Pleural malignancy

Question 1

What does the visceral pleura cover and what does it form?

Answer 1

The lungs and it forms the interloper fissures

Question 2

What does the parietal pleura cover?

Answer 2

The mediastinum, diaphragm and inner surface of the thorax

Question 3

Do the hila have pleural coverage?

Answer 3

No as the two layers combine around the hill of the lung

Question 4

What do the pleural layers combine to form?

Answer 4

The pulmonary ligament which runs inferiorly and attached the root of the lung to the diaphragm.

Question 5

What is a pleural effusion?

Answer 5

An abnormal collection of fluid in the pleural space

Question 6

What two types of pleural effusions can you get?

Answer 6

Transudates - fluid has < 30g of protein

Exudates - fluid has > 30g of protein

Question 7

What investigations should you do in a pleural effusion?

Answer 7

History and examination
PA CXR
Biochemistry - transudate or exudate
Cytology - looking for malignant cells, lymphocytes etc

Question 8

When would a pleural effusion not require drainage or sampling?

Answer 8

In cardiac failure

Question 9

What would straw-coloured pleural fluid indicate?

Answer 9

Cardiac failure, hypoalbuminaemia

Question 10

What would bloody pleural fluid indicate?

Answer 10

Trauma, malignancy, infection, infarction.

Question 11

What would turbid/milky pleural fluid indicate?

Answer 11

Empyema, chylothorax

Question 12

What would foul smelling pleural fluid indicate?

Answer 12

Anaerobic empyema

Question 13

What would food particles in the pleural fluid indicate?

Answer 13

Oesophageal rupture

Question 14

What might bilateral pleural effusion indicate?

Answer 14

LVF, PTE, Drugs, systemic path

Question 15

What is a chylothroax?

Answer 15

A chylothorax (or chyle leak) is a type of pleural effusion. It results from lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct.

Question 16

What might a transudate pleural effusion indicate?

Answer 16

Heart failure, liver cirrhosis, hypoalbuminaemia, Peritoneal dialysis, Atelectasis (ITU or post surgery)

Doesn’t always have benign aetiology - 1 in 10 are serious, not to worry too much

Question 17

What might an exudate pleural effusion indicate?

Answer 17

Malignany, infection inc TB, PE, Bacterial pneumonia

Always look for serious pathology

Question 18

describe fluid pH in pleural effusions?

Answer 18

Normal is around 7.6
< 7.3 suggests pleural inflammation (malignancy or Rh A)
< 7.2 then it requires drainage in the setting of infection

Question 19

Describe glucose in a pleural effusion?

Answer 19

LOW in infection, Tb, RhA, malignant, SLE etc

Question 20

What might some symptoms of a pleural effusion be?

Answer 20

Asymtomatic
Dyspnea
Pleuritic chest pain

Question 21

What might be some signs of a pleural effusion?

Answer 21

Decreased expansion
Stony dull percussion
Diminished great sounds over affected area
Vocal resonance are decreased
Might be trachael deviation in severe cases

Question 22

What is a mesothelioma?

Answer 22

Uncommon malignant tumour of the lining of the lung or very occasionally of the lining of the abdominal cavity.

Linked with exposure to asbestos
Often takes 30–40 years to develop.

Question 23

What might some symptoms of mesothelioma be?

Answer 23

May cause breathlessness, chest pain, weight loss, fever, sweating and cough.

Question 24

What investigations would you do for mesothelioma?

Answer 24

Imaging
PLerual flid aspiration
Biospy

Question 25

What would be the treatment of mesothelioma?

Answer 25

Pleurodese effusions
Radiotherapy
Surgery
Chemotherapy
Palliative care
Report deaths to fiscal

Question 26

What are some treatment options for people with malignant pleural effusions?

Answer 26

Do nothing and palliate symptoms?
Repeated pleural taps?
Drain and/or pleurodesis (talc slurry or during thoracoscopy)?
Long term pleural catheters?
Surgical options (abrasion, pleurectomy)

Question 27

Describe long term pleural catheters?

Answer 27

Designed to allow patients control their effusion and therefore symptoms
Inserted mostly in patients with malignant effusions
May need an overnight stay
Drain is designed to remain in place for life though some people will stop producing pleural fluid
Vacuum in drainage bottle that provides suction to drain pleural fluid
Initially people will need to drain daily for a week or so
Eventually most people drain twice to three times a week
Never drain more than 1 litre a day

Question 28

What are some complications of pleural catheters?

Answer 28

• incorrect placement, bleeding, infection

Question 29

Describe the treatment of a pleural effusion the underlying cause is….

• LVF
• Infection
• Malignancy

Answer 29

• LVF - Diuretics
• Infection - drain, antibiotics, may require surgery
• Malignancy - drain, pleurodesis, long term pleural catheter