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respiratory > Pleural Effusion + Pneumothorax + other pleural disease > Flashcards

Pleural Effusion + Pneumothorax + other pleural disease Flashcards

1
Q

What is a pleural effusion

A

Accumulation of fluid in the pleural space

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2
Q

What causes pleural effusion

A

Transudates

Exudates

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3
Q

What do transudates have

A 
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
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4
Q

What do exudates have

A

High protein content >30 due to inflammation causing protein to LEAK OUT
Ratio >0.5
Increased permeability of capillaries due to disease
Unilateral

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5
Q

What are examples of transudates that cause increased pressure

A 
LV failure / heart failure = most common
Constrictive pericarditis
Fluid overload
PD - fluid tracks up
Kidney failure
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6
Q

What transudates cause hypo albumin

A

Liver cirrhosis
Nephrotic
Malabsorption

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7
Q

What are other causes of pleural effusion

A

Hypothyroid
MS
Ovarian hyperstimulation
Meig syndrome

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8
Q

What is Meig syndrome

A

Benign ovarian tumour - fibroma
Ascites
Pleural effusion

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9
Q

What are examples of exudates

A 
Malignancy - lung cancer 
Pneumonia
TB
PE
SLE / RA (low glucose) 
Pancreatitis
MI
Yellow nail 
Drugs

4 I’s

  • Infection
  • Inflammation
  • Infarction
  • Infiltration
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10
Q

What are symptoms of pleural effusion

A 
Asymtpomatic until >300ml 
Increasing SOB
Pleuritic chest pain
Dull ache
Dry cough
Weight loss
Malaise
Fever
Night sweats
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11
Q

What are signs of pleural effusion

A 
Decreased expansion
Stony dullness
Decreased breathsounds
Bronchial breathing at upper fluid level
Decreased vocal resonance
Trachea and mediastinum shift if large
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12
Q

What are signs of underlying disease

A 
Clubbing
Tar staining
Lymphadenopathy
JVP
Oedema
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13
Q

What are levels of transudates and exudates on the ward

What is Lights criteria

A

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
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14
Q

What two investigations to Dx pleural effusion and what type

A

CXR - PA in everyone
Pleural fluid aspiration
CT = more accurate

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15
Q

What does CXR show

A 
Lose diaphragm shadow
Lose of costaphrenic angle
Mediastinal shift
Trachea deviated away
Complete white out of lung
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16
Q

What do you send aspiration for and what do levels suggest

A 
pH
Glucose 
Protein
Cell count 
LDH
Lactate
Amylase 
Triglycerides 
Cytology
Microbiology
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17
Q

What does different colours of aspiration suggest / results

A 
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

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18
Q

What other tests can be done

A

CT to detect tumour / cause

Pleural biopsy

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19
Q

What do you send after biopsy

A

3 formalehyde for histology

1 in saline to micro for TB if inconclusive

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20
Q

How do you treat pleural effusion

A

Pleural fluid aspiration to find cause
Chest drain
Surgery for persistent collections/ increasing thickness

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21
Q

When do you put in drain + Ax

A

If suspect empyema = high mortality
- Purulent fluid
- pH <7.2 - put sample in ABG
Suspected infection / abscess

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22
Q

What do you do for recurrent pleural effusions

A

Recurrent pleural aspiration
Pleurodesis + talc
Indwelling pleural catheter
Drug for Sx relief - opiod for dyspnoea

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23
Q

What do you do for malignant pleural effusion

A

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

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24
Q

What are complications of aspiration / drainage

A 
Pneumothorax
Empyema  
Pulmonary oedema due to rapid re-exapnsion of lung 
Air embolism
Tumour cell seeding
Haemothorax
Vagal - lack of anaesthesia
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25
Q

When do you use a large bore chest drain

A

Haemothorax

Trauma

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26
Q

When do you use small bore chest drain

A

Pneumothorax

Pleural effusion

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27
Q

How do you put in a drain

What is the boundaries of the safe triangle

A

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

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28
Q

What do you need for chest drain

A

Analgesia as painful to breath
Admit
Seal rises on inspiration and falls on expiration

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29
Q

What is a haemothorax

A

Blood in pleural space

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30
Q

What is a pneumothorax

A

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

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31
Q

What causes primary pneumothorax

A

Tall, thin men

Rupture of pleural bleb in healthy lung

32
Q

What is a bullae

A

Air space >2cm

33
Q

When should you suspect pneumothorax

A

Young male present SOB and pain

34
Q

What are secondary causes of pneumothorax

A 
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

35
Q

What are traumatic causes of pneumothorax

A 
Ventilation
Gun shot
Fractured rib
Pleural aspiration
Subclavian cannulation
Acupuncture
Catamenial
36
Q

What is catamenial

A

Endometriosis in thorax

37
Q

What is fatal

A

Bilateral pneuothroax

38
Q

What are symptoms of pneumothorax

A 
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
39
Q

What are signs if on a ventilator

A

Increased ventilation pressure

40
Q

What does CXR show

A

No lung markings

Ensure not just large bullae

41
Q

What position for CXR

A

Erect
Lateral decubitus
Can’t detect supine

42
Q

Other tests

A

ABG for hypoxia / chronic lung

43
Q

When do you not do CXR

A

Tension

Delays management

44
Q

How do you manage a primary pneumothorax

A

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

45
Q

When would you do chest drain in primary

A

Aspiration fails 2x

Persistent air leak >2cm and SOB

46
Q

Best advice

A

Stop smoking

47
Q

When would you do chest drain in secondary

A 
>50
>2cm
SOB
Unstable patient 
Bilateral 
2nd 
COPD / ventilation
48
Q

When would you do aspiration

A

1-2cm
If success = observe 24 hours
If no improvement = drain

49
Q

What would you do if <1cm

A

Admit for 24 hour observation

Give O2

50
Q

Can you fly an airplane

A

No airplane flight 6 weeks

51
Q

What do you do for iatrogenic

A

Most resolve

Aspiration if not

52
Q

What needs drain

A

COPD / ventilation

53
Q

When is pleurdesis recommended

A 
2nd ipsilateral
1st contralateral
Bilateral
1st in high risk - diver / pilot
Failure of lungs to re-exapnd 48hours after drain
54
Q

What are the complications of drainage

A 
Emphysema  - need larger tube
Failure to reinflate (apply suction or surgeons)
Pulmonary oedema 
Air embolism 
Haemothorax
55
Q

What does failure to re expand suggest

A

Bronchopleural fistula
Need pleurodesis
Avoid diving for life

56
Q

What is a tension pneumothorax

A 
Opening from lung to pleural space = one way valve
Air enters inspiration
Can't go out
Pressure rises
Lung deflates
Causes mediastinal shift
57
Q

Complications of tension pneumothorax

A

Venous return and CO compromised due to veins compressed
Shock
Cardio-respiratory arrest

58
Q

What is common cause of tension

A

RTA

Thoracic trauma creating a flail

59
Q

What are the symptoms

A 
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)
60
Q

How do you Dx

A

CXR but delays management so don’t

61
Q

How do you treat

A

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

62
Q

What is a mesothelioma

A

Pleural malignancy

63
Q

What causes

A

Asbestos
Building / plumber / engineer at risk
Usually latency period of 40 years

64
Q

Symptoms of mesothelioma

A 
Progressive SOB due to secondary pleural effusion 
Pleural effusion
Chest wall pain
Weight loss 
Clubbing
Mets
LN
Bone pain
Hepatomegaly
Abdominal pain
65
Q

What does a malignant effusion have

A

Blood stain

High lymphocyte

66
Q

How do you Dx

A

CXR / CT = pleural thickening
Bloody pleural fluid on aspiration
Thoracoscopy = diagnostic test
NOT bronchoscope as doesn’t affect airway

67
Q

How do you Rx

A

Palliative chemo
Pleuropneumoectomy if fit
RT
Pleurodesis for palliation

68
Q

Life expectancy

A

18 months

69
Q

What are other diseases due to asbestos

A

Pleural plaque - very common + benign

Pleural thickening

70
Q

What is asbestosis

A

LL fibrosis of lung
15-30 years after exposure
Related to degree of exposure

71
Q

What are symptoms

A

SOB

Reduced exercise

72
Q

What do you do a thoracoscopy for in pleural effusion

A

To find cause

73
Q

Complications of chest drain

A 
Failure
Bleeding
Inefction
Penetration of lung
Re-expansion pulmonary oedema
Emphysema
Failure of lung to reinflate due to bronchopulmonary fistula
74
Q

How does oedema present

A

Cough

SOB

75
Q

What do you do

A

Clamp drain and CXR

respiratory (23 decks)

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