Pleural Effusion + Pneumothorax + other pleural disease Flashcards
What is a pleural effusion
Accumulation of fluid in the pleural space
What causes pleural effusion
Transudates
Exudates
What do transudates have
Low protein content <30 Low LDH Ratio <0.5 Causes changes in hydrostatic / osmotic pressure which pushes fluid out into pleural space rather than pleural disease BILATERAL
What do exudates have
High protein content >30 due to inflammation causing protein to LEAK OUT
Ratio >0.5
Increased permeability of capillaries due to disease
Unilateral
What are examples of transudates that cause increased pressure
LV failure / heart failure = most common Constrictive pericarditis Fluid overload PD - fluid tracks up Kidney failure
What transudates cause hypo albumin
Liver cirrhosis
Nephrotic
Malabsorption
What are other causes of pleural effusion
Hypothyroid
MS
Ovarian hyperstimulation
Meig syndrome
What is Meig syndrome
Benign ovarian tumour - fibroma
Ascites
Pleural effusion
What are examples of exudates
Malignancy - lung cancer Pneumonia TB PE SLE / RA (low glucose) Pancreatitis MI Yellow nail Drugs
4 I’s
- Infection
- Inflammation
- Infarction
- Infiltration
What are symptoms of pleural effusion
Asymtpomatic until >300ml Increasing SOB Pleuritic chest pain Dull ache Dry cough Weight loss Malaise Fever Night sweats
What are signs of pleural effusion
Decreased expansion Stony dullness Decreased breathsounds Bronchial breathing at upper fluid level Decreased vocal resonance Trachea and mediastinum shift if large
What are signs of underlying disease
Clubbing Tar staining Lymphadenopathy JVP Oedema
What are levels of transudates and exudates on the ward
What is Lights criteria
Transudate <25
Exudates >25 + high LDH
Exudate = protein Light's Fluid to serum protein >0.5 Fluid LDH to serum LDH >0.6 Fluid LDH >2/3 of normal serum
What two investigations to Dx pleural effusion and what type
CXR - PA in everyone
Pleural fluid aspiration
CT = more accurate
What does CXR show
Lose diaphragm shadow Lose of costaphrenic angle Mediastinal shift Trachea deviated away Complete white out of lung
What do you send aspiration for and what do levels suggest
pH Glucose Protein Cell count LDH Lactate Amylase Triglycerides Cytology Microbiology
What does different colours of aspiration suggest / results
Straw = transudates or exudate Blood = malignancy / PE / TB / trauma Food = oesophageal rupture Pus = empyema from infection
Results
Low glucose = empyema / TB / RA / connective tissue / malignancy
Low PH = same as glucose
High LDH = empyema / malignancy / RA
High amylase = pancreatitis / lung cancer / oesophageal rupture
Lymphocytes = TB / malignancy / sarcoid
What other tests can be done
CT to detect tumour / cause
Pleural biopsy
What do you send after biopsy
3 formalehyde for histology
1 in saline to micro for TB if inconclusive
How do you treat pleural effusion
Pleural fluid aspiration to find cause
Chest drain
Surgery for persistent collections/ increasing thickness
When do you put in drain + Ax
If suspect empyema = high mortality
- Purulent fluid
- pH <7.2 - put sample in ABG
Suspected infection / abscess
What do you do for recurrent pleural effusions
Recurrent pleural aspiration
Pleurodesis + talc
Indwelling pleural catheter
Drug for Sx relief - opiod for dyspnoea
What do you do for malignant pleural effusion
Repeated aspiration
Pleurodesis if longer life expectancy
Drain all fluid (check with CXR) using drain then chemical pleurodesis
Remove drain after 12-72 hours
Surgical pleurodesis at time of thoracoscopy
What are complications of aspiration / drainage
Pneumothorax Empyema Pulmonary oedema due to rapid re-exapnsion of lung Air embolism Tumour cell seeding Haemothorax Vagal - lack of anaesthesia
When do you use a large bore chest drain
Haemothorax
Trauma
When do you use small bore chest drain
Pneumothorax
Pleural effusion
How do you put in a drain
What is the boundaries of the safe triangle
Anatomical guidance - 5th IC space mid clavicular
USS
Safety triangle 5th IC space Stay superior as NV bundle lies inferior Anterior border of latissimus dorsi Posterior border of pec major Above horizontal line of nipple Apex below axill
Get a CXR to check position
What do you need for chest drain
Analgesia as painful to breath
Admit
Seal rises on inspiration and falls on expiration
What is a haemothorax
Blood in pleural space
What is a pneumothorax
Presence of air within the pleural cavity
Lung collapses away from chest wall due to elastic recoil
If haemodynaimcall unstable or bilateral = immediate chest drain
What causes primary pneumothorax
Tall, thin men
Rupture of pleural bleb in healthy lung
What is a bullae
Air space >2cm
When should you suspect pneumothorax
Young male present SOB and pain
What are secondary causes of pneumothorax
COPD Asthma TB CF Lung cancer Sarcoid Connective tissue Fibrosing alveolitis Abscess
Typically >50
Significant smoking Hx
Evidence of underlying lung disease on exam or CXR
What are traumatic causes of pneumothorax
Ventilation Gun shot Fractured rib Pleural aspiration Subclavian cannulation Acupuncture Catamenial
What is catamenial
Endometriosis in thorax
What is fatal
Bilateral pneuothroax
What are symptoms of pneumothorax
Asymptomatic if small and large reserve Acute SOB worsening Pleuritic chest pain Sweating Tachycardia Tachypnoea Reduced breath sounds Reduced expansion Hyper-resonance on side of pneumothorax Surgical emphysema if significant air leak Left side clicking if cardiac produces friction
What are signs if on a ventilator
Increased ventilation pressure
What does CXR show
No lung markings
Ensure not just large bullae
What position for CXR
Erect
Lateral decubitus
Can’t detect supine
Other tests
ABG for hypoxia / chronic lung
When do you not do CXR
Tension
Delays management
How do you manage a primary pneumothorax
If <2cm and no SOB = discharge and follow up in 2-4 weeks
If >2cm and or breathless =
Aspiration 2nd IC space mid clavicular
If <2cm after aspiration and no SOB consider discharge
When would you do chest drain in primary
Aspiration fails 2x
Persistent air leak >2cm and SOB
Best advice
Stop smoking
When would you do chest drain in secondary
>50 >2cm SOB Unstable patient Bilateral 2nd COPD / ventilation
When would you do aspiration
1-2cm
If success = observe 24 hours
If no improvement = drain
What would you do if <1cm
Admit for 24 hour observation
Give O2
Can you fly an airplane
No airplane flight 6 weeks
What do you do for iatrogenic
Most resolve
Aspiration if not
What needs drain
COPD / ventilation
When is pleurdesis recommended
2nd ipsilateral 1st contralateral Bilateral 1st in high risk - diver / pilot Failure of lungs to re-exapnd 48hours after drain
What are the complications of drainage
Emphysema - need larger tube Failure to reinflate (apply suction or surgeons) Pulmonary oedema Air embolism Haemothorax
What does failure to re expand suggest
Bronchopleural fistula
Need pleurodesis
Avoid diving for life
What is a tension pneumothorax
Opening from lung to pleural space = one way valve Air enters inspiration Can't go out Pressure rises Lung deflates Causes mediastinal shift
Complications of tension pneumothorax
Venous return and CO compromised due to veins compressed
Shock
Cardio-respiratory arrest
What is common cause of tension
RTA
Thoracic trauma creating a flail
What are the symptoms
Same symptoms as above Mediastinal shift to affected side Display apex Deviated trachea AWAY from tension Resp distress Tachy Hypotension Increased JVP (distended neck veins)
How do you Dx
CXR but delays management so don’t
How do you treat
Needle decompression using a large bore cannula (14G) into 2nd IC space midclavicular
Place superior to rib of interest as NV runs inferiorly
Chest drain after or if patient stable
What is a mesothelioma
Pleural malignancy
What causes
Asbestos
Building / plumber / engineer at risk
Usually latency period of 40 years
Symptoms of mesothelioma
Progressive SOB due to secondary pleural effusion Pleural effusion Chest wall pain Weight loss Clubbing
Mets LN Bone pain Hepatomegaly Abdominal pain
What does a malignant effusion have
Blood stain
High lymphocyte
How do you Dx
CXR / CT = pleural thickening
Bloody pleural fluid on aspiration
Thoracoscopy = diagnostic test
NOT bronchoscope as doesn’t affect airway
How do you Rx
Palliative chemo
Pleuropneumoectomy if fit
RT
Pleurodesis for palliation
Life expectancy
18 months
What are other diseases due to asbestos
Pleural plaque - very common + benign
Pleural thickening
What is asbestosis
LL fibrosis of lung
15-30 years after exposure
Related to degree of exposure
What are symptoms
SOB
Reduced exercise
What do you do a thoracoscopy for in pleural effusion
To find cause
Complications of chest drain
Failure Bleeding Inefction Penetration of lung Re-expansion pulmonary oedema Emphysema Failure of lung to reinflate due to bronchopulmonary fistula
How does oedema present
Cough
SOB
What do you do
Clamp drain and CXR
