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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
When do you use a large bore chest drain
Haemothorax | Trauma
26
When do you use small bore chest drain
Pneumothorax | Pleural effusion
27
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
28
What do you need for chest drain
Analgesia as painful to breath Admit Seal rises on inspiration and falls on expiration
29
What is a haemothorax
Blood in pleural space
30
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
31
What causes primary pneumothorax
Tall, thin men | Rupture of pleural bleb in healthy lung
32
What is a bullae
Air space >2cm
33
When should you suspect pneumothorax
Young male present SOB and pain
34
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
35
What are traumatic causes of pneumothorax
``` Ventilation Gun shot Fractured rib Pleural aspiration Subclavian cannulation Acupuncture Catamenial ```
36
What is catamenial
Endometriosis in thorax
37
What is fatal
Bilateral pneuothroax
38
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 ```
39
What are signs if on a ventilator
Increased ventilation pressure
40
What does CXR show
No lung markings | Ensure not just large bullae
41
What position for CXR
Erect Lateral decubitus Can't detect supine
42
Other tests
ABG for hypoxia / chronic lung
43
When do you not do CXR
Tension | Delays management
44
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
45
When would you do chest drain in primary
Aspiration fails 2x | Persistent air leak >2cm and SOB
46
Best advice
Stop smoking
47
When would you do chest drain in secondary
``` >50 >2cm SOB Unstable patient Bilateral 2nd COPD / ventilation ```
48
When would you do aspiration
1-2cm If success = observe 24 hours If no improvement = drain
49
What would you do if <1cm
Admit for 24 hour observation | Give O2
50
Can you fly an airplane
No airplane flight 6 weeks
51
What do you do for iatrogenic
Most resolve | Aspiration if not
52
What needs drain
COPD / ventilation
53
When is pleurdesis recommended
``` 2nd ipsilateral 1st contralateral Bilateral 1st in high risk - diver / pilot Failure of lungs to re-exapnd 48hours after drain ```
54
What are the complications of drainage
``` Emphysema - need larger tube Failure to reinflate (apply suction or surgeons) Pulmonary oedema Air embolism Haemothorax ```
55
What does failure to re expand suggest
Bronchopleural fistula Need pleurodesis Avoid diving for life
56
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 ```
57
Complications of tension pneumothorax
Venous return and CO compromised due to veins compressed Shock Cardio-respiratory arrest
58
What is common cause of tension
RTA | Thoracic trauma creating a flail
59
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) ```
60
How do you Dx
CXR but delays management so don't
61
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
62
What is a mesothelioma
Pleural malignancy
63
What causes
Asbestos Building / plumber / engineer at risk Usually latency period of 40 years
64
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 ```
65
What does a malignant effusion have
Blood stain | High lymphocyte
66
How do you Dx
CXR / CT = pleural thickening Bloody pleural fluid on aspiration Thoracoscopy = diagnostic test NOT bronchoscope as doesn't affect airway
67
How do you Rx
Palliative chemo Pleuropneumoectomy if fit RT Pleurodesis for palliation
68
Life expectancy
18 months
69
What are other diseases due to asbestos
Pleural plaque - very common + benign | Pleural thickening
70
What is asbestosis
LL fibrosis of lung 15-30 years after exposure Related to degree of exposure
71
What are symptoms
SOB | Reduced exercise
72
What do you do a thoracoscopy for in pleural effusion
To find cause
73
Complications of chest drain
``` Failure Bleeding Inefction Penetration of lung Re-expansion pulmonary oedema Emphysema Failure of lung to reinflate due to bronchopulmonary fistula ```
74
How does oedema present
Cough | SOB
75
What do you do
Clamp drain and CXR

Respiratory (23 decks)

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