Pleural Tap Flashcards

1
Q

Diagnostic indications for pleural tap?

A
  1. Empyema
  2. TB
  3. Pleural malignancy
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2
Q

Therapeutic indications for pleural tap?

A
  1. Lung compression causing resp distress / hypoxia
  2. Drainage of empyema
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3
Q

Transudative vs exudative pleural fluid?

A

Transudative <30g/l protein = bilateral
Exudative >30g/l protein = unilateral

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4
Q

Causes of transudative pleural effusion?

A
  1. left ventricular failure
  2. chronic effusion
  3. nephrotic syndrome
  4. hepatic failure
    - lymphatic channels may open secondary to ascites and contribute to effusion
  5. hypothyroidism
    - myxoedematous
  6. peritoneal dialysis
  7. Meigs’ syndrome with benign ovarian fibroma
  8. constrictive pericarditis
  9. superior vena cava obstruction
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5
Q

Signs of left ventricular failure?

A
  1. raised jugular venous pulse
  2. pulmonary edema
  3. third heart sound
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6
Q

Signs of nephrotic syndrome?

A

generalized/facial/periorbital edema

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7
Q

Causes of exudative pleaural effusiion?

A
  1. bronchial carcinoma/mesothelioma
  2. pneumonia
  3. parapneumonic effusion and empyema
  4. tuberculosis
  5. pulmonary embolism
  6. connective tissue disease
  7. subphrenic abscess
  8. benign asbestos effusion
  9. post-coronary artery bypass graft
  10. pancreatitis
  11. drug-induced
  12. yellow nail syndrome
  13. fungal infection
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8
Q

Features of bronchial carcinoma/mesothelioma?

A
  1. cachexia
  2. clubbing
  3. tar staining
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9
Q

Features of pneumonia?

A

consolidation
1. reduced breath sounds
2. decreased vocal resonance
3. dullness on percussion
4. bronchial breath sounds
5. positive whispering pectiroloquoy
6. positive egophony

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10
Q

Pleural tap technique?

A
  1. Explain and consent of patient
    - Risks and benefits
  2. Collect equipment before starting procedure!
  3. Uncover and position patient
    - Seated, hugging forward
  4. Review available images / USS marked area
  5. Examine and identify site
    - Commonly 5th ICS Post Axilliary Line
    - Auscultate and Percuss to fluid level, aim 1-2 spaces below.
  6. Clean skin x2, spirals
  7. Create sterile field
    - Under and around patient
  8. Equipment onto sterile field
  9. (Anaesthetic)
  10. Insert needle with cannula tube
    - 90 degrees, above lower rib until fluid comes
  11. Take sample / attach drainage bag + secure
    - Purple and red or yellow tubes
  12. Remove needle
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11
Q

Tests to do on sample?

A
  1. Cytology
  2. microscopy
  3. culture
  4. sensitivity
  5. biochemistry
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12
Q

What is the site for pleural tap?

A
  • One to two interspaces below the level at which breath sounds decrease or disappear on auscultation, percussion becomes dull, and fremitus disappears
  • Above the ninth rib to avoid subdiaphragmatic puncture
  • Midway between the spine and the posterior axillary line, because the ribs are easily palpated in this location
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13
Q

Pleural tap contraindications?

A
  1. Recent tap / drain on contralateral side
  2. Skin infection at site
  3. Bleeding diathesis
    - Low platelets, clotting factors
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14
Q

Pleural tap risks?

A
  1. Infection – empyema
  2. Bleeding – haemothorax
  3. Pneumothorax – tension / non-tension
  4. Damage to long thoracic nerve – winged scapula
  5. Reperfusion pulmonary oedema
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15
Q

What is Lights criteria?

A
  • Protein concentration may be relied upon if pleural protein is <25g/l or >35g/l
  • For values in between these Light’s criteria may be used
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16
Q

What are the features of Light’s criteria?

A

> one of these favors an exudate
1. pleural fluid protein: serum protein > 0.5
2. pleural fluid LDH: serum LDH >0.6
3. pleural fluid LDH more than 2/3 the upper limit of normal serum LDH

17
Q

Low glucose in pleural fluid could indicate?

A
  1. rheumatoid arthritis
  2. TB
18
Q

What raised amylase in pleural fluid could indicate?

A
  1. Pancreatitis
  2. oesophageal rupture/perforation
19
Q

What heavy blood staining of pleural fluid could indicate?

A
  1. TB
  2. malignancy
  3. pulmonary Embolism
20
Q

What to do in all patients with a pleural effusion in association with sepsis or pneumonic illness?

A

Require diagnostic pleural fluid sampling:
1. If the fluid is purulent or turbid/cloudy, place a chest tube for drainage
2. if the fluid is clear but the PH is less than 7.2 in a patient suspected to have pleural infection then insert a chest tube

21
Q

What to do in the event of recurrent pleural effusions?

A
  1. Recurrent pleural aspiration
  2. Pleurodesis – talcum powder, bleomycin
  3. Indwelling pleural catheter
  4. Drugs to alleviate symptoms- opioids