Pleural Effusion and Malignancy Flashcards
What are the two types of pleura?
- Visceral - surrounding lungs - forms interlobal fissures
- Parietal - attached to body wall - covers mediastinum, diaphragm and inner surface of the thorax
What is the space formed due to the inferior borders of the pleural being much lower than the lung bases?
Costodiaphragmatic recess
How much intrapleural fluid should there be and what is its function?
4ml
Allows for pleura to stick together slightly and slide smoothy over each other
How much intrpleural fluid is required to be visible ona CXR?
200ml
What is a pleural effusion?
An abnormal collection of fluid in the pleural space
Which tests are required when there is a pleural effusion?
- CXR
- Pleural aspiration - sample of fluid tests for transudate or exudate
- Cytology tests
- Culturing of fluid to test for presence of microbes
- Contrast enhanced CT scan or pleural biopsy may be required
If the pleural fluid is straw coloured what can this mean?
Cardiac failure
Hypoalbuminaemia
If pleural fluid is bloody what can this suggest?
Trauma
Malignancy
Infection
Infarction
What can it signify if pleural fluid is milky/turbid?
Empyema
Chylothorax - accumulation of chyle - lymph from digestive system
When pleural fluid is foul smelling, what can this mean?
Anaerobic empyema present
If food particles are present in the pleural fluid what does this signify?
Ruptured oesophagus
If there is a bilateral pleural effusion what may be the cause?
LVF
Drugs
What is transudate fluid?
Low protein count (<30g/l)
What is exudate fluid?
High protein count (>30g/l)
Usually transudate fluid is associated with __________ conditions
Benign
What is the normal pH for pleural fluid?
7.6
At what pH will pleural fluid:
- Suggest inflammation
- Require draining due to high infection risk
- 7.3
- 7.2
If neutrophils are present in the extracted fluid from a pleural effusion what does this suggest?
The effusion is acute
Why is it difficult to differentiate between neoplasia and hyperplasia during fluid cytology?
Both possess features such as increased RNA, large nuclei and chromatin clumping
Neoplastic cells, however are less uniform, and there is more variation in the size of thier nuclei and cytoplasm
When suspecting pleural maligancy, what are the three options?
- Observe closely ofr future change
- Repeat tests - thoracentesis - no more than 2 samples
- Obtain tissue biopsy - percutaneous blind biopsy, CT guided or thoracoscopy
Why do pleural biopsies often come back negative in the presence of a postive result?
- Bad technique - no pleura obtained
- Pleural disease is discontinuous
- This effusion is not due to a malignancy, yet one is coincidentally present
What are ancillary effusions?
Effusions as a result of another condition such as a tumour
What is atelectasis?
Complete or partial collapse of a lung lobe often as a complication during surgery
What is mesothelioma?
An uncommon malignant tumour found in the lung lining or potentially in the lining of the abdominal cavity
What is the main cause of mesothelioma?
Asbestos exposure
What are the symptoms someone with mesothelioma may experience?
- Fever
- Weight loss
- Chest pain
- Sweating
- Cough
How can mesothelioma be investigated?
Imaging - view pleural nodules, pleural circumferance increases, local invasions or lung entrapment
Pleural fluid aspiration - determines cytology
Biopsy
Pleurodesis is a treatment for mesothelioma, what is it?
It is a treatment where the pleural layers are fused obliterating the pleural space
What are some treatment options for mesothelioma?
- Pleurodesis
- Radiotherapy
- Surgery
- Chemotherapy
- Palliative care
What is talc pleurodesis?
Talc is added to the pleural space to induce inflammation and fibrosis which will prevent further effusions
What is a long term solution for a patient to control thier pleural effusions?
The use of a pleural catheter
What is a LENT score?
A scoring system used to estimate survival rates for malignany pleural effusions
L - LDH (lactate dehydrogenase) estimates tissue damage
E - ECOG performace score - patient’s ability to take care of themselves
N - neutrophil to lymphocyte ratio in serum
T - tumour type
What is a pneumothorax?
The presence of air in the pleural space causing lung collapse
What is a primary pneumothorax?
Occurs in normal lungs
Often as a result of apical bullae rupture
What is a secondary pneumothorax?
Occurs as a result of an underlying lung disease such as COPD
What are risk factors for pneumothorax?
- Tall thin men
- Smokers
- Cannabis users
- Other lung disease
What are symptoms of pneumothorax?
Acute pleuritic chest pain
Hypoxia
What are the signs of pneumothorax?
Tachycardia
Hyper-resonant percussion note
Reduced expansion
Quiet breath sounds
What is a tension pneumothorax?
With each breath in, more air enters the pleural space, but the air cannot escape so only increases with time
Organs are pushed to the opposite side of the chest and acute respiratory distress may occur
What are some signs of a tension pneumothorax?
- Deviated trachea
- Hypotension
- Raised JVP
- Reduced air entry on affected side
How can a tension pneumothorax be treated?
Needle decompression
(second intercostal space mid-clavicular line)
What two main things can a deviated trachea indicate?
- Fluid build up
- Lung collapse (including pneumothorax)
On a CXR what does a line with a meniscus indicate?
A sub-diaphragmatic effusion - fluid below the lungs
What does a straight line on a CXR indicate?
Lung collapse
