Pleural Diseases

Question 1

Whats dry pleurisy?

Answer 1

Describes inflammation of pleura, when there is no effusion.
↪️ localised sharp pain made worse on inspiration, coughing, bending or twisting movements.

Common causes: pneumonia, pulm imfraction, carcinoma.

Question 2

Whats a pleural effusion?

Answer 2

Xs accumulation of fluid in pelural space.
Detected clinically when >500mL
And by CXR when more than 300mL.
If small, might be asymptomatic or just SOB.
Massive effusions usually from carcinoma.

Physical signs
-reduced chest wall movements
Dull on percussion
Absent breath sounds
Reduced vocal resonance
Mediastinum shifted away. 

CXR- meniscus mark
Almost full white- fluid- no air.
Costophrenic angle masked.

Question 3

What is the fluid accumulating in a pleural effusion made out from?

Answer 3

Transudate- hydrostatic forced favour accumulation of pleural fluid- occusionally- movement of fluid from peritoneum or retroperitoneal space.

Exudates- from pleural rub or inflammation (resulting in capillary protein leak) or from impaired lymphatic drainage of pleural space.

Rarely-
From haemothorax- blood
Pus- empyema
Lymph- chylothorax.

Question 4

How do Chylousneffusions come about?

Answer 4

leakage of lymph from the thoracic duct due to trauma or infiltration by carcinoma

Question 5

What are some common causes of pleural effusions?

Answer 5

Transudate: 0.5 and /or pleural fluid LFD/ serum LDH >0.6. 
Common:
Bacterial pneumonia
Bronchus carcinoma
Pulm infraction
TB
Connective tissue disease

Others
Post MI syndrome
Acute pancreatitis
Mesothelioma
Sarcoidosis
Drugs- methotraxate, amiodarone

Question 6

How would you investigate a pleural effusion?

Answer 6

1. Pleural fluid aspiration unless clinical picture clearly suggests transudate- eg LVF pt. - green needle (21G) and 20mL syringe.
   Small effusions often require radiological guidance.
   Appearance noted- bloody, milky, turbid.
   Sample analysed for:
   Protein
   Lactic dehydrogenase (LDH)
   pH (

Question 7

How would you manage a pleural effusion?

Answer 7

Depends on the cause.
Exudates usually drained.
Transudates managed by tx of underlying cause.
Malignant effusion usually reaccumulate after drainage.
Tx by aspiration to dryness followd by instillation into pleural space of a sclerosing agent such as tertacyclin or bleomycin.

Question 8

What is a pneumothorax?

Answer 8

Presence of air in pelural space, can be spontaneous or 2o to chest trauma.
A “tension pneumothorax” rare unless on ventilation or nasal non imvasive ventilation. Pleural tear acts as one way valve through whichnair passes only during inspiration. +ve pressure builds up, causing increasing cardiorespiratory embarassment and eventually cardiac arrest.
Tx-
Immediate decompression by needle thoracocentisis (2ICS, mid clavicular line) and then intercoastal tube drainage.

Question 9

What could cause a pneumothorax?

Answer 9

Spontaneous primary pneumothorax
Typically- otherwise healthy tall males between ages 10-30 - result of rupture of subpleural bleb (thought to be a congenital defect in the connective tissue of alveolar wall) .

Secondary pneumothorax
Assc w/ underlying disease often COPD.

CXR
Size estimated by measuring the lateral edge of the lung, to the inner wall of the ribs. >2cm - pneumothorax at least 50% so large.
Larger pneumothotaces- shift of trachea and mediastinum

CF
Sudden onset of pleuritic pain with imcreasing breathlessness.

Question 10

How would you investigate a pneumothorax?

Answer 10

PA CXR confirm diagnosis.
Pts w/ severe bullousnlung disease a CT scan will differantiate emphysematous bullae from pneumothoraces + potentially save the patient from dangerous needle aspiration.

Question 11

How do you manage a primary spontaneous pneumothorax?

Answer 11

All pts admitted should receive high flow oxygen (10L/min) to increase absorption of air from pleural cavity.

1. Breathless and or >_2cm on CXR -No- consider discharge and return if breathless.
2. Yes
   Aspiration- succesful? Yes- discharge
   No- consider repeat aspiration if remove after 24hrs of full expansion without clamping. - discahrge
   No- refer to chest physician after 48hrs. (Suction?)
   Refer to thoracic surgeon after 5 days.

Question 12

How does the management of 2o pneumothoraces differs from 1o?

Answer 12

1. All pts should remain in hospital

2. A single attempt at aspiration is recommened only in minimally breathless pts and

Question 13

What are some disorders of the diaphragm?

Answer 13

Unilateral diaphragmatic paralysis- C2-C4 phrenic nerve involvment in thorac by bronchial carcinoma. Other causes of phrenic paralysis- trauma, surgery, motor neurone disease.
Unilateral paralysis produces no sx.

Characteristics of bilateral diaphragmatic weakness
1. Orthopnoea
2. Paradoxical (inward) movement of abdo wall on inspiration
3. Larfe fall of FVC on lying down.
Result of trauma, or generalised muscular disease or neurological condition e.g. Guillan -Barre syndrome.

Tx- diaphragmatic pacing or night time assisted ventilation.