pleural disease

Question 1

Pleural Effusion causes + criteria, syx

Answer 1

Causes: based on protein concentration:
(1.) Transudate (<30g/L): HF, Hypalbuminaemia (liver disease, nephrotic syndrome, malabsorption)

(2. ) Exudate (>30g/L)
- Infection: pneumonia, TB
- Inflamm: RA, SLE, acute pancreatitis
- Neoplasia: lung Ca, mesothelioma, metastases
- PE

(3. ) Light’s Criteria for protein 25-35g. It is exudate if:
- Pleural fluid to serum protein ratio >0.5
- Pleural fluid to serum LDH >0.6
- Pleural fluid LDH >2/3 upper limit of serum LDH

Presentation
1. Asyx
2. Dyspnoea
3. Non-productive cough 
4. Pleuritic CP
5. Reduced ET
6. O/e
o Stony dull percussion
o Reduced breath sounds
o Reduced chest expansion
o Reduced tactile/vocal fremitus 
o Trachea deviated if large effusion

Question 2

Pleural effusion IX + MX

Answer 2

Ix
(1.) Bloods: FBC, UE, LFT

(2. ) CXR (1st line)
- Small effusions = costophrenic blunting
- Bigger effusions = ‘meniscus’

(3. ) USS + aspiration (Dx)
- NOT done in HF
- Sent for biochemistry (pH, protein, lactate dehydrogenase), cytology, microscopy
- Clear, straw-colour = transudate, exudate
- Turbid yellow, foul smelling = empyema
- Haemorrhagic = trauma, malignancy, PE
- pH <7.2 = empyema, malignancy, TB, RA, SLE
- Amylase = oesophageal rupture, pancreatitis

(4.) CT to identify underlying cause

Mx
(1.) WW if small + asyx

(2. ) Drainage
- Tapping fluid for syx relief
- Intercostal drain for large or empyema
- Long term indwelling pleural drainage if malignant effusion

(3.) Pleurodesis if recurrent (obliteration of pleural space via surgery /chemical /talc)

(4. ) Rx underlying cause:
- Diuretics for HF
- Dialysis for renal failure
- NSAIDs/steroid for SLE effusion

Question 3

Primary + Secondary Pneumothorax mx + how is chest drain inserted

Answer 3

Conservative

• Stop smoking
• No air flight until 6w after resolution
• No scuba diving

Primary:

(1. ) If <2cm + stable pt
- no intervention
- safetynet if more breathless to come back
- FU 2-4w

(2. ) If >2cm or breathless
- Needle aspiration
- FU 2-4w
- If still syx = chest drain

Secondary:

(1. ) If >2cm = Chest drain
(2. ) If 1-2cm = Needle aspiration
(3. ) If <1cm = Admit for 24h obs + oxygen
(4. ) Persistent and recurrent pneumothorax = Surgery

Chest drain

• inserted in pleural space + attached to underwater seal + should be swinging + bubbling
• CXR check psotion
• Insertion site: pec.major, latissmus dorsi, 5th intercostal space, base of axilla

Question 4

Tension pneumothorax - what is it? causes, signs, mx

Answer 4

• Medical emergency
• Often due to punctured lung, trauma, mechanical ventilation
• Injured pleura forms a ‘one-way valve’ so pneumthorax bigger + can displace mediastinum and cardiac compromise which can lead to cardiac arrest

Signs

(1. ) Resp distress
(2. ) Tachycardia
(3. ) Hypotension
(4. ) Distended neck veins
(5. ) Trachea deviation
(6. ) Inc percussion note, reduced AE + breath sounds of affected side

Management: ABCDE

• Insert large bore needle with syringe into 2nd ICS in midclavicular line on affected side
• Syringe should be partially filled with 0.9% saline, pull plunger back and air should bubble through.
• Insert chest tube ASAP after needle insertion
• Once above is done order CXR and then insert chest drain

Question 5

Pleurisy: what is it? causes? syx? ix? mx?

Answer 5

Inflammation of pleura
Causes: viral or bacteria infection, thoracic trauma, AI, SLE, PE

Presentation

(1. ) Sharp pleuritic CP - worse when breathing in or coughing
(2. ) Sob
(3. ) Dry cough

Ix
- CXR

Mx

• NSAIDS
• Abx