RESP - Diseases of the Pleura Flashcards
What should we measure when sampling a pleural effusion to assist diagnosis?
- Protein (transudate vs. exudate)
- glucose, LDH
- pH
- cytology
- micro & culture (don’t forget TB)
Ix of pleural effusion
- Sampling of pleural fluid if indicated
- US
- CXR
- CT chest
- Bronchoscopy: not routine unless concerns about TB/cancer
- Thoracoscopy
- LFT (problems below diaphragm can present with pleural effusion)
(3) symptoms of pleural disease
- Pleuritic chest pain (“pleurisy”)
- SOB
- Cough
(2) types of pleural signs
Air in the pleural space
- reduced chest expansion
- increased percussion note
- reduced AE
Fluid/solid tissue in pleural space - reduced chest expansion - reduced percussion note - reduced AE Note: it may be difficult to differentiate from raised hemidiaphragm (need to check with US)
Compare (4) unilateral vs. (4) bilateral pleural effusion causes
Unilateral:
- infection e.g. pneumonia, chronic TB
- malignancy (primary more so than metastatic, secondary, lymphoma)
- inflammatory (including post PE)
- heart failure (less common)
Bilateral
- heart failure
- low pressure status (e.g. low albumin)
- fluid overloaded status
- malignancy (secondary), inflammatory
When would you see chylothorax? What colour is it?
- Thoracic duct obstruction (lymphoma, lung cancer) or trauma
- Milky white colour
Why do pneumothoraces occur?
- Spontaneous. RF: smoking, FMHx, Marfan’s syndrome
- Trauma
- Underlying lung disease. COPD, lung bullae
How do we manage air in the pleural space?
- Conservative. Observe + give pain relief
- Drainage: aspiration or ICC with underwater seal (to provide one way for air to exit)
- Pain relief, oxygen (it also helps resolve pneumothorax)
what are the (2) areas ideal for intercostal catheter insertion?
5th intercostal space mid axillary line
or
2nd intercostal space mid clavicular line
What could be the (3) causes of intercostal catheter no longer working?
- Blocked/kinked tube
- Tube slipped into subcutaneous tissue etc
- Turned off tap at the end of the tube
When do you take out intercostal catheter?
When there is no longer air leak
When is surgery indicated for pneumothorax?
- Not resolving with ICC/others
- Recurrent
- Patient’s wishes
What is it called when pleural fluid is not posterior on lying down but on the side etc?
Loculated pleural fluid
What should you worry about in loculated pleural effusion?
- Rx
If this is empyema, an abscess may develop and hence sepsis.
Oral antibiotics fail as it cannot get through.
Rx: drain it with an intercostal tube (doesn’t matter what size). Better if you breakdown other loculations too.
Appearance of pleural plaques on imaging
- Common causes
- Lines & opacity
- Bump on diaphragm (they love to sit on diaphragm)
- Calcium on the lining of pleura
Causes:
- Asbestosis (Docks, builders, plumbers, mechanics, mining. Certain regions e.g. Turkey at risk).
- Previous empyema/blood in the pleural space
- Mesothelioma
