer 25

Pre-existing lung disease

Height

Smoking/Cannabis

Diving

Trauma/Chest procedure

Question 26

Clinical features of pneumothorax

Answer 26

Sudden onset of pleuritic chest pain and dyspnoea.

In tension pneumothorax they may become shocked as well.

Question 27

Signs of pneumothorax.

Answer 27

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.

Question 28

Investigations of pneumothorax.

Answer 28

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.

Question 29

Management of pneumothorax.

Answer 29

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.

Question 30

Management of simple secondary pneumothorax.

Answer 30

Same as single primary but the threshold for intercostal drainage is lowered.

Question 31

Management of tension pneumothorax.

Answer 31

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.

Question 32

Advice to patients after a pneumothorax.

Answer 32

No flying for 1 week

No diving until resolved

Smoking cessation

30-50% chance of recurrence

As a future management surgery can be considered.

Question 33

Where do you put a chest drain in pneumothorax?

Answer 33

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.

Question 34

How do you assess the size of a pneumothorax?

Answer 34

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.

Question 35

Spontaneous pneumothorax algorithm

Answer 35

Question 36

Where is aspiration done in spontaneous pneumothorax?

Answer 36

2nd intercostal mid clavicular line