Pleural Disease COPY Flashcards
What is the pleura?
Single layer of mesothelial cells
Also sub pleural connective tissue
Layers of the pleura
Visceral
Parietal
What is the pleura lubricated by?
2-3ml of pleural fluid
Systemic arterial pressure vs pleural pressure
AP > pleural pressure
What is a pleural effusion?
Abnormal collection of fluid in the pleural space
What do the symptoms of pleural effusion depend on?
Cause
Volume of fluid
Presentation of pleural effusion
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
What causes pleuritic chest pain?
Surface of pleura inflamed and rub against each other
Signs of pleural effusion
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
If the trachea is NOT deviated away from a large effusion, what may this indicate?
Possible collapse
Two classifications of causes of pleural effusion
Transudates
Exudates
What causes transudates?
An imbalance of hydrostatic forces influencing the formation and absorption of pleural fluid
Features of transudates
Normal capillary permeability
Usually (not always) bilateral
What causes exudates?
Increased permeability of pleural surface and/or local capillaries into lesions or areas of inflammation
Are exudates usually bilateral or unilateral?
Unilateral
What is the exam cut off for pleural fluid protein for transudates?
< 30g/l
What is the exam cut off for pleural fluid protein for exudates?
> 30g/l
Which of transudates and exudates have more protein?
Exudates
Causes of transudates
LVF
Liver cirrhosis
Hypoalbumineamia
Peritoneal dialysis
Hypothyroidism
Nephrotic syndrome
MS
PE
Constrictive pericarditis
Ovarian hyperstimulation syndrome
Meigs syndrome
What is meigs syndrome?
Benign ovarian fibroma, ascites and R sided effusion
Causes of exudates
Malignancy
Parapneumonic
PE/Infarction
RA
Autoimmune diseases (SLE)
Benign asbestos effusion
Pancreatitis
Post MI/cardiotomy syndrome
Yellow nail syndrome
Drugs
What is a parapneumonic
Pleural effusion that results from pneumonia, lung abscess or bronchiectasis (consider sub phrenic)
What drugs can cause exudates?
Amoidarone
Nitrofurantoin
Phenytoin
Methotrexate
Carbamazepine
Penicillamine
Bromocriptin
Pergolide
What is the name of the pleural malignancy?
Mesothelioma
80% of mesotheliomas are due to what?
Asbestos
Where can mesothelioma also occur?
Peritoneum
Presentation of mesothelioma
SOB
Chest wall pain
What does a mesothelioma look like on imaging?
Unilateral
Diffuse or localised pleural thickening
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
How much fluid is required to detect pleural effusion on CXR?
200ml
What would a pleural effusion look like on CXR?
Diaphragm shadow lost
Meniscus would be present
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
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
What could be found when looking at the fluid?
Foul smelling
Pus
Food particles
Milky
Blood stained
Blood
What would foul smelling fluid indicate?
Anaerobic empyema
What would pus in fluid indicate?
Empyema
What would food particles in the fluid indicate?
Oesophageal rupture
What would milky fluid indicate and what would this usually be caused by?
CHYLOTHORAX - usually lymphoma
What would blood stained fluid indicate?
Possible malignancy
What would blood coming out the needle indicate?
Haemothorax
Trauma
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
Treatment of pleural effusion
Treatment directed at cause e.g.
- chemo
- anti TB therapy
- corticosteriods
Pleurodhesis
Palliative treatment of pleural effusion
Repeated pleural aspiration 1-1.5 L per time
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
What is used to check if all the fluid has been drained off in Pleurodehesis?
CXR
What is a pneumothorax?
Presence of air in the pleural cavity
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
Types of pneumothorax
Spontaneous
Traumatic
Tension
Types of spontaneous pneumothorax
Primary
Secondary
Types of traumatic pneumothorax
Non iatrogenic
Iatrogenic
What is a primary pneumothorax?
A pneumothorax in normal lungs
What is a secondary pneumothorax?
A pneumothorax in lungs with underlying disease
Example of iatrogenic pneumothorax
Pleural aspiration / biopsy
Sub clavian vein cannulation
Lung, liver, breast, renal biopsy
Acupuncture
Example of non iatrogenic pnuemothorax
Penetrating chest injury
- stab / gunshot
Blunt chest injury
- rib fractures
- bronchial rupture
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
Who gets primary pneumothorax?
Young
20 - 30 years
Tall and thin
Causes of secondary pneumothorax
COPD (30-50%)
Asthma
Pneumonia
TB
CF
Fibrosing alveoli
Sarcoidosis
Histiocytosis X
Presentation of pneumothorax
Asymptomatic
Acute SOB, worsening, extreme
Pleuritic chest pain
SUDDEN ONSET OF SYMPTOMS
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
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
What is used as a local anaesthetic to aspirate the pneumothorax?
Lignocaine
How does an IC chest drain work?
Lung inflates in 1 - 2 days
Drain stops bubbling
CXR confirms lung inflated
What are the options after a chest drain has worked?
- Clamp drain for 24 hrs, re CXR and if no change remove the drain
- Re CXR after 24 hours and if there is no change then remove the drain
What should be done if the lung fails to inflate?
Contact thoracic surgeons at 3 days
Is there a high or low risk of subsequent pneumothorax?
High (54% at 4 years, 10 - 25% in first 4 months)
What % of patients get a subsequent contralateral pneumothorax?
10 - 15%
What is a pleurectomy?
Surgery where part of the pleura is removed
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)
3 main types of asbestos
Chrysotile (white)
Amosite (brown)
Crocidolite (blue)
Who gets exposure to asbestos?
Boiler men
Engineers
Electricians
Plumbers
Building trade
Ship building
Fathers or husbands work gear
When does the asbestos disease occur after exposure?
20 - 40 years after exposure
Investigation for mesothelioma
Thoracoscopy and histology
What area of the lungs does asbestosis affect?
Lower zones
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
Are pleural plaques malignant?
NO - they are benign and DO NOT undergo malignant change
Asbestos related lung diseases
Pleural plaques
Pleural thickening
Asbestosis
Mesothelioma
Lung cancer
What is the most common form of asbestos related lung disease?
Pleural plaques
How long is the latent period for pleural plaques?
20 - 40 years
What is the severity of asbestosis related to?
Length of exposure
How much exposure do you need to get a mesothelioma?
Very little
What lobes are affected in asbestosis?
Lower
What type of asbestos is the most dangerous form?
Crocidolite (blue)
What is the most common cause of exudative pleural effusion?
Pneumonia
What is the ‘safe triangle’ for chest drain insertion?
Lattismus dorsi
Pec major
Line superior to the nipple and apex at the axilla
What features of a pleural aspirate would suggest an empyema?
Pus present
pH < 7.2
Low glucose
High LDH
Sudden deterioration with ventilation suggests what?
Tension pneumothorax
What is the most common cause of transudative pleural effusion?
Heart failure
