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Respiratory Physiology, Medicine and Critical Care > Pleural disease > Flashcards

Pleural disease Flashcards

1
Q

What is a pleural effusion?

A

This is a collection of fluid in the plerual space

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2
Q

What are the different types of pleural effusion?

A
  • Transudate - due to pressure differences
  • Exudate - due to inflammatory process
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3
Q

What can cause a transudative pleural effusion?

A
  • LVF
  • Liver Cirrhosis
  • Hypoalbuminaemia
  • Peritoneal Dialysis
  • Hypothyroidism
  • Nephrotic Syndrome
  • Mitral syndrome
  • Pulmonary Embolism
  • Constrictive Pericarditis
  • Ovarian hyperstimulation syndrome
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4
Q

What can cause exudative pleural effusion?

A
  1. Malignancy
  2. Parapneumonic
  3. Pulmonary embolism/infarction
  4. Rheumatoid arthritis
  5. Autoimmune diseases
  6. Benign asbestos effusion
  7. Pancreatitis
  8. Post-myocardial infarction/cardiotomy syndrome
  9. Yellow nail syndrome
  10. Drugs
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5
Q

What are the symptoms of a pleural effusion?

A
  • Asymptomatic
  • Dyspnoea
  • Pleuritic chest pain
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6
Q

What are clinical signs of a pleural effusion?

A

Generally only in effusions > 500ml

  • Decreased expansion
  • Stony dull percussion note
  • Diminished breath sounds
  • Decreased tactile vocal fremitus
  • Decreased vocal resonance
  • Bronchial breathing - above where lung is compressed by effusion
  • Tracheal deviation - very large effusions
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7
Q

Why do you get reduced breath sounds in a pleural effusion?

A

Breath sounds are related to the intensity of flow (sound energy) as well as the transmission of the sounds through the lungs and chest wall. Abnormalities of either element will diminish breath sounds. Pleural fluid between the airways and stethoscope reduces transmission

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8
Q

Why do you get stony dull percussion in a pleural effusion?

A

Pleural fluid dampens the normal resonance of the lung fields, creating the characteristic ‘stony’ dullness.

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9
Q

What else would you look for if you suspected a pleural effusion?

A

Signs of a cause

  • Malignancy - cachexia, clubbing, lymphadenopathy
  • Chronic liver disease
  • Cardiac failure
  • Hypothyroidism
  • RA
  • SLE signs
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10
Q

How would you investigate a pleural effusion?

A
  • CXR
  • CT
  • Aspiration
  • Biopsy
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11
Q

What complications can occur from aspirating a pleural effusion?

A
  • Pneumothorax
  • Empyema
  • Pulmonary oedema
  • Vagal reflex
  • Air embolism
  • Tumour cell seeding
  • Haemothorax
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12
Q

If, when aspirating a pleural effusion, a foul smelling fluid was aspirated, what might you suspect to be the cause?

A

Anaerobic empyema

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13
Q

If, when aspirating a pleural effusion, you aspirated food particles in pleural fluid, what might suspect?

A

Oesophageal rupture

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14
Q

If, when aspirating a pleural effusion, you obtained a milky coloured fluid, what might you suspect?

A

Chylothorax

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15
Q

What investigations might you want to get done on a pleural fluid sample?

A

Depends on clinical picture

  • Gross analysis
  • Cytology
  • Clinical chemistry
  • Immunology
  • Microbiology
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16
Q

What might a bloody pleural effusion indicate?

A
  • Trauma
  • Malignancy
  • Pulmonary infarction
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17
Q

If, on biochemical analysis of a pleural fluid sample, the protein level was found to be < 25g/L, what type of effusion would this be?

A

Transudate

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18
Q

If, on biochemical analysis of a pleural fluid sample, the protein level was found to be > 35g/L, what type of effusion would this be?

A

Exudate

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19
Q

What could cause a glucose of <3.3 mmol/L in a pleural fluid sample?

A
  • Empyema
  • Malignancy
  • TB
  • RA
  • SLE
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20
Q

What could cayse a pH of < 7.2 in a pleural fluid sample?

A
  • Empyema
  • Malignancy
  • RA
  • SLE
  • TB
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21
Q

What could cause a raised LDH in a pleural fluid sample?

A
  • Empyema
  • Malignancy
  • TB
  • RA
  • SLE
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22
Q

How would you manage a pleural effusion?

A
  • Treat the cause
  • Drainage
  • Pleurodesis
  • Surgery
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23
Q

When would you drain a pleural effusion?

A

If it was symptomatic

24
Q

What anatomical landmark would you use for inserting a chest drain?

A

4th/5th intercostal space, mid-axillary line

25
Q

What would be the maximum speed of drainage of a chest drain?

A

About 500 ml/hr maximum

26
Q

When would you consider pleurodesis/surgery with a plerual effusion?

A

If it was recurrent

27
Q

What is Light’s criteria for diagnosis of an exudative pleural effusion?

A
  • Pleural fluid protein:serum protein ratio >0.5
  • Pleural fluid LDH:serum LDH ratio >0.6
  • Pleural fluid LDH > 2/3 upper limit of normal for serum (105–333 IU/L)
28
Q

What do you risk causing if you try to drain the chest too quickly?

A

Re-expansion pulmonary oedema

29
Q

What is a pneumothorax?

A

A pneumothorax occurs when either the visceral or parietal pleura is breached in some way that allows air into the pleural cavity. This results in the lung recoiling away from the chest wall due to elastic recoil, which results in it collapsing.

30
Q

What are causes of pneumothorax?

A
  • Primary
  • Chronic lung disease
  • Infection
  • Traumatic
  • Connective tissue disorders
  • Carcinoma
  • Iatrogenic
31
Q

What chronic lung diseases can cause pneumothorax?

A
  • Asthma
  • COPD
  • CF
  • Lung fibrosis
  • Sarcoidosis
32
Q

What are infectious causes of a pneumothorax?

A
  • TB
  • Pneumonia
  • Lung Abscess
33
Q

What are iatrogenic causes of pneumothorax?

A
  • CVP line insertion
  • Pleural aspiration or biopsy
  • Percutaneous liver biopsy
  • Positive pressure ventilation
34
Q

What connective tissue disorders can predispose to the development of a pneumothorax?

A
  • Marfan’s syndrome
  • Ehler’s-Danlos syndrome
35
Q

What are the symptoms of a pneumothorax?

A
  • Asymptomatic
  • Sudden onset dyspnoea
  • Pleuritic chest pain
36
Q

If there was a sudden deterioration in someone with asthma or COPD exacerbation, what might you suspect?

A

Pneumothorax

37
Q

What might indicate that someone who is mechanically ventilated has developed a pneumothorax?

A
  • Sudden hypoxia
  • Sudden increase in ventilation pressures
38
Q

What Signs might indicate a pneumothorax?

A
  • Reduced expansion
  • Hyper-resonance
  • Diminished breath sounds
  • Decreased fremitus
  • Tracheal devation - towaerds affected side
39
Q

What signs might indicate a tension pneumothorax?

A
  • Reduced expansion
  • Hyper-resonance
  • Diminished breath sounds
  • Decreased fremitus
  • Tracheal deviation - away from affected side
  • Haemodynamic Compromise
  • Increased JVP
  • Central cyanosis
  • Displaced Apex
  • Surgical emphysema
40
Q

What is surgical emphysema?

A

Air or gas present within the subcutaneous layer of the skin. On palpation there will be a crackling feeling (much like pressing bubble wrap) along with obvious changes to the skin texture.

41
Q

How does surgical emphysema occur?

A

Subcutaneous emphysema is caused by air or gas reaching the subcutaneous layer of the skin.

Skin from the neck, mediastinum and retroperitoneal space is connected by fascial planes and it is these planes that allow air to track from one space to another.

Typically, subcutaneous emphysema is caused by sharp or blunt trauma to the lungs. If the lung is punctured (whether at the parietal or visceral pleura), air is able to track up the peri-vascular sheaths, into the mediastinum and from there enter subcutaneous tissues.

Similarly, in barotrauma, excess pressure in the lungs may cause the alveoli to burst, allowing air to travel below the visceral pleura, up to the hilum of the lung, along the trachea and into the neck.

42
Q

What investigations would you do if you suspected a pneumothorax?

A
  • Examination
  • CXR
  • ABG - those with dyspnoea/hypoxia or chronic lung disease
43
Q

What features would you see on CXR in someone with a tension pneumothorax?

A
  • Affected lung completely compressed
  • Tracheal deviation
  • Heart shifted to contralateral side
  • Depressed hemidiaphragm - affected side
  • Hyperexpanded chest - affected side
44
Q

What does the following CXR show?

A

Large pneumothorax - >2cm

45
Q

What does the following CXR show?

A

Small pneumothorax - < 2cm

46
Q

Who most commonly gets a spontaneous pneumothorax?

A

Young, tall, thin males

47
Q

What is the pathophysiology of a tension pneumothorax?

A

Air gets into the pleural space, but due to the nature of the breach of the pleura, it cannot get back out (flap created either in the visceral or parietal pleura) when the diaphragm ascends. This causes a build-up of air in the pleural cavity, which leads to the lung being squashed.

The increased intrathoracic pressure also causes the mediastinum and trachea to shift away from the affected lung, thus crushing the other lung, and interfering with the blood supply to the heart.

48
Q

What are the things you need to determine before treating a pneumothorax?

A

Whether it is:

  • Tension/non-tension
  • Large/small
  • Primary/secondary
49
Q

How would you treat a tension pneumothorax?

A

Insert large grey venflon into the 2nd intercostal space in the mid-clavicular line, then insert an intercostal chest drain

50
Q

How would you treat an asymptomatic primary pneumothorax?

A
  1. Observe overnight, then repeat CXR
  2. If no change - Discharge, advise no vigorous activity and to return if breathless
  3. Review in clinic after 2 weeks.
51
Q

How would you treat a breathless primary pneumothorax?

A

Aspirate air - until surface of the lung felt tapping the end of the venflon, then pull venflon back a bit then continue to aspirate. Continue this until lung is fully inflated.

**If >3L is aspirated - persistent air leak.

**If unsuccessful - insert a chest drain

52
Q

How would you treat a symptomatic secondary pneumothorax?

A

Insert chest drain - Ideally the lung inflates in 1-2 days

Following this, either:

  1. Clamp drain for 24 hours, re CXR, and if no change, remove chest drain.
  2. CXR can be performed, and if there is no change after 24, remove chest drain without clamping.

If the lung fails to re-inflate after 48 hours - apply suction to the drain (HIGH VOLUME, LOW PRESSURE). If this still doesn’t work, contact thoracic surgeons at 3 days.

53
Q

What are indications for surgical pleurodesis in someone with a pneumothorax?

A
  • Second ipsilateral pneumothorax
  • First contralateral pneumothorax
  • Bilateral spontaneous pneumothoraces
  • First pneumothorax in high risk professions (pilots, divers)
54
Q

What proportion of patients will have a recurrence of a pneumothorax?

A

1/3rd

55
Q

What type of plerual effusion is more likely to cause a unilateral plerual effusion?

A

Exudative

56
Q

What are causes of large unilateral plerual effusions?

A
  • Tumour - bronchogenic carcinoma, mesothelioma, pleural metastases, lymphoma
  • Infection - parapneumonic effusion, empyema, extension from subdiaphragmatic primary infection
  • Chylothorax - ruptured / injured thoracic duct, tumour infiltration e.g. lymphoma
  • Haemorrhage - trauma, iatrogenic trauma

Respiratory Physiology, Medicine and Critical Care (42 decks)

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