Pleural Malignancy Flashcards
What is a pleural effusion
Buildup of fluid in pleural cavity
What pleura covers lung hilum
None, the two layers combine around the hilum
What is the pulmonary ligament
Combination of pleural layers that attaches lungs inferiorly to the diaphragm
When does pleural effusion not require sampling or drainage
If it’s caused by cardiac failure
Transudate vs exudate
Transudate is fluid pushed through capillaries due to high pressure (low protein content < 30g/L).
Exudate is fluid a around capillary cells due to inflammation (high protein content > 30g/L)
Straw coloured pleural fluid
Cardiac failure, hypoalbuminaemia
Bloody pleural fluid
Trauma, malignancy, infection, infarction
Turbid/milky pleural fluid
Empyema (pus), chylothorax (lymph)
Foul smelling pleural fluid
Anaerobic empyema
Food particles in pleural fluid
Oesophageal rupture
Bilateral pleural fluid
LVF, pulmonary thromboembolism, drugs
Common causes of transudates
Heart failure, liver cirrhosis, hypoalbuminaemia, atelectasis, peritoneal dialysis
Common cause of exudates
Malignancy, infection including TB, pulmonary infarction, asbestos
What does fluid pH < 7.3 suggest
Pleural inflammation due to malignancy
What is fluid pH < 7.2
Requires drainage in setting of infection
Lymphoctye vs neutrophil presence in pleural fluid
Neutrophils suggest an acute process whereas presence of lymphocytes suggests TB or malignancy
Example of an acid-fast stain
Ziehl-Neelsen stain where the acid-fast bacteria stand out as bright red against a blue background
Does increasing volume of aspirate in thoracentesis increase yield
No
Third and subsequent sample effective in thoracentesis pleural aspirate
No, second sample increases yield slightly. Third and more are useless
Why are biopsies often negative
Pleural disease is often discontinuous
Systemic causes of ancillary effusions
Systemic tumour effects such as embolism or hypoalbuminaemia (type of hypoproteinaemia)
What is mesothelioma
Malignant tumour of lining of lungs or sometimes abdominal cavity
What increases likelihood of developing mesothelioma
Degree and length of exposure to asbestos. May also occur in persons who have been associated with people who have worked with asbestos
Symptoms of mesothelioma
Breathlessness, chest pain, weight loss, fever, sweating and cough
Cytological yield of mesothelioma
Poor, avoid repeated aspiration
What can be seen on imaging of mesothelioma
Pleural nodularity, circumferential pleural thickening, local invasion and lung entrapment
Treatment of mesothelioma
Pleurodesis, radiotheraphy, chemotherapy, surgery, palliative care
Talc slurry vs talc poudrage for pleurodesis
Talc poudrage is preferred due to lower incidence of chest pain during the procedure. Poorer results also seen with talc slurry
Common complications of talc pleurodesis
Minor pleuritic pain and fever
When are long term catheters generally used
Patients with malignant effusions. Allows patients to control their effusion and symptoms
Complications of long term pleural catheter
Incorrect placement, bleeding, infection
How can survival be predicted in malignant pleural effusions
Using the LENT score - LDH - Lactate dehydrogenase ECOG score - Ability of patients to tolerate therapies serum Neutrophil to lymphocyte ratio Tumour type
Treatment for LVF pleural effusion
Diuretics
Treatment for infection related pleural effusion
Drain, antibiotics, surgery
Treatment for malignancy related pleural effusion
Drain, pleurodesis, long term pleural catheter
What is a pneumothorax
Abnormal collection of air between plural space
Pneumothorax usually occurs in
Tall thin men, smokers, cannabis users, underlying lung disease
Types of pneumothorax
Primary - Normal lungs, apical bullae rupture
Secondary - Underlying lung disease eg: COPD
Which type of pneumothorax symptomatic
Secondary spontaneous pneumothorax is usually symptomatic even if small unlike primary spontaneous pneumothroax which are largely asymptomatic
General signs of pneumothorax
Dyspnoea, hypoxia, acute onset pleuritic chest pain, tachycardia, hyper-resonant percussion sound, reduced expansion, quiet breath sounds on auscultation
What is Hamman’s sign
A mediastinal crunch or click sound, similiar to crackles, heard upon auscultation. It correlates with the heart beat and not respirations
How can amount of pneumothorax be approximated
Measure rim of air at hilar level not apex
Small < 2 cm rim of air
Large > 2 cm rim of air
2 cm rim of air is approx 50 % pneumothorax
Is chest x-ray sufficient to diagnose pneumothorax
Yes
Management of pneumothorax
Oxygen even if no drain
Aspiration if primary spontaneous pneumothorax, time consuming, avoids chest drain and may fail is ago > 50 or secondary spontaneous pneumothorax
Surgery
May need suction (air leak > 48 hours)
Treatment of asymptomatic and small pneumothorax
No treatment if asymptomatic and small
When can aspiration fail in pneumothorax
If age > 50 or secondary spontaneous pneumothorax
When should surgery be considered for pneumothorax
Secondary ipsilateral ptx Primary contralateral ptx Bilateral spontaneous ptx Persistent air leaks Risk professions after first ptx (divers, pilots)
Pneumothorax follow up
Chest x-ray until resolution
Discuss flying and diving
Risk of re-occurrence
Smoking caessation
What is tension pneumothorax
Progressive build-up of air in pleural space usually due to lung laceration which allows air to escape into the pleural space but not return
Is tension pneumothorax an emergency
Yes
Signs of tension pneumothorax
Trachea deviated to opposite signs, Hypotension, raised JVP, reduced air entry on affected side
Treatment of tension pneumothorax
Needle compression, usually with large bore venflon
Causes of tension pneumothorax
Ventilated patient, trauma, CPR, blocked/kinked/misplaced drain, pre-existing airway disease, patients undergoing hyperbaric treatment
Where is venflon inserted for needle compression
Second intercoastal space, mid-clavicular line
How can empyema be cleared
Paraneumonic effusions can be cleared by drainage however empyema can rapidly coagulate and organize to fibrous peels even with antibiotics. This needs surgery
