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Respiratory > The pleura > Flashcards

The pleura Flashcards

1
Q

Describe the normal pleura

A

Glistening, smooth, thin membrane
It covers the thoracic cavity and the lung

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2
Q

What is the outer layer of the pleural cavity called?

A

Parietal pleura

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3
Q

What is the inner layer of the pleural cavity called?

A

Visceral pleura

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4
Q

What is in between the parietal and visceral pleura?

A

Pleural fluid

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5
Q

Explain the pleural fluid

A

Straw coloured
0.26ml/kg/cavity
Filtration
Protein 1.5-3g/dl
Contains few cells - macrophages, lymphocytes and mesothelial cell

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6
Q

Describe the pleural pressure

A

Subatmospheric (negative)
-3 to -5cm of water
Gradient from apex to base

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7
Q

What is a pleural effusion?

A

Collection of fluid in the pleural space
There is an imbalance between production and absoption

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8
Q

What controls absorption?

A

Pleural lymphatics in the parietal pleura

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9
Q

What are the 2 types of effusion?

A

Transudate
Exudate

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10
Q

What is transudate effusion?

A

Non inflammatory and is due to filtration. Low protein content

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11
Q

What is exudate effusion?

A

Inflammatory, high protein content
Protein content: 3g/dl or more

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12
Q

What is lights criteria?

A

Light’s criteria are used to determine the nature of a pleural fluid sample, and narrow down the differential diagnosis of a pleural effusion.
A pleural fluid sample is most likely exudate if one or more of the criteria are met

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13
Q

What is the criteria in lights criteria?

A

Protein : Pleural Fluid / serum fluid ratio > 0.5
LDH : Pleural Fluid / serum fluid ratio > 0.6
Pleural fluid LDH > 2/3rd ULN serum LDH

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14
Q

What are some common causes of transudates?

A

Left ventricular failure
Liver cirrhosis (scarring of the liver caused by long term lung damage)

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15
Q

What are less common causes of transudates?

A

Hypoalbuminemia, peritoneal dialysis, hypothyroidism, nephrotic syndrome and mitral stenosis

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16
Q

What some common causes of exudates?

A

Malignancy (pulmonary or not)
Parapneumonic effusions
Empyema
TB

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17
Q

What are some less common causes of exudate?

A

Pulmonary embolism, connective tissue disease, benign asbestos pleural effusion, pancreatitis, post-myocardial infarction, post-coronary artery bypass graft and haemothorax

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18
Q

What investigations are used?

A

Ultrasound, CXR and CT thorax

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19
Q

What are the benefits for using ultrasounds?

A

More sensitive than CXR
Can mark site of aspiration and assess the pleura
Can do at patients bedside
Need someone trained to read the US

20
Q

What are the benefits of using CXR?

A

Accessible and easy to interpret
Often the first test
Usually need 200 ml of fluid to show up

21
Q

What are the benefits of using CT thorax?

A

Good for complex effusions
and visualising the pleura, vascular and mediastinal structures

22
Q

How is the pleural fluid analysed?

A

Aspiration is simple and safe and can mark with US. Trained operator needed
Inspect the fluid for blood or pus…
PH measured by ABG machine
Biochemistry, microbiology and cytology

23
Q

What PH suggests pus in the pleural fluid?

A

Under 7.2 may suggest pus

24
Q

What is the management needed if PH is less than 7.2?

A

Pus or blood may need a chest drain

25
Q

What is the management of transudate?

A

Treat the underlying cause and may not need CT imaging unless it does not resolve

26
Q

What is the management of exudate?

A

Unless the cause is identified then will need further investigation like further imaging and/or pleural biopsy

27
Q

What is a pneumothorax?

A

Collection of air in the pleural space
Air enters the pleural cavity an lung collapses

28
Q

What is a primary spontaneous pneumothorax?

A

In absence of lung disease
Rupture of blebs in lungs and cause leak of air which compresses the lung
Is an abnormal accumulation of air

29
Q

What is secondary pneumothorax?

A

There are existing lung problems that are known

30
Q

What is a spontaneous traumatic pneumothorax?

A

Caused by an injury or blunt force
Ex. Broken ribs or knife stab
Causes a tear in lung so air enters the pleural cavity

31
Q

What is iatrogenic pneumothorax?

A

Acquired in hospital
A result of biopsy for diagnosis
Patient can be on ventilation and air used causes pressure or pacemaker

32
Q

What is tension pneumothorax?

A

Air in the pleural cavity builds up in pressure and pushes central structures (trachea) and pushes the opposite lung
This causes pressure on the heart and patient can go into cardio-resp. arrest

33
Q

What are the presentations of a spontaneous pneumothorax?

A

Sudden event
Chest pain or breathlessness
Usually happens in tall thin young males - uncommon underlying lung disease

34
Q

What are the clinical examination presentations for spontaneous pneumothorax?

A

Breathing fast - tachypnoeic, hypoxic, reduced chest wall movements and reduced/ no breath sounds
Not uncommon for exam to be normal

35
Q

What is used to diagnose a patient with a pneumothorax?

A

CXR, US and CT thorax

36
Q

What is taken into account when managing a pneumothorax?

A

Size
Effect on the patient
Trained operator and staff needed for the aftercare

37
Q

What is the management for pneumothorax?

A

Observe - if small and patient well
Aspiration - over 2 cm in size and patient well
Chest drain insertion
Surgery - recurrent events or resolving

38
Q

Where is the safe triangle used in pleural aspiration/ drain?

A

2nd intercostal space midclavicular line
Lateral edge of pectoris major, base of axilla, lateral edge of latissimus dorsi and 5th intercostal edge

39
Q

What are the types of pleural tumours?

A

Benign - rare
Malignant pleural effusions are common - poor outcome
Primary malignancy - mesothelioma is the most common

40
Q

Describe a Mesothelioma

A

Is rare and aggressive
Primary malignancy - caused spontaneously by mutation, common with asbestos
Inhaled asbestos fibres reach pleura and cause inflammation which provokes tumour formation
Long latent period

41
Q

What are the clinical presentation of mesothelioma?

A

Breathlessness, chest pain, weight loss, clubbing and signs of pleural effusion
Possible palpable neck nodes

42
Q

How would you diagnose pleural tumours with CXR?

A

Look for pleural effusion and pleural based mass

43
Q

How can you diagnose pleural tumours?

A

CT thorax and biopsy - needed to stage. Need to show invasion of tissues
Thoroscopy - directly visualise pleura and samples, spray lining to stop fluid reaccumulating

44
Q

What can be found when diagnosing pleural tumours?

A

Thickened pleura, pleural nodules or masses, pleural plaques, an effusion and soft tissue infiltration

45
Q

What is the management of pleural tumours?

A

Treatment options are limited and palliative
Treating the effusion
Chemo for fit patients
Recruitment to trails via MDTs
Palliative surgery in select pateints

Respiratory (24 decks)

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