Pleural diseases Flashcards
What is the structure of normal pleura
Glistening, smooth, thin membrane covers thoracic cavity & lung
Outer layer : Parietal Pleura
Inner Layer : Visceral Pleura
In between : Pleural fluid
What is pleural fluid
Straw coloured
0.26ml/kg/cavity
Used for filtration
Protein - 1.5-2g/dl
Few cells : macrophages, lymphocytes, mesothelial cells
What are the differerent pleural problems
Collection of fluid: Pleural effusion
Collection of Air : Pneumothorax
Pleural malignancy : Mesothelioma
What is the pathogenesis of pleural effusion
Collection of fluid in the pleural space
Imbalance between production and absorption
Absorption : Pleural lymphatics in the parietal pleura
What are the different types of effusion
Transudate- Non- inflammatory
Exudate- Inflamatory
Protein content of exudate- 3g/dl
What is LIGHTS criteria for pleural effusion
Protein : Pleural fluid /serum fluid ratio > 0.5
LDH : Pleural fluid /serum fluid ratio > 0.6
Pleural fluid LDH > 2/3 rd ULN serum LDH
What are some common causes of transudates
Left ventricular failure
Livercirrhosis
What are the less common causes of tansudates
Hypoalbuminaemia
Peritoneal dialysis
Hypothyroidism
Nephrotic syndrome
Mitral stenosis
What are the rare causes of transudate
Constrictive pericarditis
Urinothorax
Meigs’ syndrome
What are the comon causes of exudate
Malignancy
Parapneumonic effusions
Empyema
Tb
What are the less common causes of exudates
Pulmonary embolism
Connective tissue disease
Benign asbestos pleural effusion
Pancreatitis
Post-myocardial infarction
Post-coronary artery bypass graft
Haemothorax, chylothorax
What are the rare causes of exudate
Yellow nail syndrome (and other lymphatic disorders eg, lymphangioleiomyomatosis)
Drugs (see table 2)
Fungal infections
What are the investigations for pleural effusion
US : more sensitive than CXR , mark site for aspiration, assess pleura, bedside
CXR : accessible , easy to interpret
CT Thorax : Complex effusions , visualising the pleura , vascular and mediastinal structures
How would you analyse pleural fluid
Aspiration : simple and safe, trained operator
Inspect the fluid
PH ( bedside ABG machine ), biochemistry, microbiology and cytology
What are the management options for pleural effusion
PH < 7.2 with pneumonia, pus or blood -> chest drain
Transudate: treat underlying cause, may not need CT imaging
Exudate : Unless cause identified will need further investigation for eg further imaging , and or pleural biopsy
What is the pathogenesis for pneumothorax
What are different types of pneumothorax
Primary Spontaneous
Secondary Spontaneous
Traumatic
Latrogenic
Tension
What is the presentation of pneumothorax
Sudden event
Chest pain or breathlessness
Tall thin young men
Underlying lung disease
History of biopsy /line insertion/mechanical ventilation
What do the examinations show in pneumothorax patient
tachypneic
Hypoxic
Reduced chest wall movement & reduced/no breath sounds
Not uncommonly examination may be normal
What are the investigations for pneumothorax
CXR
US
CT thorax
What do the management options depend on
Size
Effect on patient
Trained operator and staff aftercare
pneumothorax
What are the treatment options
Observe : small and patient well
Aspiration : over 2 cm in size , patient well
Chest drain insertion
Surgery : recurrent events, unresolving
Where does a pleural aspiration take place
Safe triangle
2nd intercostal space midclavicular line
What is the pathogenesis of pleural tumour
Benign- rare
Malignant pleural effusions common
Primary malignancy- Mesothelioma common
What are the chracteristics of mesothelioma
rare, aggressive
Affects- Men , plumbers, electricians, shipbuilding , power plants, boilers, engines
Inhaled asbestos fibres reach pleura & cause inflammation provokes tumour formation
What are the symptoms/signs of mesothelioma
Breathlessness
Chest Pain
Weight loss
Clubbed , signs of a pleural effusion
What are the investigations for Mesothelioma
CXR- pleural effusion, pleural based mass
CT Thorax and Biopsy: needed to stage
What is shown in the investigations for mesothelioma
Thickened pleura
pleural nodules or masses,
pleural plaques,
an effusion
soft tissue infiltration
WHat are the management options for mesothelioma
Treating the effusion
Chemotherapy
Recruitment to trials via MDTs
Palliative surgery in select patients
WHat are the management options for mesothelioma
Treating the effusion
Chemotherapy
Recruitment to trials via MDTs
Palliative surgery in select patients
