Pleural disease - pleural effusion, pneumothorax, mesothelioma Flashcards
Describe the pleura
Single layer of mesothelial cells with sub-pleural connective tissue
Two layers: visceral and parietal
Pleural cavity inbetween with negative pressure and 2-3ml pleural fluid
What is a pleural effusion?
abnormal collection of fluid in the pleural space
Symptoms of pleural effusion
Asymptomatic Breathlessness Pleuritic chest pain Dull ache Dry cough Weigh loss, malaise, fevers, night sweats
Signs of pleural effusion
On affected side: reduced expansion stony dullness to percussion reduced breath sounds reduced vocal resonance
clubbing, tar staining cervical lymphadenopathy raised JVP trachea away from large effusion peripheral oedema
What are the two classifications of effusion?
transudates and exudates
Pathophysiology of transudate effusion
an imbalance of hydostatic forces influencing the formation and absorption of pleural fluid
usually bilateral
Pathophysiology of exudate effusion
increased permeability of pleural surface and/or local capillaries
usually unilateral
Protein content of transudates and exudates?
Transudate less than 30g/l
Exudate more than 30g/l
Very common causes for transudate effusions?
Left ventricular failure
Liver cirrhosis
Hypoalbuminaemia
Peritoneal disease
Less common causes for transudate effusion
Hypothyroidism
Nephrotic syndrome
Mitral stenosis
Pulmonary embolism
Very common causes for exudate effusions
Malignancy
Parapneumonic
Less common causes for exudate effusions
Pulmonary embolism/infarction Rheumatoid arthritis Autoimmune diseases Benign asbestos effusion Pancreatitis Post-myocardial infarction
Investigations (with exudates mainly)
Chest x-ray Contrast enhanced CT of thorax Pleural aspiration Pleural biopsy Thoracopy/ video assisted thorascopy
How much fluid must be in a pleural effusion before it is detectable on a chest x-ray?
200ml
What might you find in a CT of the thorax?
nodular pleural thickening mediastinal pleural thickening parietal pleural thickening > 1cm Circumferential pleural thickening other malignant manifestations in the lung/liver
When ‘looking and sniffing’ the sample from a pleural aspiration, what do the following results indicate?
- foul smelling
- pus
- food particles
- milky
- blood stained
- blood
foul smelling - anaerobic empyema pus - empyema food particles - oesophageal rupture milky - chylothorax (lymph) blood stained - malignancy blood - haemothorax, trauma
Where/ how should a pleural biopsy be done?
Immediately above a rib to avoid neurovascular bundle
Cutting edge downwards
Abram’s needle or Tru-cut
How many pleural biopsies should be taken?
At least 4
3 in formaldehyde for histology
1 in saline to microbiology if TB suspected
Management of pleural effusion
Treatment directed at the cause: chemotherapy, anti TB drugs, corticosteroids
Pleural aspiration
Pleurodhesis
Surgical pleurodhesis
What surface anatomy is used to locate position for a pleurodhesis?
4th intercostal space mid-axillary line
What is a pneumothorax?
Presence of air within the pleural cavity, lung collapses
Describe the 4 causes
Primary spontaneous - young, thin, tall male (apical blebs rupture)
Secondary spontaneous - underlying lung disease
Traumatic (non-iatrogenic) - car accident, stabbing
Traumatic (iatrogenic) - surgeon/physician makes cut
What is it called when there is a progressive build up of air within the pleural space due to a one way valve which eventually pushes the lungs and mediastinum to one side?
Tension pneumothorax
Symptoms of pneumothorax
asymptomatic
acute breathlessness
pleuritic chest pain
Signs of non-tension pneumothorax
surgical emphysema (bubble wrap feeling under skin) trachea deviated to affected side on affected side: reduced expansion hyper resonant absent or reduced breath sounds
Signs of tension pneumothorax
trachea deviated away from affected side
haemodynamic compromise
raised JVP
Management of tension pneumothorax
cannula in 2nd intercostal space mid-clavicular line and chest drain
management of small primary pneumothorax
observe overnight, repeat chest x-ray
discharge
review in chest clinic in 2 weeks and advise no vigorous activity
management of breathless primary/ secondary pneumothorax and worsening
aspirate
intercostal chest drain
apply suction
thoracic surgeon at 3 days
3 main types of asbestos
chrysotile (white)
amosite (brown)
crocidolite (blue)
What is mesothelioma?
Pleural malignancy, normally due to asbestos
