Week 4 - Pleural Disease

Question 1

Where is the pleural cavity most negative?

Answer 1

apex

Question 2

What is hydropneumothorax?

Answer 2

mix of fluid and air in pleural cavity

Question 3

What is pleural effusion Exudate vs Transudate?

Answer 3

• Exudate has a high protein content, transudate does not.
• Exudate is inflammatory, transudate is not - process of filtration

Question 4

What is a common cause of transudate?

Answer 4

left ventricular failure, liver failure, kidney failure. they increase capillary pressure, causing filtration of fluid out

Question 5

What are common causes of exudate?

Answer 5

pulmonary causes.
- malignancy,
- parapneumonic effusion (most common),
- empyaema,
- TB

Question 6

How do you investigate a pleural effusion?

Answer 6

Ultrasound is more sensitive than CXR sensitive for pleura. CT used to detect complex effusions - thickening of pleura and mediastinal and vascular structures

Question 7

How do you analyse pleural fluid?

Answer 7

• aspiration.
• ABG to see if acidic or not,
• microbiology lab for microorganisms,
• biochem lab for protein,
• cytology for general cells to help decision making

Question 8

What LDH and Glucose levels would you expect to find in a pleural effusion?

Answer 8

high LDH and low glucose

Question 9

When may you drain the fluid?

Answer 9

• if pH is below 7.2,
• has pneumonia,
• blood/pus

Question 10

What step should you take if its transudate?

Answer 10

treat underlying cause and it should fix the effusion

Question 11

What step should you take if its exudate?

Answer 11

unless cause is found, further imaging and biopsies needed to know what to do

Question 12

What is primary spontaneous vs secondary spontaneous pneumothorax?

Answer 12

primary - out of nowhere in someone with normal lungs. secondary - in someone with pre-existing lung condition (asthma, COPD, CF)

Question 13

What is a cause and process of primary spontaneous pneumothorax?

Answer 13

bleb in lung bursts suddenly, causing air accumulating and compressing lung

Question 14

What is a traumatic pneumothorax?

Answer 14

after injury to chest wall - broken rib pierces it, stabbing.

Question 15

What is an iatrogenic pneumothorax?

Answer 15

occurs in hospital - biopsy, venous line etc accidentally pierces lung

Question 16

What is a tension pneumothorax? When may it occur?

Answer 16

air in pleural cavity builds up and squashes contralateral heart and lung. other lung compressed leads to lower O2 levels. pressure on heart means doesnt fill well - BP drops. need emergency aspiration. may occur following mechanical ventillation

Question 17

What are the symptoms of a spontaneous pneumothorax?

Answer 17

sudden onset breathlessness and chest pain - may be mistaken for gym muscle pain

Question 18

What presentation would you expect to see in a pneumothorax?

Answer 18

• tachypneic,
• hypoxic,
• reduced chest wall movements,
• little to no breath sounds.

MAY be totally normal

Question 19

How is a pneumothorax diagnosed?

Answer 19

CXR detects large one. air rises to top of lung so small one may not be seen. ultrasound may be used if patient too sick to get up. CT for complex cases.

Question 20

How is pneumothorax managed?

Answer 20

Patient specific. may need apsiration, may resolve itself. chest drain insertion.

Question 21

What is the recurrence rate and what should you follow post-operatively?

Answer 21

25-50% chance within a year.

if recurs on same side, surgery may be required

no heavy weights or flying for a week.

Question 22

What is the triangle of safety?

Answer 22

area on body (armpit area) which identifies safe spot when inserting chest drain or doing surgical procedures

Question 23

What do most pleural tumours present as? what is the outcome?

Answer 23

Pleural effusion. Poor outcome

Question 24

Which type of malignancy in the pleura is most commmon?

Answer 24

secondary. primary isn’t common. secondary may be from lung, breast, ovary, GI or thyroid

Question 25

How does a tumour actually metastasise the pleura? (2)

Answer 25

• either studs the surface or
• enters lymphatics and blocks drainage of lung, causing pleural effusion

Question 26

What is the most common primary malignancy of the pleura and how does it arise?

Answer 26

mesothelioma. rare, agressive, occupational tumour. asbestos fibres reach pleura and cause inflammation. lays latent for 20-40 years.

Question 27

What are the symptoms of mesothelioma?

Answer 27

• chest pain,
• breathlessness,
• weight loss,
• clubbing,
• pleural effusion signs

Question 28

what screening methods are used to stage and diagnose pleural tumours?

Answer 28

CT sees pleural surface in detail. tissue needed to diagnose mesothelioma - not fluid. CT and biopsy can stage. Thoroscopy - visualise and get samples directly

Question 29

How is mesothelioma managed?

Answer 29

its incurable and survival is poor. chemo is for a select few individuals, but has very little benefit to offer.

Question 30

What is pleurodesis?

Answer 30

closing pleural space with talc powder to palliate issue and stop fluid reaccumulating

Question 31

What is decortication?

Answer 31

picking off layers of thickened pleura to allow underlying lung to expand and relieve breathlessness

Question 32

What causes low glucose levels in pleural fluid analysis?

Answer 32

Infection, empyema, malignancy, rheumatoid arthritis

Question 33

What must be carried out prior to an ultrasound guided biopsy for a pleural malignancy?

Answer 33

• Spirometry for lung function as pneumothorax is common
• full bloods for platelet check