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
2
Q
What lines the pleural space?
A
Mesothelial cells
Lymphatic openings in between allowing fluid to leave pleural space
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
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
5
Q
What are exudates?
A
- local factors
- suggest protein levels are greater in fluid
6
Q
What are transudates?
A
- systemic factors
- indicate protein levels in fluid are low
7
Q
Exudate examples?
A
- permeable capillaries
- pleural permeability
- lymphatic drainage reduced
- increase in negative pleural pressure
8
Q
What causes permeable capillaries?
A
- trauma
- malignancy
- inflammation
- infection
- pancreatitis
9
Q
What causes pleural permeability?
A
- malignancy
- inflammation
- PE
10
Q
What causes reduced lymphatic drainage?
A
- malignancy
- trauma
11
Q
What causes increase in negative pleural pressure?
A
- atelectasis
- mesothelioma
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
13
Q
What causes increase in capillary hydrostatic pressure?
A
HF
14
Q
What causes increase in pulmonary interstitial fluid?
A
HF
15
Q
What causes intravascular oncotic pressure reduction?
A
- hypoalbuminemia
- cirrhosis
16
Q
What causes increase in flow of fluid from other cavities?
A
- peritoneal dialysis
- cirrhosis
17
Q
Symptoms of pleural effusion?
A
- asymptomatic
- dry cough
- breathlessness
- pleuritic chest pain
- shoulder pain/heaviness
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?
19
Q
Normal protein count in pleural space?
A
30g/L
> = exudate
< = transudate
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
21
Q
Light’s criteria for exudate
A
EXUDATE IF
- pleural fluid protein/serum protein >0.5
- pleural fluid LDH/serum LDH >0.6
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
