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2. Respiratory Medicine (Lectures) > Pleural Disease COPY > Flashcards

Pleural Disease COPY Flashcards

1
Q

What is the pleura?

A

Single layer of mesothelial cells
Also sub pleural connective tissue

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2
Q

Layers of the pleura

A

Visceral
Parietal

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3
Q

What is the pleura lubricated by?

A

2-3ml of pleural fluid

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4
Q

Systemic arterial pressure vs pleural pressure

A

AP > pleural pressure

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5
Q

What is a pleural effusion?

A

Abnormal collection of fluid in the pleural space

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6
Q

What do the symptoms of pleural effusion depend on?

A

Cause
Volume of fluid

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7
Q

Presentation of pleural effusion

A

Asymptomatic
Increasing SOB
Pleuritic chest pain
- inflammatory (early, may improve as fluid accumulates)
- malignancy (progressively worsening)
Dull ache
Dry cough
Weight loss
Malaise
Fever
Night sweats

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8
Q

What causes pleuritic chest pain?

A

Surface of pleura inflamed and rub against each other

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9
Q

Signs of pleural effusion

A

Chest affected on ONE side
Decreased expansion
Stony dullness to percussion
Decreased breath sounds (band of bronchial breathing)
Decreased vocal resonance
Clubbing
Tar staining
Cervical lymphadenopathy
Increased JVP
Trachea deviated away from large effusion
Peripheral oedema

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10
Q

If the trachea is NOT deviated away from a large effusion, what may this indicate?

A

Possible collapse

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11
Q

Two classifications of causes of pleural effusion

A

Transudates
Exudates

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12
Q

What causes transudates?

A

An imbalance of hydrostatic forces influencing the formation and absorption of pleural fluid

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13
Q

Features of transudates

A

Normal capillary permeability
Usually (not always) bilateral

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14
Q

What causes exudates?

A

Increased permeability of pleural surface and/or local capillaries into lesions or areas of inflammation

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15
Q

Are exudates usually bilateral or unilateral?

A

Unilateral

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16
Q

What is the exam cut off for pleural fluid protein for transudates?

A

< 30g/l

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17
Q

What is the exam cut off for pleural fluid protein for exudates?

A

> 30g/l

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18
Q

Which of transudates and exudates have more protein?

A

Exudates

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19
Q

Causes of transudates

A

LVF
Liver cirrhosis
Hypoalbumineamia
Peritoneal dialysis
Hypothyroidism
Nephrotic syndrome
MS
PE
Constrictive pericarditis
Ovarian hyperstimulation syndrome
Meigs syndrome

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20
Q

What is meigs syndrome?

A

Benign ovarian fibroma, ascites and R sided effusion

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21
Q

Causes of exudates

A

Malignancy
Parapneumonic
PE/Infarction
RA
Autoimmune diseases (SLE)
Benign asbestos effusion
Pancreatitis
Post MI/cardiotomy syndrome
Yellow nail syndrome
Drugs

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22
Q

What is a parapneumonic

A

Pleural effusion that results from pneumonia, lung abscess or bronchiectasis (consider sub phrenic)

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23
Q

What drugs can cause exudates?

A

Amoidarone
Nitrofurantoin
Phenytoin
Methotrexate
Carbamazepine
Penicillamine
Bromocriptin
Pergolide

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24
Q

What is the name of the pleural malignancy?

A

Mesothelioma

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25
80% of mesotheliomas are due to what?
Asbestos
26
Where can mesothelioma also occur?
Peritoneum
27
Presentation of mesothelioma
SOB Chest wall pain
28
What does a mesothelioma look like on imaging?
Unilateral Diffuse or localised pleural thickening
29
Investigation for pleural effusion
Investigation not usually required for transudates (clincial picture characteristic) 1. to confirm presence - CXR 2. Contrast enhanced CT thorax 3. Pleural aspiration and biopsy - ward analysis of fluid and blood gas analysis 4. Labs - protein, LDH, amylase, glucose, MC+S, gram stain, AAFB, culture, cytology 5. Interpret fluid protein 6. Pleural biopsy (4x) 7 If still no diagnosis - (video assisted) thoracoscopy
30
How much fluid is required to detect pleural effusion on CXR?
200ml
31
What would a pleural effusion look like on CXR?
Diaphragm shadow lost Meniscus would be present
32
What does a contrast enhanced CT thorax look at?
Differentiates between malignant and benign disease Nodular pleural thickening Parietal pleural thickening > 1cm Circumferential pleural thickening Other malignant manifestations in lung/liver
33
Complications of pleural aspiration and biopsy
Pneumothorax Empyema Pulmonary oedema Vagal reflex if not enough anaesthesia Air embolism Tumour cell seeding (cells may track along needle) Haemothorax
34
What could be found when looking at the fluid?
Foul smelling Pus Food particles Milky Blood stained Blood
35
What would foul smelling fluid indicate?
Anaerobic empyema
36
What would pus in fluid indicate?
Empyema
37
What would food particles in the fluid indicate?
Oesophageal rupture
38
What would milky fluid indicate and what would this usually be caused by?
CHYLOTHORAX - usually lymphoma
39
What would blood stained fluid indicate?
Possible malignancy
40
What would blood coming out the needle indicate?
Haemothorax Trauma
41
How to interpret pleural protein
Transudate < 25g/l Exudate > 35g/l For protein 25 - 35g/l, use lights criteria Exudate if greater and including 1 of the following then the criteria are met - pleural/serum protein > 0.5 - pleural/serum LDH >0.6 - pleural/LDH > 0.66 of upper limit of serum LDH
42
Treatment of pleural effusion
Treatment directed at cause e.g. - chemo - anti TB therapy - corticosteriods Pleurodhesis
43
Palliative treatment of pleural effusion
Repeated pleural aspiration 1-1.5 L per time
44
How does pleurodhesis work?
Patient lies on bed at 45 degrees arm above head 4TH IC SPACE MID AXILLARY LINE Drain all fluid using a chest drain Hole in pleura and attached to underwater seal Drained at 500ml/hr
45
What is used to check if all the fluid has been drained off in Pleurodehesis?
CXR
46
What is a pneumothorax?
Presence of air in the pleural cavity
47
Pathology of pneumothorax
Breach of visceral or parietal pleura with entry of air, lung collapses away from the chest wall because of the elastic recoil of the lung
48
Types of pneumothorax
Spontaneous Traumatic Tension
49
Types of spontaneous pneumothorax
Primary Secondary
50
Types of traumatic pneumothorax
Non iatrogenic Iatrogenic
51
What is a primary pneumothorax?
A pneumothorax in normal lungs
52
What is a secondary pneumothorax?
A pneumothorax in lungs with underlying disease
53
Example of iatrogenic pneumothorax
Pleural aspiration / biopsy Sub clavian vein cannulation Lung, liver, breast, renal biopsy Acupuncture
54
Example of non iatrogenic pnuemothorax
Penetrating chest injury - stab / gunshot Blunt chest injury - rib fractures - bronchial rupture
55
What is a tension pneumothorax?
Lungs get smaller and pneumothorax gets bigger Vena cava becomes stretched and so reduces venous blood to the heart Shifts the mediastinum to one of the sides
56
Who gets primary pneumothorax?
Young 20 - 30 years Tall and thin
57
Causes of secondary pneumothorax
COPD (30-50%) Asthma Pneumonia TB CF Fibrosing alveoli Sarcoidosis Histiocytosis X
58
Presentation of pneumothorax
Asymptomatic Acute SOB, worsening, extreme Pleuritic chest pain SUDDEN ONSET OF SYMPTOMS
59
Signs of pneumothorax
May be no signs if small Surgical emphysema if significant air leak - feels like bubble wrap Non tension - trachea deviated to affected side - at affected side decreased expansion, hyper resonant, absent/decreased breath sounds Tension - trachea deviated away from affected site - haemodynamic compromise - Increased JVP
60
Treatment of pneumothorax
Tension - cannula be inserted into 2nd IC SPACE MID CLAVICULAR LINE Then insert an intercostal chest drain Is pneumothorax space or large? - small rim of air <2cm. Observe overnight, repeat CXR, if no change hole has sealed. Advise no vigorous activity and to return if become breathless. Review with CXR clinic in 2 weeks - large; rim of air greater or equal to 2cm. Breathless primary pneumothorax - aspirate pneumothorax - if successful, CXR and observe for 24 hours, unsuccessful - chest drain Breathless secondary pneumothorax - may aspirate if small but less successful - insert IC drain (4th IC space mid axillary line) Talc poudrage Pleurectomy
61
What is used as a local anaesthetic to aspirate the pneumothorax?
Lignocaine
62
How does an IC chest drain work?
Lung inflates in 1 - 2 days Drain stops bubbling CXR confirms lung inflated
63
What are the options after a chest drain has worked?
1. Clamp drain for 24 hrs, re CXR and if no change remove the drain 2. Re CXR after 24 hours and if there is no change then remove the drain
64
What should be done if the lung fails to inflate?
Contact thoracic surgeons at 3 days
65
Is there a high or low risk of subsequent pneumothorax?
High (54% at 4 years, 10 - 25% in first 4 months)
66
What % of patients get a subsequent contralateral pneumothorax?
10 - 15%
67
What is a pleurectomy?
Surgery where part of the pleura is removed
68
Who with pneumothorax gets refered for surgical pleurodesis?
Second ipsilateral pneumothorax First contralateral pneumothorax Bilateral spontaneous pneumothoraces First pneumothorax in high risk professionals (pilots, drivers)
69
3 main types of asbestos
Chrysotile (white) Amosite (brown) Crocidolite (blue)
70
Who gets exposure to asbestos?
Boiler men Engineers Electricians Plumbers Building trade Ship building Fathers or husbands work gear
71
When does the asbestos disease occur after exposure?
20 - 40 years after exposure
72
Investigation for mesothelioma
Thoracoscopy and histology
73
What area of the lungs does asbestosis affect?
Lower zones
74
What are the main indications for placing a chest tube in a pleural infection?
Patients with frank purulent or tubid/cloudy pleural fluid on sampling The presence of organisms identified by gram stain and/or culture from a non purulent pleural fluid sample Pleural fluid pH < 7.2 in suspected infection
75
Are pleural plaques malignant?
NO - they are benign and DO NOT undergo malignant change
76
Asbestos related lung diseases
Pleural plaques Pleural thickening Asbestosis Mesothelioma Lung cancer
77
What is the most common form of asbestos related lung disease?
Pleural plaques
78
How long is the latent period for pleural plaques?
20 - 40 years
79
What is the severity of asbestosis related to?
Length of exposure
80
How much exposure do you need to get a mesothelioma?
Very little
81
What lobes are affected in asbestosis?
Lower
82
What type of asbestos is the most dangerous form?
Crocidolite (blue)
83
What is the most common cause of exudative pleural effusion?
Pneumonia
84
What is the 'safe triangle' for chest drain insertion?
Lattismus dorsi Pec major Line superior to the nipple and apex at the axilla
85
What features of a pleural aspirate would suggest an empyema?
Pus present pH < 7.2 Low glucose High LDH
86
Sudden deterioration with ventilation suggests what?
Tension pneumothorax
87
What is the most common cause of transudative pleural effusion?
Heart failure

2. Respiratory Medicine (Lectures) (50 decks)

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