Pleural diseases Flashcards
what colour is healthy pleural fluid
what is the normal volume of pleural fluid?
Straw coloured (resembles plasma) and zero odor
15-20 mls
how is a pleural fluid made?
where is this process?
(and inner) but due to balance forces, it’s parietal that does most
filtration which happens from the parietal pleura
how much protein is in the pleura?
1.5-2g of protein
what cells can you find within the pleura?
macrophages, lymphocytes filtered out from blood
mesothelial cells - shed from pleural space
what pressure is the pleural cavity at?
subatmospheric
-3=-5cm of water
the gradient is apex to base being more negativeive
name a few pleural problems
- pleural effusion - collection of fluid
- pneumothorax - a collection of air
- mesothelioma - pleural malignancy
what is blood in pleural area called?
haemothorax
what is pus in pleural space
empyema
describe pleural effision and how this occurs
a collection of fluid in the pleural space
caused by an imbalance between production and absorption (either excessive production or reduced absorption or a combination of both
when effusion collects in space there are 2 kinds (transudate; exudate)
protein contents of educate is 3/dl or more
what are the two kinds of pleural effusion
transudate - non-inflammatory
exudate - inflammatory
protein content of exudate is 3/dl or more
what is the protein content of exudate pleural effusion
3/dl or more/
whats is transudate pleural effision?
happens purely by the process of filtration = low protein content and is non-inflammatory
What is the lights criteria?
to differentiate transudate and exudate pleural effusion
protein: pleural fluid/serum fluid radio > 05
LDH pleural fluid /serium fluid ratio >0.6
pleural fluid LDH >2/3 ULN serum LDH
serum lactate dehydrogenase
what is serum lactate dehydrogenase?
an enzyme found in blood and bodily fluid
what does serum dehydrogenase compare?
pleural fluid to serum fluid levels
what usually causes transudates? pleura
Very Common causes - Left ventricular failure; liver cirrhosis
Less common causes: hypoalbuminaemia; peritoneal dialysis; hypothyroidism; nephrotic syndrome, mitral stenosis
rare causes: constrictive pericarditis urinothorax Meigs syndrome
Caused of pleural exudates
common causes - malignancy (pulmonary and non-pulmonary), Parapneumonic effusions empyema tuberculosis
less common causes: pulmonary embolism, connective tissue damage benign asbestos pleural effusion pancreatitis post-myocardial infarction post-coronary artery bypass graft haemothorax chylothorax
rare causes - Yellow nail syndrome (and other lymphatic disorders e.g. lymphangioleiomatosis) drugs fungal infections
investigations for pleural effusion
chest x-ray - accessible east to interpret (first one usually) (usually need 100-200ml to be seen)
Ultrasound: more sensitive than chest x-ray - mark site for aspiration bedside assessment
CT thorax - complex effusions visualising the pleura, vascular and mediastinal structure help also identify nodules.
what do you expect to see in xray pleural effusion
white out significant portion
concave upper margin
what do you expect to see ct image pleural effusion
grey crescent and dense white is squashed tissue between lung and fluid
how to analyse for pleural effusion
aspiration: simple and same, trained operation - ultrasound mark spot for aspiration (green needle) with or without anaesthetic.
inspect flood - if pus and blood obvious on inspection
ph (bedside ABG machine) biochemistry, microbiology and cytology
if ph less than 7.2 in prescence pneumonia - need for chest drain as likely this acidic fluid will eventially form pus
in aspiration of pleural fluid. what ph would need a chest drain and why?
if ph less than 7.2 in presence pneumonia - the need for chest drain as likely this acidic fluid will eventually form pus
what is good practice in aspirations for samples: where to send?
biology, microbiology and cytology
what does :
biochemistry
microbiology
cytology
do with aspiration samples
microbiology - sample will be cultured to find the presence of bacteria
biochemistry - process the protein levels: LDH, lactate dehydrogenase and glucose levels (narrow to find the cause)
cytologists - look for abnormal cells in the sample
how long does it take for lab results from :
biochemistry
do with aspiration samples from pleura
biochemistry - few hours (+) ph of fluid help make decision regarding management early in diagnostic process
what if pleural aspiration fluid is transudate?
treatment
treat the underlying cause - may not need ct imaging
cardiac failure, renal failure, sepsis, liver failure or any condition causing hypoalbuminemia e.g. poor nutrition.
PLeural effusion treatment for low ph <7.2
(ph less than 7.2 with pneumonia pus or blood = chest drain
pleural effusion treatment for exudate
Unless the cause is identified, will need further investigation e.g. imaging and/or pleural biopsy
the standard way to get imaging for biopsy pleural effusion
image-guided biopsy (thoracoscopy) - the gold standard
define pleural effusion
fluid in pleural space
difference between transudate and exudate
Transudate” is fluid buildup caused by systemic conditions that alter the pressure
“Exudate” is fluid buildup caused by tissue leakage due to inflammation or local cellular damage.
list 3 causes for transudate
3 causes for exudate
exudate - malignancy, empyema, tuberculosis
transudate - liver cirrhosis, hypoalbuminaemia, left ventricular failure,
what is pneumothorax
collection of air in pleural space
different terms for pneumothorax
primary spontaneous (normal lungs)( cause weak areas to cause bleb to rupture) = leak air cavity cause compress lung.
secondary spontaneous (pre-existing condition) (COPD, cystic fibrosis, asthma) (rarely pleural endometriosis- menstruation)
traumatic - injury
latrogenic - hospital setting result biopsies of lung - ventilator pressure of central venous line neck or pacemaker
tension - can be life threatening emergency air cavity pressure build up pushed central structure (trachea) squashes lung. can compress heart b/p drop. and drop spo2 = cardiac arrest. emergency aspiration.
primary spontaneous pneumothorax -
primary spontaneous (normal lungs)( cause weak areas to cause bleb to rupture) = leak air cavity cause compress lung.
secondary pneumothorax
secondary spontaneous (pre-existing condition) (COPD, cystic fibrosis, asthma) (rarely pleural endometriosis- menstruation)
latrogenic pneumothorax -
latrogenic - hospital setting result biopsies of lung - ventilator pressure of central venous line neck or pacemaker
traumatic pneumothorax
traumatic - injury - blunt trauma, knife,
tension pneumothorax -
tension - can be life-threatening emergency air cavity pressure build-up pushed central structure (trachea) squashes lung. can compress heart b/p drop. and drop spo2 = cardiac arrest. emergency aspiration., chest drain
tend to build up with traumatic pneumothorax and occasionally on mechanical ventilation.
what is usual presentation of spontaneous pneumothorax
- sudden event
chest pain or breathlessness
tall thin young men often dismissed as a bit of pain and musculoskeletal after doing exercise.
less commonly people with underlying health issues.
history of biopsy/line insertion/mechanical ventilation
on examination what would you expect to see on spontaneous pneumothorax
breathing fast (tachpneic)
hypoxic
reduces chest wall movement and reduced or no breath sounds
not uncommonly examination may be normal
how to diagnose pneumothorax
chest x-ray
ultrasound by experiences operator a&e and ITU use for is a patient is too sick to be moved
ct of the thorax - not usually required may be good for people with underlying conditions (COPD) or (COPD with large bleb) (cystic fibrosis)
management of pneumothorax
- maybe well patient - observe if well and small pneumothorax
- aspiration if over 2cm and the patient is well
- chest insertion
- surgery for recurrent events and unresolving
a patient who is well with a small pneumothorax - how would you treat?
observe if well and small pneumothorax
is pneumothorax is over 2cm and the patient is well, how to treat it?
aspiration if over 2cm and the patient is well
in fairly large pneumothorax how would you consider treating?
or people with underlying conditions that are not likely to heal on their own.
chest drain insertion pleural cavity by the bedside or local anaesthetic - leave until pneumothorax completely resolves
how to treat recurring pneumothorax/ unresolving.
surgery
what is usual advice to the patient after a pneumothorax
how likely is it for it to reoccur?
25-50% recurrence in first year
advice to not lift heavy weights or fly for at least a week until after it’s completely resolved.
what is it called is a pneumothorax recurs on the same side?
ipsilateral
advice surgical repair.
what happens if you have a pneumothorax while flying?
potentially life-threatening as you may develop tension pneumothorax
what is the safe triangle?
the place for aspiration or drain.
2nd intercostal space pn the midclavicular line
(lateral border of the pectoralis major, border f latissimus dorsi, the lower edge of triangle level at 5th intercostal space)
benign Pleural tumours are how common?
benign and rare
malignany pleural tumours
most pleural malignancy presents as pleural effusion are common and associated with poor outcome
primary malignancy: mesothelioma is the most frequent
The secondary is more common than primary (result cancer elsewhere in body) usually intra parenchymal lung cancer
secondary malignancy pleural tumour
(come from elsewhere)
most frequent intra-paranchymal Lung ca
others include breast, ovarian, renal, Gi or thyroid.
can block lymphatics preventing drainage of pleural fluid
what is mesothelioma?
primary malignancy of pleura
a rare aggressive tumour (an occupational lung disease caused by mutation or exposure to asbestos fibres)
commonly seen in men, plumber, electrician shipbuilding, powerplant, boiler, engine
with exposure - inflammation and repair cycle for long time latency can be 20-40 years
symptoms of mesothelioma
breathless
chest pain (parietal pleura tumour forming)
weight loss
clubbed fingers - signs of pleural effusion.
Diagnosing mesothelioma
chest xray - pleural effusion and base mass
diagnosing mesothelioma
ct of thorax and biopsy - needed to stage, gauge extent and distant spread
thickened pleura, pleural nodules or masses
pleural plaques, an effusion or soft tissue infiltration
biopsy via thoracoscopy
spray lining with sterile talcum powder to obliterate pleural space called pleurodesis (stop fluid accumulating)
treatment of mesothelioma
- treatment limited, palliative due to poor survival
treating effusion
chemotherapy
MDT discussion or trials
palliative surgery for select patients for symptom control
due to occupational illness can claim compensation
how many deaths appro are there in scotland from smoking?
10,000 death a year 1/5th of beaths
what is the average loss of life with smoking?
7.5 years
Lung cancer 25%
COPD 20%
heart disease 20%
what are other illnesses associated with smoking
endocrine - type 2 diabetes rheumatology - osteoporosis dermatology - psoriasis
cardiovascular - coronary artery disease peripheral vascular disease
Opthalmology - macular degeneration
gastroenterology peptic ulceration crohns disease
lavoured cigarettes are illegal.
Select one:
True
False
True – it is illegal to sell cigarettes with a distinguishable flavour, as this makes them far too appealing!
After PET/CT scan, up to 15% of patients will have the stage of their cancer downgraded, i.e. it will be found to be at an earlier stage than originally thought.
Select one:
True
False
False – up to 15% of patients will have their cancer UPstaged. This is because PET/CT can detect small foci of high metabolic activity (likely metastases) that may have been missed on CT imaging.
Very high dose radiotherapy can be used instead of surgery in some patients with lung cancer, to remove tumours by ablation.
Select one:
True
False
True – SABR (stereotactic ablative radiotherapy) can have similar results to surgery in carefully selected patients with small tumours, who would not be fit for surgery. It involves a short course of very high dose radiation.
Regarding Light’s Criteria: If the ratio of pleural fluid LDH/Serum LDH is greater than 0.6, the effusion is exudative.
Select one:
True
False
Feedback
True. Light’s Criteria help us decide whether an effusion is transudative or exudative, and therefore helps us determine the cause. The criteria (one or more required) for an exudative effusion are:
Pleural fluid protein/Serum protein >0.5
Pleural fluid LDH/Serum LDH >0.6
Pleural fluid LDH >2/3 the upper limit of the lab reference range for serum LDH
what is the lights criteria for transudative or exudative, pleural effusion
True. Light’s Criteria help us decide whether an effusion is transudative or exudative, and therefore helps us determine the cause. The criteria (one or more required) for an exudative effusion are:
Pleural fluid protein/Serum protein >0.5
Pleural fluid LDH/Serum LDH >0.6
Pleural fluid LDH >2/3 the upper limit of the lab reference range for serum LDH
Squamous cell carcinoma of the lung is more likely to arise peripherally in the lung.
Select one:
True
False
False - squamous cell epithelium lines the larger central airways, and so this tumour type tends to arise centrally.
Pleural fluid has a positive pressure relative to atmospheric pressure.
Select one:
True
False
False – pleural fluid has a slight negative pressure, with the lowest pressure being at the apex. This negative pressure helps keep the surfaces of the lung, pleura and thoracic cavity adherent and facilitates breathing.
“Radical” treatment for lung cancer means the treatment is new or experimental.
Select one:
True
False
False – Radical treatment is any cancer treatment that is given with the intent to cure the cancer.
The only treatment for pleural effusion is drainage by a chest drain.
Select one:
True
False
False – many transudative pleural effusions can be managed by treating the underlying cause, and will eventually resorb without drainage (as will many exudative effusions). Effusions require drainage when the pH is low (indicating high likelihood of empyema), when there is frank pus, or when they are of a volume that breathing is severely impacted.
Smoking increases the risk of bladder cancer.
Select one:
True
False
True – smoking does not just increase risk of lung cancer. Bladder cancer risk is increased three-fold by smoking (and the relative risks of many other cancers are also increased).
Giving chemotherapy and radiotherapy concurrently doubles the survival compared to radiotherapy alone.
Select one:
True
False
False – unfortunately the effect is much more modest, with an increase in survival of about 5%.
CT screening for lung cancer is now widely offered to people who smoke.
Select one:
True
False
False – this has not yet been established, but is in development.
Compression of the phrenic nerve by enlarged lymph nodes leads to voice hoarseness.
Select one:
True
False
False – the phrenic nerve innervates the diaphragm, so phrenic nerve damage will cause paralysis of the affected hemidiaphragm. Recurrent laryngeal nerve damage leads to voice hoarseness.
10% of smokers will develop lung cancer.
Select one:
True
False
True – the risk of developing lung cancer is relative to consumption (quantified in terms of pack-years, where 20 cigarettes a day for 1 year is 1 pack-year) but there is no safe smoking threshold.
In lung collapse, you will see the mediastinum shift towards the abnormal side on a chest x-ray.
Select one:
True
False
True – collapse involves loss of volume, so it creates a pulling force on the mediastinum, causing it to deviate towards the side of the collapsed lung.
A pneumothorax can resolve without treatment.
Select one:
True
False
True – not all pneumothoraces require treatment. Small pneumothoraces in well patients can simply be monitored, as the air will eventually be absorbed by the pleura.
Regarding chest x-rays: A pulmonary mass is classed as an opacity over 1cm.
Select one:
True
False
False – the cut-off is 3cm. Anything smaller than this is classed as a nodule.
Any lung cancer with distant metastases is termed Stage IV.
Select one:
True
False
True – Stage IV designates the development of distant metastases.
Rheumatoid arthritis causes an exudative pleural effusion.
Select one:
True
False
True – Rheumatoid arthritis is a multi-system inflammatory disease, and the fluid accumulates due to inflammatory changes.
Ectopic ACTH secretion and SIADH are endocrine effects of small cell lung cancer.
Select one:
True
False
True. You will learn more about these hormones later in MBChB.
ACTH = adrenocorticotropic hormone
SIADH = Syndrome of Inappropriate Antidiuretic Hormone secretion
Adenocarcinoma of the lung is more likely to arise peripherally.
Select one:
True
False
True – bronchioalveolar epithelial stem cells transform and undergo atypical adenomatous hyperplasia, developing into adenocarcinoma in situ and then invasive adenocarcinoma of the lung. This epithelium is found in small airways, so this cancer is more likely to arise peripherally.
what is tumour ablation
treatment for lung tumour. Ablation is a technique that destroys tissue through heating. In order to produce the heat needles are placed into the lung, using image guidance (e.g. CT scanning).
person who has to rest less than 50% of their day due to their cancer symptoms and is unable to work has a performance status of 3.
Select one:
True
False
False – this describes a performance status of 2. A person who is PS3 has to sit or lie down for more than 50% of their day due to their cancer symptoms, and is likely to struggle with self-care. Performance status will be considered while deciding treatment options with a patient and a multidisciplinary team.
Most pleural tumours arise from cancers of the pleura itself.
Select one:
True
False
False – most pleural tumours are metastatic deposits from cancer elsewhere – often lung or breast cancers.
A pneumothorax which occurs without prior injury in a patient with a pre-existing lung condition is called a primary spontaneous pneumothorax.
Select one:
True
False
False – primary pneumothoraces occur in people with no pre-existing lung disease. The description above is of a secondary spontaneous pneumothorax.
Very high dose radiotherapy can be used instead of surgery in some patients with lung cancer, to remove tumours by ablation.
Select one:
True
False
True – SABR (stereotactic ablative radiotherapy) can have similar results to surgery in carefully selected patients with small tumours, who would not be fit for surgery. It involves a short course of very high dose radiation.
Putting sterile talcum powder into the pleural cavity can help treat recurrent malignant pleural effusion.
Select one:
True
False
True – this provokes an inflammatory reaction, which causes the visceral and parietal pleura to fuse, preventing recurrence of pleural effusion.
The increased risk of heart attack associated with smoking will remain life-long, even if a person stops smoking.
Select one:
True
False
False – 15 years after stopping smoking, heart attack risk returns to that of a never-smoker. An encouraging reason to stop smoking!
Adjuvant treatment is chemotherapy or radiotherapy that is given after surgery to resect a lung cancer.
Select one:
True
False
True – compare this to neoadjuvant treatment, which is used in other cancer types (not lung, currently) and refers to treatment given before planned curative surgery.
orner’s syndrome can be a sign of an apical lung tumour, and results from compression of the sympathetic trunk.
Select one:
True
False
True – Horner’s syndrome is an important cluster of signs to be aware of. You will cover a lot of the underlying anatomy later in MBChB, but in simple terms, Horner’s syndrome is damage to the sympathetic nerve supply to the head and neck. This is the component of the nervous system that mediates the “fight or flight” response. Patients with Horner’s syndrome have a constricted pupil (miosis), a drooping eyelid (partial ptosis), and decreased sweating (anhidrosis) on the affected side. One of the ways the sympathetic trunk can become damaged is by direct invasion or compression by a tumour at the apex of the lung.
n cancer staging, “TNM” stands for “Tumour, Nodes, Metastasis”
Select one:
True
False
True – TNM staging is widely used to describe the staging (i.e. the extent of spread) of many cancers. It looks at the size and/or direct invasion of the primary tumour, the involvement of local and distant lymph nodes, and the presence or absence of distant metastases. You do not need to know the exact details, but it is important to know what the components of TNM staging refer to, and how this corresponds to overall cancer stage.
Tyrosine Kinase Inhibitors (TKIs) are specialised drugs targeted to tumours carrying specific mutations in small cell lung cancers.
Select one:
True
False
False – these drugs target tumours carrying specific mutations in adenocarcinoma (a non-small-cell lung cancer)
Patients with mesothelioma are entitled to compensation.
Select one:
True
False
True – it is an occupational lung disease, and patients (or their families) are entitled to compensation.
Mesothelioma usually develops within 5 years of asbestos exposure.
Select one:
True
False
False – there is a long latency period (about 20 – 40 years) between exposure and development of mesothelioma, therefore it is most commonly a disease of older people.
Heart failure causes an exudative pleural effusion.
Select one:
True
False
False – left ventricular failure causes pulmonary vascular congestion, which forces more fluid into the pleural space. It is therefore a transudative process that causes the pleural effusion seen in heart failure.
Primary lung cancer is often detected early because it causes multiple symptoms.
Select one:
True
False
False – primary lung cancer (i.e. cancer that arises from lung tissue, rather than metastasizing from a cancer elsewhere) often goes undetected for a long time, because it usually does not cause symptoms until it is advanced, and usually incurable. Symptoms include shortness of breath, weight loss, cough, haemoptysis… can you think of any more?
Adenocarcinoma of the lung is more likely to arise centrally.
Select one:
True
False
False - bronchioalveolar epithelial stem cells transform and undergo atypical adenomatous hyperplasia, developing into adenocarcinoma in situ and then invasive adenocarcinoma of the lung. This epithelium is found in small airways, so this cancer is more likely to arise peripherally.
ollowing pneumonectomy, the patient will have an air-filled cavity for the rest of their life.
Select one:
True
False
False – the space left by the resected lung will fill with fluid.
Bronchiectasis is a side-effect of radiotherapy for lung cancer.
Select one:
True
False
False – side effects of radiotherapy include pulmonary fibrosis, oesophagitis, ulceration and burning to skin and pericarditis.
PET/CT shows metabolic activity of a lesion.
Select one:
True
False
True – in addition to showing cross-sectional CT imaging, PET imaging involves injection of a radio-labelled glucose analogue. High uptake of glucose (i.e. a high metabolic activity) will therefore show up on the scan as a bright spot, and this may identify metastatic deposits (as cancers typically have high metabolic activity due to their rapid growth).
Small cell lung cancers are much faster-growing than non-small-cell lung cancers.
Select one:
True
False
True – non-small-cell lung cancers have an average doubling time of 129 days, whereas in small cell lung cancers it is 29 days.
what is normal growth of
small cell cancer
non-small cell cancer
in lungs
True – non-small-cell lung cancers have an average doubling time of 129 days, whereas in small cell lung cancers it is 29 days.
Lung cancer which has spread to mediastinal lymph nodes can often be successfully surgically resected.
Select one:
True
False
False – the finding of malignant lymph nodes on mediastinoscopy means lung cancer is not surgically resectable.
Parathyroid Hormone (PTH) secretion is a feature of small cell lung cancer.
Select one:
True
False
False – this is typically a feature of squamous cell lung cancer. You will learn more about PTH later in MBChB.
Paraneoplastic syndromes occur due to direct metastatic invasion of endocrine glands by lung cancer.
Select one:
True
False
False – paraneoplastic syndromes are hormonal or chemical changes that occur in the body due to lung cancer, often as a result of the secretion of hormones by the primary tumour itself, or through immune system stimulation.
Lung cancer can cause bronchiectasis.
Select one:
True
False
True – small airway obstruction by a lung tumour can cause the abnormal dilatation of airways known as bronchiectasis.
Ultrasound is the only imaging modality that allows a site for drainage of a pleural effusion to be marked.
Select one:
True
False
True – ultrasound imaging allows the fluid to be visualised and quantified with the patient in a seated position, and a marking can be made on the skin to show a safe site for needle insertion and fluid drainage. This cannot be done from a CXR because it is a 2D image, and a CT scan is performed in a supine position, so fluid would move as soon as the patient sits up!
T4 lung tumours are usually not surgically resectable.
Select one:
True
False
True – T4 tumours are locally advanced – i.e. invading into surrounding structures such as the aorta or the trachea, and so generally are not suitable for surgical resection.
Prevalence of smoking correlates positively to economic deprivation.
Select one:
True
False
True – adults in the most deprived postcodes are three times more likely to smoke than adults in the least deprived postcodes.
Exudative pleural effusions are inflammatory in nature.
Select one:
True
False
True – examples include pleural effusion secondary to cancer or to pneumonia. Pleural fluid sampled from an exudative effusion will have a high protein content, which can help make the diagnosis.
Regarding Light’s Criteria: If the pleural fluid protein concentration is more than half the serum protein concentration, the effusion is exudative.
Select one:
True
False
True. Light’s Criteria help us decide whether an effusion is transudative or exudative, and therefore helps us determine the cause. The criteria (one or more required) for an exudative effusion are:
Pleural fluid protein/Serum protein >0.5
Pleural fluid LDH/Serum LDH >0.6
Pleural fluid LDH >2/3 the upper limit of the lab reference range for serum LDH
Cigarettes contain over 60 known carcinogens.
Select one:
True
False
True – in Scotland alone, over 10,000 deaths per year are attributable to smoking, and many of these deaths are caused by cancer.
Small cell lung cancer tends to have a faster response to treatment than non-small-cell lung cancer.
Select one:
True
False
True – because these cancers grow quickly and are highly metabolically active, they are also vulnerable to treatment and respond quickly.
Generally, fluid from a transudative effusion contains 3g/dL of protein or more.
Select one:
True
False
False – this describes the protein content of an exudative effusion, which is caused by inflammation.
Lung cancer can be staged from a chest x-ray.
Select one:
True
False
False – the “stage” of a cancer refers to its spread, therefore cross-sectional whole-body imaging is required. This will normally be a CT scan.
Adult patients must have an estimated post-operative FEV1 of at least 1L for resective surgery to be considered.
Select one:
True
False
True – a post-op FEV1 of less than this is likely to cause severe breathlessness.
Lung cancer commonly metastasizes to the thyroid gland.
Select one:
True
False
False – lung cancer commonly metastasizes to the adrenal glands.
By law, cigarette packets cannot contain more than 20 cigarettes.
Select one:
True
False
False – cigarette packets must contain at least 20 cigarettes. This is to prevent the sale of small, inexpensive packets of cigarettes that people buy for fun and then become addicted!
