Pleural Diseases Flashcards

1
Q

Pleural space

A

Small amount of fluid in it normally
Between visceral and parietal
Pressure in the space allows lung inflation

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2
Q

What lines the pleural space?

A

Mesothelial cells

Lymphatic openings in between allowing fluid to leave pleural space

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3
Q

Pleural fluid pressure

A
  • hydrostatic pressure and oncotic pressure between parietal and visceral
  • hydrostatic pressure > in parietal than visceral
  • oncotic the same
  • fluid into pleural space mostly from parietal through lymphatic channels
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4
Q

What mechanisms cause excess fluid in pleural space?

A
  • problem with drainage of fluid via lymphatic channels
  • excess production of fluid from parietal moving to space

= PLEURAL EFFUSION

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5
Q

What are exudates?

A
  • local factors

- suggest protein levels are greater in fluid

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6
Q

What are transudates?

A
  • systemic factors

- indicate protein levels in fluid are low

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7
Q

Exudate examples?

A
  • permeable capillaries
  • pleural permeability
  • lymphatic drainage reduced
  • increase in negative pleural pressure
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8
Q

What causes permeable capillaries?

A
  • trauma
  • malignancy
  • inflammation
  • infection
  • pancreatitis
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9
Q

What causes pleural permeability?

A
  • malignancy
  • inflammation
  • PE
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10
Q

What causes reduced lymphatic drainage?

A
  • malignancy

- trauma

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11
Q

What causes increase in negative pleural pressure?

A
  • atelectasis

- mesothelioma

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12
Q

Examples of transudates?

A
  • increase in capillary hydrostatic pressure
  • increase in pulmonary interstitial fluid
  • reduced intravascular oncotic pressure
  • increase in flow of fluid from other cavities
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13
Q

What causes increase in capillary hydrostatic pressure?

A

HF

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14
Q

What causes increase in pulmonary interstitial fluid?

A

HF

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15
Q

What causes intravascular oncotic pressure reduction?

A
  • hypoalbuminemia

- cirrhosis

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16
Q

What causes increase in flow of fluid from other cavities?

A
  • peritoneal dialysis

- cirrhosis

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17
Q

Symptoms of pleural effusion?

A
  • asymptomatic
  • dry cough
  • breathlessness
  • pleuritic chest pain
  • shoulder pain/heaviness
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18
Q

Clinical signs of pleural effusion?

A
  • reduced chest expansion
  • reduced tactile vocal fremitus
  • trachea deviation
  • stony dull percussion
  • reduced or absent breath sounds
  • bronchial breathing?
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19
Q

Normal protein count in pleural space?

A

30g/L
> = exudate
< = transudate

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20
Q

Light’s criteria function

A
  • helps to distinguish between exudate and transudate if individual has borderline pleural protein (25-30) OR abnormal serum protein
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21
Q

Light’s criteria for exudate

A

EXUDATE IF

  • pleural fluid protein/serum protein >0.5
  • pleural fluid LDH/serum LDH >0.6
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22
Q

Common Causes of exudates

A
  • para pneumonic effusion
  • malignancy
  • PE
  • Rheumatoid arthritis
  • mesothelioma
23
Q

Less common causes of exudates

A
  • drugs
  • empyema
  • TB
  • pancreatitis
  • oesophageal rupture
  • post cardiac injury (dressler’s syndrome)
  • post CABG
  • benign asbestos-related effusion
24
Q

Common causes of transudates

A
  • LV failure
  • cirrhotic liver disease
  • peritoneal dialysis
  • nephrotic syndrome
25
Less common causes of transudates
- constrictive pericarditis - hypothyroidism - Meig's syndrome
26
Investigations for pleural effusion
- CXR - Pleural fluid analysis - Chest US scan - Chest CT scan - pleural biopsy (image guided/medical thoracoscopy) - video assisted thoracic surgery (VATS)
27
Pleural aspiration
- insert needle in safe triangle | - patient in position with arm on head OR sitting down leaning on arm with pillow or lying down on arm
28
Safe triangle borders
- anterior = lateral border of pec major - posteriorly = lateral edge of lattisimus dorsi - inferiorly = line along 5th ICS - superiorly = axillae
29
Pleural Fluid analysis
- appearance - pH - protein - glucose - LDH - cytology (malignant cells, differential cell counts) - microbiology (gram stain and culture, AFB)
30
Diagnostic Algorithm
- History, exam, CXR | - clinically transudate?
31
How to treat transudate?
- treat cause - see if resolved - if not = refer to chest physician - they will likely pleural aspirate via US guidance with other diagnostic tests
32
How to treat exudate?
- after done transudate investigations and ruled out - fluid analysis - treat cause appropriately - CT thorax if fluid analysis doesn't give cause - if still uncertain = medical thoracoscopy or surgical VATS or biopsy with chest drain for symptomatic relief
33
VATS
- video associated thoracic surgery - general anaesthetic - minimal invasive - multiple incisions between ribs - visualise pleura and can take biopsies and drain fluid - helps in making diagnosis - advantage as small incisions - less pain than traditional thoracotomy
34
Pleural infection presentation
- fever - sputum - chest pain - breathlessness
35
high risk groups for pleural infection
- diabetes - excess ETOH intake - GORD - IVDU - aspiration and poor dental hygiene - malaise/weight loss - pleural effusion with fever - slow response to pneumonia
36
Investigations for pleural infection
- diagnostic pleural tap for exudate/pus - blood culture - chest US - chest CT
37
How may pleural infection progress?
- simple parapenumonia effusion - complicated parapneumonic effusion - empyema
38
Simple parapneumonic effusion investigation results
- ABs resolve - fluid = clear, sterile, normal pH, glucose and LDH - chest drain usually not required
39
Complicated parapneumonic effusion investigation results
- fibrinopurlent fluid - fluid infected - glucose <2.2 - LDH > 1000 - fluid gram stain positive - chest drain needed
40
Empyema investigation results
- pus in pleural space - free flowing - multi loculated - fluid gram stain positive - fibroblasts causing thick pleura - chest drainage required
41
What causes CAP?
- streptococcus (mileri, pneumoniae, intermedius) cause majority - then anaerobes - then staph aureus - then gram negative aerobes (Enterobacteriaceae, E coli)
42
What causes HAP?
- often gram negative aerobes (E coli, pseudomonas, Klebsiella) - staphylococci (MRSA, S aureus) - Anaerobes
43
Management of pleural infection
- AB - Chest tube drainage - intrapleural fibrinolytics (not routine) - nutritional support - surgery (VATS, thoracotomy, open thoracic drainage)
44
Indicates for chest tube drainage in pleural infection
- purulent or turbid fluid - pleural fluid pH<7.2 - organisms in pleural fluid gram stain or culture
45
Define mesothelioma
- malignant tumour of serosal surfaces - asbestos exposure major RF - latent >40yrs of exposure
46
Prognosis of mesothelioma
- poor | - 9-12 months
47
3 main types of asbestos fibres
- crocidolite= blue (thinnest) - armosite = brown - chysotile = white (most commonly used now)
48
Symptoms and signs of mesothelioma
- chest pain (dull ache) - pleural effusion symptoms - weight loss and fatigue - chest wall invasion
49
Investigations for mesothelioma
- CXR and CT thorax - pleural fluid analysis (bloody/straw coloured) - biopsy (US or CT guided of pleura OR medical thoracoscopy or VATS)
50
CXR of mesothelioma
- loss of volume - pleural effusion - pleural thickening
51
Histological types of mesothelioma
- epithelioid (better prognosis) - mixed (biphasic) - sarcomatoid
52
Management of mesothelioma?
- pleural effusion = drainage and pleurodesis - radiotherapy = pain relief and reduce chest wall invasion risk - chemo - surgery (high mortality, selected cases) - pain relief - palliative care - compensation for asbestos exposure
53
Chemo for mesothelioma
- cisplatin with pemetrexed or gemcitibine