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Week 8 - Phase 3 > Pleural Problems > Flashcards

Pleural Problems Flashcards

1
Q

What is a pleural effusion?

A

Accumulation of fluid in the pleural space.

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2
Q

How much pleural fluid is there normally?

What is it like?

A

<15ml

Clear, serous fluid, few cells.

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3
Q

How much fluid would you need in a pleural effusion to be able to diagnose it clinically easily?

A

> 500ml

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4
Q

What features would you see on CXR that may indicate a pleural effusion?

A

Blunting of the costophrenic angle

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5
Q

What are the clinical features of pleural effusion?

A
  • SOB
  • Dry cough
  • Pleuritic chest pain due to pleural inflammation
  • Reffered pain to shoulder or abdomen
  • Chest heaviness
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6
Q

What clinical signs would you see on examination in a pleural effusion?

A
  • Reduced chest expansion
  • Quiet breath sounds
  • Decreased tactile vocal cremates
  • Stony dull percussion
  • Bronchial breathing above fluid level.
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7
Q

What is the physiological principle that explains why a pleural effusion would arise?

A

Arises when balance between pleural fluid production and absorption has been disturbed.

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8
Q

List mechanisms of pleural effusions?

A
  • Increased hydrostatic pressure
  • Decreased osmotic pressure
  • Increased vascular permeability
  • Decreased lymphatic drainage
  • Increased intra-pleural negative pressure.
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9
Q

How would you investigate a pleural effusion?

A 
CXR 
Pleural fluid sample 
CT chest 
Biopsy 
Thoracoscopy
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10
Q

What could cause a unilateral pleural effusion?

A
  • Infection: Always consider sepsis
  • Breast/gynae malignancy
  • Asbestos history
  • TB
  • Liver disease
  • Cardiac failure
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11
Q

What is the difference between a transudate and exuded pleural effusion and what causes them?

A

Transudate:

  • Either less proteins in the blood or in congestive HF.
  • In HF there is increased pressure in the hear and blood backs up to the lungs causing an increased in hydrostatic pressure. Fluid leaks out and causes a pleural effusion.

Exudate:

  • Normally inflammatory.
  • In inflammation vessels are dilated and endothelial cells are more spaced out, therefore fluid AND proteins leak out.
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12
Q

What tests must be done through pleural fluid sampling?

A
  • 100ml to cytology
  • Biochemistry for LDH, glucose, proteins
  • Microbiology for TB culture (also send blood culture if empyema suspected)
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13
Q

How is pleural fluid sampled?

A

Under ultrasound guidance
Remove 1L if symptomatic then stop
DO NOT drain to dryness

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14
Q

How much protein is in a transudate vs exudate effusion?

A

T: <30g/L
E: >30g/L

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15
Q

How does serum LDH compare in transudate vs exudate effusion?

A

T: LDH <2/3rds of upper limit of normal.
E: >2/3rd of upper limit of normal.

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16
Q

Are transudates/exudates normally bilateral or unilateral?

A

T: Often bilateral
E: Usually unilateral

17
Q

Describe the appearance of transudate pleural fluid vs. exudate pleural fluid?

A

T: clear usually
E: Can be clear, cloudy or blood stained.

18
Q

List causes of transudate pleural effusions?

A

Cardiac failure
Hepatic cirrhosis
Nephrotic syndrome
Hypoalbulminaemia

19
Q

List causes of exudate pleural effusions?

A

Bacterial pneumonia
Malignancy
Mesothelioma
TB

20
Q

What is a medical thoracoscopy?

A

An investigation to examine parietal pleura, visceral pleura and diaphragm with a thoracoscope.

Allows direct visualization of pleura, biopsies to be performed, and therapeutic manouvers to be performed e.g. pleural drainage or pleurodesis.

21
Q

Describe how a thoracoscopy is performed?

A
  • Give oramorph/atropine
  • Patient in lateral decubitus position
  • Spot marked with ultrasound
  • Local anesthetic e.g. Lidocaine
  • Creation of pneumothorax
  • Blunt dissection and port inserted
  • Drainage of fluid with suction catheter
  • Inspection of pleural surface
  • Biopsies x10
  • Talc pleurodesis if clearly malignant
  • Size 24-28 chest drain - removed once lung re expanded.
22
Q

What is the name for cancer of the pleura?

A

Mesothelioma

23
Q

Where do metastases to the pleura normally come from?

A

Breast/ovary

Also bowel, renal, lymphoma

24
Q

What % of pneumonias has an associated effusion?

A

50%

25
Q

Describe results seen in a complex parapneumonic infection effusion?
(pH, LDH, glucose, ultrasound report)

A
  • pH: <7.2
  • LDH: >1000
  • Glucose <2.2
  • loculated on ultrasound
26
Q

What is empyema?

A

Collection of pus in the pleural cavity usually due to bacterial infection.

27
Q

How is empyema managed?

A
  • Small bore chest drain (12-16F) - larger drains are more painful and not more effective
  • Frequent sterile saline flushes
  • IV antibiotics
  • DVT prophylaxis
  • Fibrinolytics e.g. streptokinase, DNAase and alteplase.

Week 8 - Phase 3 (6 decks)

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