Pleural Diseases (Effusion/Mesothelioma) Flashcards
What is the pleura
A layer that covers the chest wall and the lung
- made out of the parietal pleura and visceral pleurae
What is the pleural space
- the potential space between the visceral and the parietal pleura
What is usually in the pleural space
- usually there is a small amount of pleural fluid
- sub atmospheric pressure normally allowing lungs to remain inflated
What is the pleural space lined with
mesothelial cells
What goes through the parietal pleura
blood vessels
what goes through the visceral pleura
blood vessels
What is on either side of the pleural space
- Next to the parietal pleura is the extra pleural parietal interstitial
- next to the visceral pleura is the pulmonary interstitial
- in the middle in the pleural space
What are local factors (exudates) that cause pleural effusion
- increase in capillary permeability = caused by trauma, malignancy, inflammation, infection, pancreatitis
- increase in pleural permeability = inflammation, malignancy, pulmonary embolus
- decrease in lymphatic drainage = malignancy, trauma
- increase in negative pleural pressure (usually negative but becomes even more negative) = atelectasis, mesothelioma
What are the systemic factors (transudates) that cause pleural effusion
- increase in capillary hydrostatic pressure = due to heart failure
- increase in pulmonary interstitial fluid = due to heart failure
- decrease in intravascular oncotic pressure = hypoalbuminaemia, cirrhosis
- increase in flow of fluid from other cavities = peritoneal dialysis, cirrhosis
What are the symptoms of pleural effusion
- Asymptomatic
- Dry cough
- Breathlessness
- Pleuritic chest pain
- “Shoulder pain”/ “Heaviness”
What are the clinical examination signs of pleural effusion
Inspection
- decrease chest expansion
Palpation
- decrease chest expansion
- decrease tactile vocal fremitus
- decrease tracheal deviation
Percussion
- stony dull
Auscultation
- decrease or absent breath sounds, bronchial breathing
What is bronchial breathing
- hollow sound
What is classification of pleural effusion
- Pleural fluid protein
- then use Light’s criteria if borderline
describe the pleural effusion types due to pleural fluid protein
Pleural fluid protein
- exudate - greater than 30g/L
- transudate - less than 30g/L
Describe how lights criteria works and what case you use it in
- use light’s criteria in those with borderline pleural protein (25 to 30g/L) or abnormal serum protein
Lights criteria - pleural fluid is an exudate if one of the following criteria are met:
- pleural fluid protein divided by serum protein > 0.5
- pleural fluid LDH divided by serum LDH > 0.6
using Lights criteria what makes a pleural effusion an exudate
Lights criteria - pleural fluid is an exudate if one of the following criteria are met:
- pleural fluid protein divided by serum protein > 0.5
- pleural fluid LDH divided by serum LDH > 0.6
what are the common causes of exudate pleural effusion
- Para pneumonic effusion
- Malignancy
- Pulmonary embolism
- Rheumatoid arthritis
- Mesothelioma
What are the less common causes of exudate pleural effusion
• Drugs • TB • Pancreatitis • Oesophageal rupture • Post cardiac injury (Dressler’s syndrome) • Post-CABG • Benign asbestos-related effusions - empyema
What are the two types of pleural effusion
- exudate
- transudate
What are the common causes of transudate of pleural effusion
- left ventricular failure
- cirrhotic liver disease
- peritoneal dialysis
- nephrotic syndrome
What are the less common causes of transudate pleural effusion
- constrictive pericarditis
- hypothyroidism
- Meig’s syndrome
What are the investigations that you need for pleural effusion
- Chest x-ray (CXR)
- Pleural fluid analysis
- Chest Ultrasound scan
- Chest CT scan
- Pleural biopsy (image-guided or Medical thoracoscopy)
- Video-assisted thoracic surgery (VATS)
Where do you aspirate pleural fluid from
Triangle of safety
- lateral border of pec major, lateral edge of lat doors, line along 5th intercostal space, axilla
What do you remove pleural fluid from the triangle of safety
- triangle of safety - minimise the complications and puncturing of internal organs
what do you analyse in the pleural fluid
• Appearance • pH • Protein • Glucose Pleural Fluid Analysis • LDH • Cytology (malignant cells, differential cell counts) • Microbiology (Gram stain and culture, AFB)
What is the diagnostic algorithm for pleural fluid
- History, examination, CXR
- if yes to clinically transudate - treat cause and if it doesn’t resolve then refer to a chest physician
- chest physician will do a pleural aspirate ultrasound guided
- then if still transudate - treat cause
- if not transudate has the fluid analysis and clinical features given a diagnosis
- if yes treat appropriately
- if no request a contrast enhanced CT thorax
- consider medical thoracoscopy or surgical VATS and consider radiologically guided pleural biopsy +/- chest tube drainage if symptomatic
- if the cause is found then treat appropriately
- if not then reconsider treatable conditions such as PE, TB, chronic heart failure, lymphoma
how does pleural infection present
Fever, sputum, chest pain, breathlessness
Who should you consider a diagnosis of pleural infection in
- Slow to respond pneumonias
- Pleural effusion with fever
- Malaise/weight loss
• High risk groups o Diabetes o Excess ETOH intake o GORD o IVDU o Aspiration and poor dental hygiene
How is at high risk of developing a pleural infection in
o Diabetes o Excess ETOH intake o GORD o IVDU o Aspiration and poor dental hygiene
What are the investigations for pleural infection
- Diagnostic pleural tap
- Blood culture
- Chest ultrasound
- Chest CT chest
How does a pleural infection progress
- Simple parapneumonic effusion
- complicated parapneumonic effusion
- empyema
describe the stages of pleural infection progress
Simple parapneumonic effusion
- Clear sterile fluid, normal pH, glucose and LDH, resolves with antibiotics, chest drain usually not required
Complicated parapneumonic effusion
- Fibrinopurulent stage, fluid infected but not purulent. pH<7.2, Gluc <2.2 mmol/L, LDH > 1000 IU/L, fluid gram stain may be positive, chest drain indicated
Empyema
- Pus in pleural space, free flowing, or multi- loculated, fluid gram stain may be positive, Drainage required. Fibroblasts may cause thick pleura
What can cause community acquired pleural infection
o Streptococcus spp. (~ 52%)
S milleri, S pneumoniae, S intermedius
o Staphylococcus aureus (11%)
o Gram-negative aerobes (9%)
Enterobacteriaceae, E coli
o Anaerobes (20%) Fusobacterium spp., Bacteroides spp., Peptostreptococcus spp., Mixed
What can cause hospital acquired pleural infection
o Staphylococci
MRSA (25%), S. aureus (10%)
o Gram-negative aerobes (17%)
E coli, Pseudomonas aeruginosa, Klebsiella spp.
o Anaerobes (8%)
What is the management of pleural infection
- Antibiotics = IV initially
- Chest tube drainage if:
- Purulent or turbid fluid
- Pleural fluid pH<7.2
- Organisms in pleural fluid gram stain or culture
- Intrapleural fibrinolytics (not routinely used)
- Nutritional support
- Surgery
- VATS procedure
- Thoracotomy and decortication
- Open thoracic drainage
What is a mesothelioma
Malignant tumour of serosal surfaces (usually pleura)
- due to tumour on pleura
What can cause mesothelioma
Asbestos exposure history identified in 90% of cases
What is the survival of mesothelioma
- Latent period (> 40 years after exposure)
* Poor prognosis (Median survival : 9 – 12 months)
What are the three main types of asbestos
- blue asbestos - thin and can be inhaled easily
- brown asbestos
- white asbestos - most commonly used
What occupations that are at risk of mesothelioma
- plumbers
- pipe fitters
- steamfitters
- electricians
- insertion workers
- carpenters
- labourers
- boilermakers
- welders and cutters
- janitors
What are the symptoms and signs of mesothelioma
• Chest pain (dull ache) • Symptoms of pleural effusion • Weight loss and fatigue (uncommon) • Chest wall invasion- - clubbing - dyspnoea
What investigations do you use for mesothelioma
- Radiology (CXR and CT thorax)
- pleural fluid analysis
- biopsy - ultrasound or CT guided pleural biopsy, medical thoracoscopy or VATs
- histological types
what would you seen in pleural fluid analysis of mesothelioma
o bloody/straw-coloured o Cytology (30%-80% yield)
What are the histological types of mesothelioma
- Epitheloid (50% of cases, better prognosis)
- Mixed (biphasic)
- Sarcomatoid
What is the management of mesothelioma
• Pleural effusions
- Drainage & pleurodesis (medical or surgical)
• Radiotherapy
- To reduce chest wall invasion risk & pain relief
• Chemotherapy
- Cisplatin with Pemetrexed or Gemcitibine
• Surgery
- selected cases only (high mortality)
- Pain relief
- Palliative Care
- Compensation
What chemotherapy drugs should be used for mesothelioma
- Cisplatin with Pemetrexed or Gemcitibine
what should CRP be less than
5
What lung diseases can asbestos cause
- pleural plaques - plaques are benign and do not undergo malignant change
- pleural thickening - asbestos exposure may cause diffuse pleural thickening
- asbestosis
- mesothelioma
- lung cancer
How do you confirm an asbestos related lung disease
- Lung scarring must be evident in imaging scans and lung function tests are frequently abnormal (restrictive lung disease)
- patient must have a history of asbestos exposure with an appropriate latency period between initial exposure and onset of symptoms
What type of lung disease does asbestos produce? restrictive or obstructive?
restrictive lung disease
What diseases do you have to have to be able to be entitled to compensation from asbestos related lung disease
- asbestosis
- mesothelioma
- lung cancer with asbestosis
- lung cancer without asbestosis if there has been extensive occupational exposure to asbestos in specified occupations
- diffuse pleural thickening
What is blood in the pleural space called
haemothroax
What is pus in the pleural space called
empyema
What is lymph with fat in the pleural space called
chylothorax
describe the management of a pleural effusion
- Drainage = if the effusion is symptomatic drain it, repeatedly if necessary
- pleurodesis with talc may be helpful for recurrent effusions
- intra-pleural alteplase and dornase alfa may help with empyema
- surgery
What is the definition of a haemothorax
The definition of haemothorax is a pleural fluid to blood haematocrit ratio greater than 50%.
What is the management of haemothorax
- intercostal drainage with a chest drain - 28-30G minimum
- ideal insertion is the 6th intercostal space mid-axillary line
- If it persists then go to VATs
what are the indications for surgery or urgent thoracotomy in haemothorax
◆ Haemodynamic instability despite adequate resuscitation.
◆ Initial drainage >1500 mL.
◆ Continued bleeding >200 mL/hour for 3 consecutive hours.
◆ Continued bleeding >1500 mL/day.
◆ Radiographic evidence of significant retained clot (>1/3 of pleural space)
