Pleural and Chest Wall disease Flashcards

1
Q

Pleura

A

Covered by a layer of mesothelial cells
Pleural space normally at negative pressure and has a few mls of fluid for lubrication
Pleura is 0.3-0.5mm thick, but fluid forms a <1mm film
Fluid contains lymphocytes, macrophages and mesothelial cells (pH 7.6)
Fluid/air can move into pleural space - effusion/pneumothorax
This accumulation of positive pressure within pleural space -> partial or complete collapse of underlying lung

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2
Q

Pneumothorax

A

Air in pleural space
Entry of air creates positive pressure -> collapse of lung
Tension pneumothorax -> one way valve
Primary/secondary/traumatic/iatrogenic (caused by procedures/doctors)

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3
Q

1) Primary Spontaneous Pneumothorax

2) Secondary Pneumothorax

A
1) Occurs in healthy young tall males
Apical blep
More common in smokers (esp cannabis)
Tension - rarely occurs
Managed according to size and symptoms of patient
Won't always need a drain/admission
2) background of known lung disease (COPD, bronchiectasis, ILD)
Mostly will need a drain
Tension more common
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4
Q

Follow up and Advice

A

Primary - 54% recurrence in first 4 years, recurrent primary - surgical/medical thoracoscopy and pleurodesis
Secondary - attempt pleurodesis after the first episode as the recurrence rate is high
Advice: no deep sea diving, coast guards/naval officers/air force should change jobs, high altitude sports and travel done with caution, stop smoking, diving less that 10 feet depth is fine

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5
Q

Pleural Effusions

A

Small volume of lubricating fluid is maintained via a delicate balance of hydrostatic and oncotic pressure, and lymphatic drainage
Disturbances in any of these mechanisms may lead to pathology and cause a pleural effusion
Clinical features: SOB, cough, pleuritic chest pain, reduced breath sounds, dull to percuss

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6
Q

Causes of Pleural Effusion

A

Acute vs chronic / benign vs malignant
Altered permeability of pleural membranes (infection, inflammation, cancer)
Reduced oncotic pressure - low albumin (renal disease, liver cirrhosis)
Increased capillary hydrostatic pressure (HF)
Decreased lymphatic drainage or blockage (malignancy, trauma)
Increased peritoneal fluid (liver cirrhosis, peritoneal dialysis)
Commonest causes: HF, pneumonia, malignancy
- infection - benign (high oncotic pressure: HF/fluid overload - low protein state, autoimmune disease, reactive PE, Dresslers syndrome) - malignant

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7
Q

Pleural Infection

A

Risk factors: diabetes, immunosuppression, alcohol, IVDU, poor oral hygiene, aspiration, iatrogenic, trauma.
Seen of CXR with systemic features of infection (fever, raised CRP, WCC) - take pleural fluid sample.
Predictors of worse outcome: pH <7.2, high LDH, low glucose, positive culture, loculations (seen on u/s or CT)

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8
Q

Spectrum of Parapneumonic effusions

A

Uncomplicated parapneumonic effusion: resolve on treatment of underlying pneumonia, may not need to be drained
Complicated parapneumonic effusion: bacterial invasion into pleural space, fibrin deposition may form locules/septations, patient will likely need a drain
Empyema: frank pus within pleural cavity, may organise with thickening of pleural surface preventing lung re-expansion and impairing lung function

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9
Q

Malignant Effusion

A

High recurrence rate
Median life expectancy - 6 months
Impact on wider health economy
Mostly unilateral
Massive unilateral effusion are usually not benign
Often present with breathlessness, cough and hypoxia
Mostly they are haemorrhagic
Management: minimally invasive and reduced number of interventions - aspiration, chest drain +/- pleurodesis, indwelling pleural catheter (avoids admission to hospital, suitable for long term drainage), thoracoscopic drainage + pleurodesis

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10
Q

Talc Pleurodesis for Pleural effusions

A

To prevent recurrence
Mediated talc
Creates a talc slurry to stick the pleura together
Works in 70%
Lungs need to be reinflated, and output <200ml/24 hrs
Drain cannot be blocked - needs to not fall out
Pain/fever

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11
Q

Haemothorax

A

Not a bloody effusion (HCT >50%)
Traumatic/iatrogenic
Aortic dissection
Depending on cause: resuscitate, urgent drainage, consider VATS

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