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Respiratory Anatomy & Disease Mechanisms > Pleural Malignancy (DISEASE MECHANISMS) > Flashcards

Pleural Malignancy (DISEASE MECHANISMS) Flashcards

1
Q

What is the plural cavity?

A

The space between the visceral and parietal pleura

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2
Q

How much fluid does the pleural cavity normally contain?

A

Approx. 4 ml

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3
Q

How much fluid is approximately needed, in the pleural cavity to be detected on plain CXR?

A

Approx 200 ml

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4
Q

The two layers of the pleura combine around the ______

A

hila (of the lung)

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5
Q

The layers of the pleural cavity combine to form the _________ _______ which runs inferiorly and attaches the lung root to the ______

A

pulmonary ligament

diaphragm

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6
Q

What is pleural effusion?

A

Abnormal collect not fluid in pleural space

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7
Q

Which type of pleural effusions are a particular cause of concern?

A

Large unilateral effusions

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8
Q

What tools can be used to diagnose pleural effusion?

A 
History + Examination
CXR
Pleural aspirate
Biochemistry (Exudate/Transudate) 
Cytology
Culture 
Contrast CT chest
Repeated pleural tap
Pleural biopsy (blind or thoracoscopy)
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9
Q

What can straw-coloured pleural fluid suggest?

A

Cardiac failure

Hypoalbuminaemia

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10
Q

What can bloody pleural fluid suggest?

A

Trauma
Malignancy
Infection
Infarction

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11
Q

What can turbid/milky pleural fluid suggest?

A

Empyema

Chylothroax

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12
Q

What can foul-smelling pleural fluid suggest?

A

Anaerobic empyema

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13
Q

What can food particles in the pleural fluid suggest?

A

Oesophageal rupture

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14
Q

If pleural effusion is bilateral the likely causes include?

A

LVF
PTE
Drugs

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15
Q

What distinguishes transudate and exudate?

A 
Transudate = < 30 g/L of protein
Exudate = > 30 g/L of protein
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16
Q

Why can transudate pleural effusion occur?

A 
Heart failure 
Hypoproteinaemia
Hypoalbuminaemia
Atelectasis
peritoneal dialysis 
Hypothyroidism 
Meig's syndrome (right pleural effusion + ovarian fibroma
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17
Q

What causes an exudate pleural effusion?

A 
Increased leakiness of pleural cavity secondary to: 
- infection
- Inflammation 
- Injury 
caused by: 
- pneumonia
- TB
- pulmonary infarct 
- RA
- SLE
- Bronchogenic carcinoma 
- malignant metastase
- lymphoma 
- mesothelioma
- lymphogitis carcinoma 
- Asbestos
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18
Q

What does a pleural fluid pH < 7.3 indicate?

A

Pleural inflammation (malignany / empyema / TB / RA / SLE)

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19
Q

A pleural fluid pH requires …?

A

Drainage in the setting of infection

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20
Q

Pleural fluid glucose level of <3.3 mmol/L suggest…?

A 
Empyema
Malignancy
TB
RA
SLE
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21
Q

What does SLE stand for?

A

Systemic lupus erythematosus

22
Q

What does an increase in lymphocytes in pleural fluid indicate?

A

TB
Malignancy
SLE
Sarcoidosis

23
Q

What does an increase in neutrophils in the pleural fluid indicate?

A

Para-pneumonic effusion

PE

24
Q

How can microbiology be used to analyse pleural fluid?

A

Gram stain + microscopy
Culture
PCR, AFB stain + liquid culture
Put in blood culture bottles for greater yield

25
Q

What are the signs of pleural effusion?

A

Decreased chest expansion
Stony dull percussion note
Reduced breath sounds on affected side
Decreased tactile vocal remits and vocal resonance
Above effusion where lung is compressed there may be bronchial breathing
Possible tracheal deviation if large effusion
Look are aspiration marks
Look for signs of associated disease

26
Q

What are the associated diseases of pleural effusion?

A 
Malignancy 
Stigmata of chronic liver disease
Cardiac failure 
Hypothyroidism
RA 
SLE (shows butterfly rash)
27
Q

Which tests can be used to investigate pleural effusion?

A

CXR
US
Diagnostic Aspiration
Pleural Biopsy

28
Q

What is a mesothelioma?

A

Uncommon tumour of mesothelial cells that usually occurs in the pleura and rarely in the peritoneum or other organs

29
Q

What is the risk of developing a mesothelioma linked to ?

A

Asbestos exposure - often takes 30-45 yrs to develop

30
Q

What are the symptoms of a mesothelioma?

A 
Chest pain
Dyspnoea
Weight loss
Finger clubbing
Recurrent pleural effusions
Fever
Sweating 
Cough
31
Q

Which investigations are possible for mesothelioma?

A

Imagina (plural nodularity / circumferential pleural thickening / lung invasion/ lung entrapments)
Pleural fluid aspiration ( low cytological yield / avoid repeated aspiration / biopsy (thoracoscopy or CT-guided)

32
Q

How can mesotheliomas be treated?

A 
Pleurdodese effusions
Radiotherapy
Surgery
Chemotherapy
Palliative care
Report deaths to fiscal (compensation if occupational asbestos exposure)
33
Q

What are the treatment options for malignant pleural effusion?

A 
Palliative treatment of symptoms
Repeated pleura leaps
Drain and/or pleurodesis (TALC) 
Long-term pleural catheter
Surgical: abrasions/pneumectomy
34
Q

What are the advantages of TALC: sclerosing agent?

A

Success of 60%

35
Q

What are the disadvantages of TALC: sclerosing agent?

A 
Involves stay in hospital
Common Complications
- minor pleuritic pain &amp; fever
Rare Complications
- Pneumonia
- Respiratory failure 
- Talc pneumonitis/ARDS
  • Secondary empyema
  • Local tumour implantation at port site in mesothelioma
36
Q

Malignant pleural effusions are due to ______ of many cancers to the _____

A

metastasis

pleura

37
Q

What does a long-term pleural catheter involve?

A

Drain designed to stay for life
Vacuum in drainage bottle produces vacuum providing suction to drain
Drain fluid by demand

38
Q

What is the maximum amount of a fluid a patient should drain using a long-term pleural catheter?

A

1 L a day

39
Q

How is the prognosis of a patient with a malignant pleural effusion calculated?

A 
LENT Score 
LDH level in pleural fluid (<1500 = 0 / > 1500 = 1) 
ECOG PS (0 = 0 / 1 = 1 / 2= 2 / 3-4 = 3)
(serum) Neutrophil to Lymphocyte ratio (<9 = 0 / >9 = 1)
Tumour type (Low risk: mesothelioma/haematological malignancy = 0 // Moderate risk: Breast / gynaecological / renal cell = 1 // High risk: lung cancer / other tumour types = 2)
40
Q

How is the LENT score interpreted?

A 
0-1 = low score
2-4 = Moderate risk 
5-7 = Higher risk
41
Q

Treatment for malignant pleural effusion depends on ________

A

underlying cause

42
Q

How would each of the malignant pleural effusions be treated considering the underlying cause:
LVF
Infection
Malignancy

A

LVF - Diuretics
Infection - drain/antibiotics/maybe surgery
Malignancy - pleurodesis / long-term pleural catheter

43
Q

What distinguishes primary and secondary pneumothoraces?

A 
Primary = normal lungs; occurs due to apical bullae rupture / often asymptomatic
Secondary = due to underlying lung disease / usually symptomatic
44
Q

Under which patient category are pneumothoraces more common in?

A

Tall thin men
Smokers
Cannabis
Underlying lung disease

45
Q

What are the symptoms of a pneumothorax?

A

Acute onset of pleuritic chest pain
Dyspnoea
Hypoxia

46
Q

What are the signs of a pneumothorax?

A

Tachycardia
Hyper-resonant percussion notReduced chest expansion
Quiet breath sounds on auscultation
Herman’s sign - click on auscultation of left side

47
Q

How can a pneumothorax be investigated?

A 
CXR usually sufficient 
CT chest (differentiation between bullous lung disease and small pneumothorax)
48
Q

How is a pneumothorax managed?

A 
Oxygen even if no drain
If small &amp; asymptomatic = no treatment 
1st line is aspiration in PSP 
Chest drain - may need suction
Surgical intervention
49
Q

What causes a tension pneumothorax?

A

One-way valve causing progressive increase in pleural space pressure

50
Q

What are the clinical signs of a tension pneumothorax?

A

Trachea deviated to opp. side
Hypotension
Increased JVP
Reduced air entry on affected side

51
Q

Why/when would a tension pneumothorax occur?

A 
Patient ventilated 
Trauma
CPR esp. PEA
Blocked, kinked or misplaced drain
Pre-existing airways disease 
Patients undergoing hyperbaric treatment
52
Q

How is a tension pneumothorax treated?

A

Needle decompression usually with a large bore venflon

Insert at second intercostal space anteriorly & mid-clavicular line

Respiratory Anatomy & Disease Mechanisms (13 decks)

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