Pleural Diseases Flashcards
Define, in general, pleural disease.
Any conditions affecting the pleura/ pleural cavity.
What are the layers of the pleura?
What are 3 examples of pleural diseases?
Pleural Effusion
Pleural Malignancy
Pneumothorax
Define a pleural effusion. Classify and list the causes of a pleural effusion
Accumulation of fluid in the pleural space
Causes:
Transudative: Increased hydrostatic pressure
Hypoalbuminemia: Cirrhosis, nephrotic syndrome
Congestive HF
Constrictive pericarditis
Exudative: Increased oncotic pressure
Infective: Tb, fungal, !parapneumonic, empyema)
Malignancy
Pancreatitis
Post-op (e.g. CABG)
List 2 types of pleural malignancies.
Mesothelioma, metastasis
Define a pneumothorax. Classify and list the possible causes.
the also classified as simple or tension
fluid in the pleural space is considered to be pleural effusion if how many mls are present?
At what volume would symptoms most likely begin to be present?
25ml to be considered pleural effusion
300mls for sc
What are the common symptoms of pleural diseases?
What exam findings would you expect to see on general and closer inspection of a pleural disease case?
orange - pleural malignancy
pink - pneumothorax
green - pleural effusion
What exam findings would you expect to illicit on palpation, percussion and auscultation of a pleural disease case? What special tests can you offer?
What are ALL your exam findings for pleural disease?
Is asymmetric chest expansion a common findings in significant pleural disease?
Yes
What are your diagnostic investigations for pleural diseases? what are your expected findings?
How would you grade a pneumothorax?
What are the non-diagnostic investigations to support your dx of a pleural disease? Justify each.
Describe this image.
right sided pneumothorax
This is the CXR of the a patient with a pneumothorax. A was taken first and then B, both on the same day. What is a possible reason for the pneumothorax appearing different in image B?
Inspiration and expiration CXR in a case of right sided spontaneous pneumothorax. Note that the extension of pneumothorax is larger during expiration than inspiration and the expansion of the affected hemi-lung is more evident in the affected side.
You are performing a chest drain or needle thoracocentesis on a patient with massive pleural effusions. You note blood in the fluid escaping the thorax. What are the 3 most likely differentials?
PE
Malignancy
Trauma
When you obtain pleural fluid, or any fluid in that case, What do you send it for?
Cytology/Microscopy (malignancy? Exudate)
Gram stain
Culture and sensitivity (infective? Exudate)
+ in pleural diseases: LDH and protein to compare to levels in the serum
You perform a chest drain and send the fluid to microbiology for gram staining, culture, sensitivity and pathology for cytology and microscopy. The report from microbiology comes back noting a high level or neutrophils in the pleural fluid.
What are your top 3 differentials?
For these 3 differentials state if they are transudative or exudative
What if your found lymphocytes?
3 Ps:
Pneumonia (exudative)
Pulmonary embolus
Pancreatitis (extends into the pleural space)
Lymphocytes in the context of pleural fluid means a chronic process is there => every other diagnosis
What is used to determine if pleural fluid is transudative or exudative?
Light’s criteria
What is Light’s criteria?
What labs will you order for this?
Go through it
Set of guidelines used to distinguish between transudative and exudative pleural effusions.
It requires Serum protein and LDH + Pleural fluid protein and LDH
If one or more of the following are true then it is likely exudative:
1) PF protein/serum protein >0.5
2) PF LDH/Serum LDH >0.6
3) PF LDH >2/3 upper normal limit of Serum LDH
What can cause both pleural and pericardial effusions? (2)
Tb
Constrictive pericarditis
Is Tb transudative or exudative?
Exudative
What is a parapneumonic pleural effusion?
Parapneumonic refers to any pleural effusion caused by pneumonia
Is malignancy transudative or exudative?
Exudative
A patient post op develops reduced breath sounds and bronchial breathing over their left lung. You ask the patient and they say it was a heart procedure. The patient is unstable.
What procedure is the most likely one?
What has occurred?
Is it transudative or exudative
Post- CABG pleural effusion
Exudative
Is a PE transudative or exudative?
Can be either but mostly exudative due to the inflammation that ensues
Remember anything causing inflammation or infection is exudative
What are your differentials for a transudative pleural effusion vs exudative?
Transudative:
Hypoalbuminemia: Cirrhosis, nephrotic syndrome
Congestive HF
Constrictive pericarditis
SVC obstruction
Exudative:
Infective: Tb, fungal, !parapneumonic, empyema)
Malignancy
PE
Pneumonia
Pancreatitis
Post-op (e.g. CABG)
You notice this on the ward. What do you think this is? or at least what is it used for?
It is a PleurX catheter
used to drain pleural or ascitic fluid from the pleural or peritoneal spaces.
The bottle is iconic
Pleurodesis is performed for a variety of reasons. Only tell me how it works (not full details)
It causes inflammation to allow the visceral and parietal pleura to stick together (adhesion)
Malignancies typically cause exudative pleural effusions. There is, however, one exception. What is it?
Any cancer causing SVC obstruction => some lung cancers, oesophageal…
“grading of pneumothorax” is based on size and clinical compromise. How do you assess the size of a pneumothorax? What size is considered small? Large?
Between lung margin and chest wall
Small <2cm
Large >2cm
Outline the management of a pneumothorax.
What is the treatment of a pleural effusion caused by
1) empyema
2) malignancy
What are the complications of pleural diseases?
Where is a chest drain inserted? Include the boundaries of the safety triangle.
4-5th ICS midaxillary line from above the rib (to avoid neurovascular bundle)
Boundaries:
Lateral border of Pec Major (Follow axillary fold
Anterior border of Latissimus dorsi
5th ICS
Where should the contents from a chest drain empty into? Explain the system briefly
Underwater seal used for one way flow of both
fluid and air - Ventilation to prevent air ingress.
This system is attached to wall suction.
After performing a chest drain, how will you confirm it is properly performed?
Assessment involves checking for:
1) Oscillation -> Moving with breath (if not, blocked or dislodged)
2) Bubbling if pneumothorax
3) Repeat CXR shows improvement + clinical improvement
After performing a chest drain for a patient with a pneumothorax, you assess to ensure it has been done correctly. you notie the oscillations moving with the breath and bubbling. After a few hours, the clinical status of the patient is improved. You perform a repeat X-ray to confirm this and see that it is now resolved. You look back at the underwater seal and its actually still bubbling. 24 hours pass and it is still bubbling. Whats going on? How will you manage?
If still bubblin but CXR shows that it has resolved, this suggests a persistent leak => Pleurodesis (VATS)
What is this device?
CHEST DRAIN
