Pleural Disease COPY Flashcards
What is pleura composed of?
- Single layer of mesothelial cells
- Sub-pleural connective tissue
What is found between the visceral and parietal pleura?
- The pleural cavity
- Lubricated by 2-3ml of pleural fluid which has a 30-75% turnover per hour
What pressure moves fluid from the chest wall to the pleural cavity?
Systemic arterial pressure (4kPa), negative intra pleural pressure
What pressure moves fluid from the pleural cavity to the chest wall?
Plasma osmotic/oncotic pressure
What pressure moves fluid from the pleural cavity to the lungs?
Plasma osmotic/oncotic pressure
What pressure moves fluid from the lungs to the pleural cavity?
Pulmonary arterial pressure (1.5kPa), negative intra pleural pressure
Overall, what is the net movement of fluid due to pressure?
From systemic circulation through the pleura into the lungs
How high up does the pleura extend?
Above the 1st rib
How far down does the pleura extend?
Pleura found over the liver, spleen and kidneys
Pleural effusion
Abnormal collection of fluid in the pleural space
What are the symptoms of pleural effusion dependent on?
Depends on cause and volume of fluids
What symptoms can pleural effusion present with?
- Asymptomatic
- Increasing breathlessness
- Pleuritic chest pain
- Dull ache
- Dry cough
- Weight loss
- Malaise
- Fevers
- Night sweats
What do you need to enquire about when asking about symptoms relating to pleural effusion?
- Peripheral oedema
- Liver disease
- Orthopnoea
- PND
What are the 2 reasons for pleuritic chest pain due to pleural effusion?
- Inflammatory: early, may improve as fluid accumulates
- Malignancy: progressively worsening
What are the main signs of pleural effusion?
Chest on affected side:
- Decreased expansion
- Stony dullness to percussion
- Decreased breath sounds with band of bronchial breathing
- Decreased vocal resonance
What other signs might be present in pleural effusion?
- Clubbing
- Tar staining of fingers
- Cervical lymphadenopathy
- Increased JVP
- Trachea deviated away from effusion
- Peripheral oedema
What are the 2 ways the pleural effusions can be classed by cause?
- Exudates
- Transudates
What causes transudate pleural effusions?
An imbalance of hydrostatic forces influencing the formation and absorption of pleural fluid
What are the characteristics of transudate pleural effusions?
- Normal capillary permeability
- Usually but not always bilateral
What are the characteristics of exudate pleural effusions?
- Increased permeability of pleural surface and/or local capillaries
- Usually unilateral
For exam purposes how do you separate exudates and transudates?
- Transudates have pleural fluid protein of <30g/l
- Exudates have pleural fluid protein of >30g/l
What are the ‘very common’ causes of transudates?
- Left ventricular failure
- Liver cirrhosis
- Hypoalbuminaemia
- Peritoneal dialysis
What are the ‘less common’’ causes of transudates?
- Hypothyroidism
- Nephrotic syndrome
- Mitral stenosis
- Pulmonary embolism
What are the ‘rare’ causes of transudates?
- Constrictive pericarditis
- Ovarian hyperstimulation syndrome
- Meigs’ syndrome
What are the ‘very common’ causes of exudates?
- Malignancy (lung, breast, mesothelium, metastatic)
- Parapneumonic (consider sub-phrenic)
What are the ‘less common’ causes of exudates?
- Pulmonary embolism/infarction
- Rheumatoid arthritis
- Autoimmune diseases
- Benign asbestos effusion
- Pancreatitis
- Post-myocardial infarction/ cariotomy syndrome
What are the ‘rare’ causes of exudates
- Yellow nail syndrome
- Drugs
What drugs can cause exudates?
- Amiodarone
- Nitrofurantoin
- Phenytoin
- Methotrexate
- Carbamazapine
- Penicillamine
- Bromocriptine
- Pergolide
When is investigation not usually required for pleural effusion?
Transudates
When is investigation required regarding pleural effusion?
- If there is unusual features
- Failure to respond to appropriate treatment
What is used to confirm presence of effusion?
Chest radiograph
How much fluid is required before it is detectable on a chest X-ray?
At least 200ml
What can a contrast enhance CT of the thorax usually differentiate between?
Malignant and benign disease
What can be seen on a contrast CT which can differentiate between malignant and benign disease?
- Nodular pleural thickening
- Mediastinal pleural thickening
- Parietal pleural thickening >1cm
- Circumferential pleural thickening
- Other malignant manifestations in lung/liver
What is required for aspiration of pleural effusion?
- 50ml syringe 21G needle
- Lignocaine anaesthesia
- Sterile universal containers
- Blood culture bottles
What are the possible complications from aspiration/biopsy of pleural effusion?
- Pneumothorax
- Empyema
- Pulmonary oedema
- Vagal reflex
- Air embolism
- Tumour cell seeding
- Haemothorax
What ward analysis can be carried out during pleural aspiration?
Look and sniff
What can you tell by looking and sniffing contents of a pleural aspiration?
- Foul smelling: anaerobic empyema
- Pus: empyema
- Food particles: oesophageal rupture
- Milky: chylothorax
- Blood stained: malignancy
- Blood: haemothorax, rupture
What does a pH of< 7.2 for the contents of pleural aspiration suggest?
Infection
What is the intervention required if contents of pleural aspiration are infected and have a pH of <7.2?
Chest drain
What will the biochemists be looking at when testing samples of pleural aspirations?
- Protein, LDH
- Amylase
- Glucose
What does raised amylase suggest?
Pancreatitis
What does glucose <3.3mM suggest?
- Empyema
- Rheumatoid arthritis, SLE
- TB
- Malignancy
What tests will the microbiologists carry out on pleural aspiration samples?
- MC&S
- Gram stain
- AAFB
- Culture
What are they looking for in cytology when testing pleural aspiration samples?
- Malignant cells, lymphocytes (TB, lymphoma)
- Eosinophils (Churg-Strauss, asbestos, malignancy)
When is a pleural effusion exudate?
If 1 or more of the following criteria apply:
- Pleural/serum protein >0.5
- Pleural/serum LDH>0.6
- Pleural LDH >0.66 of upper limit of serum LDH
What instruments can be used for pleural biopsy?
- Abrams needle for blind biopsy
- Tru-cut for CT guided biopsy
Where should the needle be inserted during biopsy?
- Immediately above a rib.
- Do not biopsy with cutting edge upwards
How many biopsy samples must be obtained?
At least 4
Where are biopsy samples sent?
- 3 in formaldehyde to histology
- 1 in saline to microbiology if TB suspected
What investigations can be carried out if there remains no diagnosis after biopsy?
- Thoracoscopy
- Video assisted thoracoscopy
What can thoracoscopy be used for?
- Direct inspection of pleura
- Directed biopsies
- Therapeutic
What treatment can be directed at the cause of pleural effusion?
- Chemotherapy
- Antituberculous chemotherapy
- Corticosteroids
What palliative treatment options are there for pleural effusion?
- Repeated pleural aspiration 1-1.5 litres at one time
- Pleurodhesis
How is a pleurodhesis performed?
- Patient lying on bed at 45 degree angle with arm above head.
- Insertion of chest tube into 4th intercostal space mid-axillary line
What rate should fluid be drained at with pleurodhesis?
Drain fluid no faster than 500ml/hr
If after draining the lung it hasn’t re-expanded what should be done?
- Apply suction for 24 hours
- Remove drain
If the lung has re-expanded what should you do next?
- Instill 3mg/kg lignocaine
- Instill talc slurry, clamp drain after 1 hour
- Remove drain after 12-72 hours if lung remains re-expanded
When is surgical pleurodhesis usually performed?
At time of diagnostic thoracoscopy
Pneumothorax
Presence of air within the pleural cavity
What is pneumothorax caused by?
Breach of visceral or parietal pleura with entry of air, lung collapses away from chest wall because of elastic recoil of the lung
How can pneumothorax be classed?
- Primary spontaneous
- Secondary spontaneous
- Non-iatrogenic traumatic
- Iatrogenic traumatic
What is the key characteristic of tension pneumothorax?
Mediastinal shift away from affected side
What is the difference between primary and secondary spontaneous pneumothorax?
- Primary there is no underlying lung disease
- Secondary there is underlying lung disease
What is the typical patient of primary spontaneous pneumothorax?
Tall, thin males
What are primary spontaneous pneumothorax believed to be due to?
The weight of lung inducing development of apical blebs that rupture
What pre-existing lung diseases can lead to secondary spontaneous pneumothorax?
- COPD
- Asthma
- Pneumonia
- TB
- Cystic fibrosis
- Fibrosing alveolitis
- Sarcoidosis
- Histiocytosis X
What can cause non-iatrogenic traumatic pneumothorax?
- Penetrating chest injury
- Blunt chest injury
What can cause iatrogenic traumatic pneumothorax?
- Pleural aspiration/biopsy
- Sub clavian vein cannulation
- Lung, liver, breast, renal biopsy
- Acupuncture
What are the symptoms of pneumothorax?
- Asymptomatic
- Acute breathlessness
- Pleuritic chest pain
- Extreme dyspnoea
What are the signs of pneumothorax?
- May be no signs
- Surgical emphysema
What are the signs in non-tension pneumothorax?
-Trachea deviated to affected side Affected side: -Decreased expansion -Hyper resonant -Absent or decreased breath sounds
What are the signs of tension pneumothorax?
- Trachea deviated away from affected side
- Haemodynamic compromise
- Increased JVP
What decisions must be made in the management of pneumothorax?
- Is it tension?
- Is pneumothorax small or large?
- Is patient breathless?
- Is pneumothorax likely to be primary or secondary?
What is the management for a tension pneumothorax?
- Cannula 2nd intercostal space mid-clavicular line
- Then insert intercostal chest drain
What is the management for a small primary pneumothorax, not breathless?
- Observe overnight, repeat CXR, if no change, hole has sealed
- Discharge
- Advise no vigorous activity, to return if it becomes breathless.
- Review with CXR clinic 2 weeks
What is the management for a breathless primary pneumothorax?
- Aspirate pneumothorax
- Patient at 45 degree angle
- Lignocaine to 2nd intercostal space, midclavicular line
- 50ML syringe, venflon, 3 way tap, tube to water
- If successful, CXR, observe 24 hours
- If unsuccessful, chest drain
In a breathless primary pneumothorax, when should you aspirate until?
- Feel lung surface on tip of venflon just beneath surface of chest wall
- Aspirate > 3 litres
What is the management for breathless secondary pneumothorax?
- May try to aspirate if small but less successful
- Insert intercostal chest drain to 4th intercostal space mid-axillary line
- Small bore 10-14F
- If surgical emphysema use large 24-32F
What is the ideal outcome of an intercostal chest drain?
-Lung inflates in 1-2 days
-Drain stops bubbling
-CXR confirms lung inflated
THEN
1) Clamp drain fro 24 hours, re CXR, no change, remove drain
OR
2) Re CXR after24 hours, no change, remove drain
What are the less than ideal outcomes of a chest drain?
- Lung fails to re-inflate after 48 hours
- Drain continues bubbling
What can you do if the chest drain does not work?
Apply suction to drain (high volume, low pressure)
What should you do if the lung fails to re-inflate even after suction?
- Contact thoracic surgeons at 3 days
- Thoracoscopic inspection if visceral pleura
- Identification of blebs, tears, clipping and talc poudrage pleurodesis
Who should be referred for surgical pleurodesis?
- Second ipsilateral pneumothorax
- First contralateral pneumothorax
- Bilateral spontaneous pneumothoraxes
- First pneumothorax in high risk professions (pilot, divers)
Asbestos
Highly fibrous naturally occurring mineral
What are the 3 main types of asbestos?
- Chrysotile (white)
- Amosite (brown)
- Crocidolite (blue)
What is the most dangerous to health type of asbestos?
Crocidolite
What are the properties of asbestos?
- High tensile strength
- Fire resistant
- Insulation to electrical charge
- Resistant to chemical attack
- Commonly found in building materials
Who is at highest risk of exposure to asbestos?
- Boiler men
- Engineers
- Electricians
- Plumbers
- Building trade
- Ship building
- Relatives who washed dirty overalls
When does asbestos related disease occur?
20-40 years after exposure
What is mesothelioma?
Pleural malignancy mainly due to asbestos exposure
What is the clinical presentation of mesothelioma?
- Breathlessness
- Chest wall pain
- Weight loss
What is usually found on radiology of mesothelioma?
- Usually unilateral
- Diffuse or localised pleural thickening
What can be performed if asbestos related pleural malignancy is diagnosed early in a patient that is otherwise well?
Pleuropneumonectomy
What are the palliative treatment options for mesothelioma?
- Radiotherapy to drain biopsy sites
- Chemotherapy being trialled
- Pleuradhesis
- Analgesia
What is the life expectancy for mesothelioma?
18 months
What must be done if there is a mesothelioma death?
Reported to Procurator Fiscal
Why is mesothelioma regarded as a compensatable disease?
Legal compensation available
