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Respiratory system > Diseases of the Pleura > Flashcards

Diseases of the Pleura Flashcards

1
Q

to where does the pleura extend vertically?

A

above the first rib superiorly and covering the kidney, liver an spleen inferiorly

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2
Q

what is a pleural effusion?

A

an abnormal collection of fluid in the pleural space

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3
Q

what symptoms would you expect to see in a pleural effusion?

A 
> none if it is a small effusion
> increasing breathlessness
> pleuritic chest pain
> dull ache
> dry cough
> weight loss, malaise, fevers, night sweats
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4
Q

what signs would you expect to see in a pleural effusion?

A

> decreased expansion
stony dullness to percussion
breath sounds
vocal resonance

(less common include clubbing, cervical lymphadenopathy, elevated JVP and peripheral oedema)

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5
Q

describe a transudate pleural effusion

A

this is caused by an imbalance of hydrostatic force influencing the formation and absorption of pleural fluid. it is normally related to capillary permeability and is usually bi-lateral. they have proteins less than 30mg.

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6
Q

describe an exudate effusion

A

this is due to the permeability of the pleural surface and/or the local capillaries. they are usually unilateral. they have proteins more than 30mg.

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7
Q

what are some common causes of a transudate?

A

> left ventricular failure
liver cirrhosis
hypoalbuminaemia
peritoneal dialysis

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8
Q

what are some less common causes of transudates?

A

> hypothyroidism
nephrotic syndrome
pulmonary embolism

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9
Q

what are some rare causes of transudates?

A

> constrictive pericarditis
ovarian hyper stimulation syndrome
meigs syndrome

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10
Q

what are common causes of exudates?

A

> malignancy

> parapneumonic

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11
Q

what are some less common causes of exudates?

A 
>pulmonary embolism
> rheumatoid arthritis
> autoimmune disease
> benign asbestos effusion
> pancreatitis
> post myocardial infarction
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12
Q

what are some rare causes of exudates?

A

> yellow nail syndrome

> drugs (amiodarone, nitrofurantoin)

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13
Q

when would you investigate a pleural effusion?

A

if there are abnormal features or a failure to respond to treatment

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14
Q

what investigations would you carry out to confirm a pleural effusion?

A

> chest radiograph (at least 200ml required before it becomes visible)
contrast enhanced CT of the thorax (differentiates between malignant or benign disease)
pleural aspiration and biopsy

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15
Q

describe how a pleural aspiration would be carried out?

A

using a 50ml syringe 21g needle and lignocaine anaesthesia. it is carried out where it is maximally dull.

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16
Q

what are some complications that might arise from an aspiration?

A 
> pneumothorax
> empyema
> pulmonary oedema
> air embolism
> tumour cell seeding
> haemothorax
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17
Q

what would be looked for on a ward analysis of an aspiration of a pleural effusion?

A 
> foul smell: anaerobic empyema
> pus: empyema
> food particles: oesophageal rupture
> milky: chylthorax
> blood stained malignancy
> blood: haemothorax, trauma
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18
Q

if a blood gas analyser shows the fluid from an aspiration of a pleural effusion is less than 7.2 what would that indicate?

A

that there is an infection

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19
Q

where in relation to the rib would a biopsy be taken from?

A

immediately above the rib

20
Q

in what form are the biopsies sent to microbiology?

A

three are sent in formaldehyde and one in saline if TB is suspected

21
Q

when taking a biopsy what way should the cutting edge be facing?

A

downwards, it should never be facing upwards

22
Q

what is the name of the needle used for:
> blind biopsies?
> CT guided biopsies

A

> Abrams’ needle for blind

>Tru0cut needle for CT guided

23
Q

what palliative care would be given to a patient with a pleural effusion?

A

repeated aspiration, 1-1.5 litres at any one time

24
Q

what treatment can be given to a patient with a pleural effusion?

A

treatment that is directed at the cause such as chemotherapy, ant-tuberculosis chemotherapy and corticosteroids.

25
Q

Describe a pleurodhesis

A

the patient lies on the bed with their arm at 45 degrees above their head and a tube is placed at the 4th intercostal space in the maxillary line. the fluid drained goes into a bucket with water to create a one way valve so a pneumothorax is not created. the fluid id also not drained faster than 500ml/hr to avoid a pulmonary oedema.

26
Q

after a pleurodhesis what should be carried out?

A

a CXR to check that the lung has re-expanded.

27
Q

if the lung has not expanded after a pleurodhesis what should you do?

A

> apply air suction for 34 hours

> remove drain, to prevent infection

28
Q

what is carried out if the lung has expanded after a pleurodhesis?

A

a chemical pleuradhesis is carried out with 3mg/kg of lignocaine and talc slurry 2-5g and clamp drain for 1 hour. this creates a chemical pleurisy and the drain can be removed after 12-72 hours

29
Q

what is a pneumothorax?

A

this is the presence of air within the pleural cavity caused by a breach of visceral or parietal pleura with entry of air. the lung then collapses away form the chest wall due to elastic recoil.

30
Q

what is the difference between a primary spontaneous pneumothorax and a secondary spontaneous pneumothorax?

A

primary occurs in a healthy lung and secondary is due to an underlying condition.

31
Q

what is the difference between an iatrogenic and non-iatrogenic pneumothorax?

A

iatrogenic is caused by a surgeon making a hole in the lung and non-iatrogenic is caused by a knife or a bullet.

32
Q

what is a tension pneumothorax?

A

this is due to a flap of lung that allows air to enter the lung but not leave. the pressure then builds up and the mediastinum is pushed to the other side. the vena cava can potentially be stretched preventing blood form returning to the heart.

33
Q

what are the symptoms of a pneumothorax?

A

> none if it is small with a large respiratory reserve
acute/worsening breathlessness
extreme dyspnoea

34
Q

what is a surgical emphysema?

A

this is when a significant air leak causes it to track in the subcutaneous fat creating bubble wrap skin.

35
Q

in an pneumothorax in what direction will the trachea deviate to?

A

in a non-tension it will deviate towards the affected side and in a tension it deviate away from the affected side

36
Q

what would the signs be in a non-tension pneumothorax?

A

trachea deviation
decreased expansion
hyper-resonant percussion

37
Q

what would the signs be in a tension pneumothorax?

A

trachea deviation
haemodynamic compromise, elevated JVP
the patient will look really ill

38
Q

how would you manage a tension pneumothorax?

A

a cannula is placed in the 2nd intercostal space in the mid-clavicular line and an intercostal chest drain inserted.

39
Q

how would you manage a small primary pneumothorax with no breathlessness?

A

observe over night and then repeat the CXR, if there is no change then discharge and advise to do no vigorous activity and return if they get breathless. they are then reviewed in 2 weeks with another CXR.

40
Q

how would you manage a breathless primary pneumothorax?

A

aspirate the patient until you feel the surface of the lung on the tip of the venflon or more that 3l has been aspirated. if it is successful CXR after 24 and if not insert a chest drain.

41
Q

how is a breathless secondary pneumothorax managed?

A

an intercostal chest drain is placed at the 4th intercostal space in the mid-axillary line.

42
Q

what happens if the drain to an pneumothorax continues to bubble as the lung has not re-inflated after 48 hours?

A

suction is applied to the drain that is high volume and low pressure. if they still do not re-inflate contact the thoracic surgeons after 3 days and they will carry out an inspection.

43
Q

in what situation should a patient with a pneumothorax be referred for a surgical pleurodesis?

A

> second ipsilateral pneumothorax
first contralateral pneumothorax
bilateral spontaneous pneumothorax
first pneumothorax in a high risk profession (diver/pilot)

44
Q

what is the most dangerous form of asbestos?

A

crocidolite

45
Q

what is mesothelioma?

A

this is a pleural malignancy which is 80% due to asbestos. it can also ossur in the peritoneum. it presents as breathlessness and chest wall pain due to pleural thickening.

Respiratory system (19 decks)

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