Pleural diseases Flashcards
What is a pleural effusion?
- abnormal collection of gluid in the pleural cavity
- 2-3mL
State investigations of a pleural effusion
- CXR
- Ultrasound
- Pleural aspiration( needle/tube inserted into pleural space to remove fluid)
- Blood test to assess for tissue damage
State features of a pleural effusion on a CXR
- Loss of costophrenic angle ( place where diaphragm meets rib)
- Tracheal deviation
- concave/horizontal fluid level
- opacifications ( pleural plaque or calcifications due to asbestos exposure)
State the importance of using a chest wall ultrasound in the event of a pleural effusion
- it will help localise area most suited to aspirate pleural fluid
Which signs give a clue to the cause?
Foul smell= anaerobic empyema
Pus= empyema
Food particles= oesophageal rupture
Milky= cyclothorax, damage to thoracic duct
Blood stained= malignancy, TB, trauma, infarct
Cloudy: exudate, infection
???
Possible complications of a pleural effusion
- empyema,
- pneumothorax?
- vagal reflex( fainting)
- haemothorax
Pleural fluid inspections
Transudative: clear
Exudative: cloudy ( immune cells)
Lymphatic fluid: Milky ( fats)
Investigations of pleural fluid
- check pH
- Biochemistry( protein level in sample, LDH, glucose, triglyceride, cholesterole, amylase, rheumatpod factpr
- Microbiology ( gram stain, AAFB + culture
- Cytology( examination of cells in microscope)
Lights criteria criteria for Exudate + Transudate
Exudate: ( lights crieteria only)
- Protein >3.5
- LDH high
- Protein Lights criteria: >0.5
- LDH /serum LDH >0.6
- pleural fluid LDH>2/3 the upper limits of normal serum LDH
Transudate:
-protein < 2.5
-LDH normal
to differentiate transudate and exudate; aslong as fluid is 25-35g Lights criteria is used
Exudate causes
-inflammation of capillaries>leaky so more proteins leaks to pleural space
Respiratory related problems:
- infection, malignancy
- pulmonary embolus, rheumatoid arthritis, SLE
- pancreatis, benign asbestos effusions, drug related effusions
- post MI, yellow nail syndrome
Transudate causes
-Fluid accumulation due to high hydrostatic pressure + low oncoid pressure in capillaries
Any organ failure/condition causing a decrease in protein levels
- chylothorax ( TD duct interupted and LF accumulates in pleural space
- cardiac, liver, renal failure
- Hypoalbuinemia, hypothyroidism, pulmonary embolus
-Malginancy, constrictive pericarditis, meigs syndrome, nephrotic syndrome, cirrhosis
Where is LDH found?
-many tissues; cardiac, skeletal, liver, lungs, kidney
What can a large loculated effusion cause, how is it caused + state the treatment
- caused by pneumonia/TB
- can lead to empyema
- surgical removal
Symptoms of a pleural effusion
- dypsnoea ( worsens)
- unproductive cough
- pleuritic chest pain ( sharp + stabbing, if due to inflammatory exudate then can improve as inf.exudate causes pleura to seprate, but if malignancy worsens)
- dull ache
- pressure on mediastinum
- weight loss
- malaise
- fever
- night sweats
Clinical signs of pleurall effusion
- refuced lung expansion on affected side
- dull percussion
- reduced breath sounds
- reduced vocal resonance
- finger clubbing
- tar stained fingers
- cervical lymphadenopathy
- raised jugular venous pressure
- tracheal deviation ( in very large effusions, if same indicated lung collapse)
- peripheral oedema
Treatment of parapneunomic effusions
- drain if pH<7.2) as it indicates immune response
- drain largest locule
- inoculate blood culture bottles at time of sampling
- IV ABx?
- surgical referral early is poor control of sepsis/effusion
Treatment of pneumonic effusion
-chest drain in 4th intercostal space mid axillary line + patients arm at 45 degree angle + local anesthetic
Location of chest drainage ( safe triangle)
- 4th intercostal space of mid axillary line
- border of pectorals ( antetiorly)
- anterior border of latissimus dorsi muscle ( posterirly)
- Line at horizontal level of nipple/5th int space ( whichever is higher)
Options after chest drainage
Removal:
- if after drainage lung rexpands ( lower chance of infection)
Suction:
- if after drainage the lung has not completely re-expanded then suction is applied
PLeurodesis:
-If after lung has reexpanded but high chance it will occur again, pleurodesis is done(cancer) < seals up pleural space to prevent reoccurence
What is pleurodesis + state types
- sealing up of pleural space to prevent PE
- 2 types: Chemical/Surgical
Chemical
What is a chemical pleurodesis?
- talc slurry is injected into pleural cavity through chest drain.
- talc slurry = 4g fractionated ( prevents ARDS) and 50ml slurry.
- Talc irritates pleura triggering an inflammatory response which leads to pleura sticking together
- after talc instilled clamp added around chest drain
- remove drain after 12-72hrs if lung re-expands
What is surgical pleurodesis
- Video assisted thorascopy ( VATS)
- insert telescope to pleural cavity so fluid can be visualised + suction done
- talk then insufflated(blown into pleural cavity)
What is a tension pneumothorax?
- large pneumothorax that pushes mediastinum to opposite side > reduced venous return to the heart > fall in O2 > cardiac arrest?
- intrapleural pressure higher than atmospheric pressure
- air moves into pleural cavity but not out and accumulates
Types of pneumothorax
tension, primary, secondary
Treatment of tension pneumothorax
- O2
- aspirtate in 2nd intercostal space in midclavicular line + chest drain
- CXR
Asbestos related jobs
marine enginerr, ship building, docks, construction sites, jointers, plumbers, engine rooms, boilers
-Latent period ( 20-40)
Types of asbestos
Chrysotile (white)
Amosite (brown)
Crocidolite (blue)< DA
What do pleural plaques indicate?
- previous asbestos exposure
- found normally on parietal pleura
Benign asbestos effusion
- exudate, lymphotcytic, blood stained(maybe)
- chronic
- diffuse pleural thickening
What is a mesothelioma?
- malignant tumour of mesothelial cells(lines cavities)
- affects pleura of lungs/abdomen
- begins as nodules in pleura, then grows tos urround lungs + enters dissures, possible cause of pleural effusion
- linked with asbestos exposure
Clinical presentations of mesothelioma
- pleural effusion
- cough
- chest pain, breathlesness
- worsening dypsnoea
- weight loss, clubbing, haemoptysis, fever
Treatment and investigation of malignant mesothelioma
- CXR: pleural effusion, pleural based opacity/mass
- CT scan
- aspirtate; blood stained effusion abnormal mesothelial cells
- image bipsy/thorascopy/VATS
- chemotherapy
- palliation: plerudesis + long term drain insetion
