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01. Respiratory System - HP > - Pleural Disease > Flashcards

- Pleural Disease Flashcards

1
Q

What is the pleura composed of?

A

Single layer of mesothelial cells

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2
Q

What are the forces acting across the pleura?

A
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3
Q

Where does the pleura extend to?

A

Pleura over the first rib

Pleura over the liver, spleen, kidney

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4
Q

What is pleural effusion defined as?

A

Abnormal collection of fluid in the pleural space

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5
Q

What are the symptoms of pleural effusion?

A

Asymptomatic – if small and accumulates slowly

Increasing breathless (days, weeks, months)

Pleuritic chest pain

(cause of pleural fluid) inflammatory: early, may improve as fluid accumulates

malignancy: progressively worsening

Dull ache

Dry cough – especially if rapid accumulation

Weight loss, malaise, fevers, night sweats

Need to enquire about peripheral oedema, liver disease, orthopnoea, PND

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6
Q

What are the signs of pleural effusion?

A
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7
Q

What are the causes for pleural effusion?

A
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8
Q

What are the two types of pleural effusion?

A

transudates and exudates

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9
Q

How do you distinguish between transudates and exudates?

A

Determined by the pleural fluid protein

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10
Q

What is the definition of a transudate?

A

Pleural fluid protein < 25g/l, for exams < 30g/l

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11
Q

What are the causes of a transudate?

A
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12
Q

What is the definition of an exudate?

A

Pleural fluid protein > 35g/l, for exams > 30g/l

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13
Q

What are the causes of exudate?

A
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14
Q

Do you need to investigate for transudates?

A

Not usually, clinical picture is usually characteristic

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15
Q

When should you investigate a transudate?

A

If there are unusual features

Failure to respond to appropriate treatment

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16
Q

How do you confim presence of effusion?

A

Chest radiograph

Pleural aspiration and biopsy

Contrast enhanced CT of thorax (

Usually differentiates between malignant and benign disease

nodular pleural thickening

mediastinal pleural thickening

parietal pleural thickening >1cm

circumferential pleural thickening

other malignant manifestations in lung/liver)

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17
Q

What are the possible complications for aspiration?

You use (

50ml syringe 21G needle (green), lignocaine anaesthesia

(guidelines recommend bedside US guidance)

Sterile universal containers

Blood culture bottles)

A

Pneumothorax

Empyema

Pulmonary oedema

Vagal reflex

Air embolism

Tumour cell seeding

Haemothorax

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18
Q

Define pleural aspiration

A

A pleural aspiration is a procedure where a small needle or tube is inserted into the space between the lung and chest wall to remove fluid that has accumulated around the lung.

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19
Q

What does foul smelling pleural fluid indicate?

A

Anaerobic empyema

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20
Q

What does pus in the pleural fluid indicate?

A

Empyema

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21
Q

What does food in the pleural fluid indicate?

A

Oesophageal rupture

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22
Q

What does milky pleural fluid indicate?

A

Cyclothorax - usually lymphoma

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23
Q

What is cyclothorax?

A

A chylothorax (or chyle leak) is a type of pleural effusion. It results from lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct.

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24
Q

What is the biochemistry anaysis of the pleural fluid?

A

Measures levels of protein, Lactate dehydrogenase (LDH), amylase (increase could indicate pancreatitis), looking out for empyema, rheumatoid arthritis, SLE

(Systemic lupus erythematosus (SLE) is an autoimmune disease. In this disease, the body’s immune system mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs.)

TB

Malignancy

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25
Q

What do Microbiology test the pleural fluid for?

A

Gram stain (determines the class of bacteria)

AAFB - Alcohol, acid fast bacilli?

Culture

Microscopy, culture and sensitivity

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26
Q

What is cytology?

A

The branch of biology concerned with the structure and function of plant and animal cells.

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27
Q

What do cytlogy do with the pleural fluid?

A

Search for malignant cells, lymphocytes (Tb, lymphoma)

eosinophils

28
Q

How do you tell the difference between the two types of pleural aspiration?

A

Transudate if <25g/l, exudate if >35g/l

29
Q

How do you perform a biopsy without hitting the colateral branch of a rib?

A

Biopsy immediately above a rib

30
Q

What are the two common needles used in a biopsy?

A

Abram’s needle for blind biopsies

Tru-cut - for CT guided biopsies

31
Q

What happens to the 4 biopsies taken?

A

Send at least 3 in formaldehyde for histology

Send at least 1 in saline to microbiology if TB suspected

32
Q

If there is no dagnosis from investigating the pleural fluid, what is the next thing to do?

A

Thoracoscopy involving direct inspection og the pleura, directed biopsies, therapeutic

33
Q

What are the treatment plans?

A

Directed at the cause

Chemotherapy

Antituberculosis chemotherapy

Corticosteroids

Palliative

Repeated pleural aspiration

34
Q

What is pleurodhesis?

A

Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae.

35
Q

How is pleurodhesis carried out?

A

Drain fluid until dry - chest X-ray confirms this

If the lung has not re-expanded - apply suciton and remove the drain becuase of infection risk

If the lung has re-expanded, chemical pleurodhesis - The instilled chemicals via chest drain cause irritation between the parietal and the visceral layers of the pleura which closes off the space between them and prevents further fluid from accumulating. Chemicals used can be (slurry of talc)

36
Q

What is surgical pleurodhesis?

A

Performed during thoracectomy or thoracoscopy. Involves mechanically irritating the parietal pleura, often with a rough pad. Removal of the parietal pleura is also an effective way of achieving a stable pleurodesis.

Tunneled pleural catheters used inconjunction with portable vacuum bottles are used to stimulate auto-pleurodesis. Constant excavation of pleural fluid keeps the pleura together, resulting in physical agitation by the catheter, which slowly causes the pleura to scar together.

37
Q

What is pneumothorax defined as?

A

Presence of air within the pleural cavity, lung collapses away from chest wall because of elastic recoil of the lung.

38
Q

What are the two different types of pneumothorax?

A

Spintaneous

Traumatic

39
Q

What are the different types of spontaneous vs Traumatic pneumothoraxes

A
40
Q

What are the common feature of a primary spontaneous pneumothorax?

A

No clinically apparent disease

Most common in young people aged 20-30

People are usually tall and thin

41
Q

What is thought to be the cause of a spontaneous primary pneumothorax?

A

Due to the weight of the lung inducing development of apical blebs that rupture

42
Q

What are pulmonary blebs?

A

Pulmonary blebs are small subpleural thin walled air containing spaces, not larger than 1-2 cm in diameter. Their walls are less than 1 mm thick. If they rupture, they allow air to escape into pleural space resulting in a spontaneous pneumothorax.

43
Q

What are the suspected reasons for a secondary spontaneous pneumothorax

A

Pre-existing lung disease

COPD

Asthma

Pneumonia

TB

Cystic Fibrosis

Fibrosing alveolitis

Sarcoidosis

Histocytosis X

44
Q

What are the non-iatrogenic causes of traumatic pneumothorax?

A

Penetrating chest injury

Blunt chest injury (rib fractures, bronchial rupture)

45
Q

What are the iatrogenic causes of traumatic pneumothorax?

A

Pleural aspiration biopsy

Sub-clavian vein cannulation

Lung, liver, breast, renal biopsy

Acupuncture

46
Q

What are the symptoms of pneumothorax?

A

Assymptomatic if good respiratory reserve

Acute breathlessness, worsening breathlessness

Pleuritic chest pain

Extreme dyspnoea

47
Q

What are the signs of pneumothorax?

A

Perhaps none

Surgical emphysema if significant air leak (air tracking in subcutaneous fat), bubble wrap feeling

Non-tension

Trachea deviated to affected side

Affected side: decreased expansion

hyper resonant

absent, decreased decreased breath sounds

Tension

Trachea deviated away from affected side

Haemodynamic compromise

Increased JVP

48
Q

What is the distinguishment between a small and a large pneumothorax?

A

Small: Rim of air is less than 2 cm

Large: Rim of air is greater than or equal to 2

49
Q

What is the management for a small primary pneumothorax?

A

Observe overnight, repeat chest X-ray, if no change, hole has sealed

Discharge -

Advise no vigorous activity, to return if becomes breathless

Pneumothorax will resolve at about 1.25% /day

Review with CXR clinic 2 weeks

50
Q

How do you manage a breathless primary pneumothorax?

A

Aspirate

Patient at 45 degrees - allows the air to travel to the apex of the lung

Lignocaine to second intercostal space (local anaesthetic), mid clavicular line

50ml syringe, venflon, 3 way tap, discharges into a bucket of water

51
Q

When do you stop aspirating a pneumothorax?

A

Until you can feel the tip of the venflon just beneath the surface of the chest wall

Stop if you have aspirated 3 litres - indicates persistant air leak

52
Q

What is the post aspiration management?

A

Repeat chest X-ray to confirm success

If unsuccessful - chest drain

53
Q

How do you manage a secondary pneumothorax?

A

Try aspiration if small, but usually less successful

Insert intercostal chest drain - 4th intercostal space mid-axillary line

54
Q

What is likely to happen after a chest drain?

A

Lung will inflate in 1-2 days

Drain stops bubbling in the underwater seal

Chest X-ray confirms the lung is inflated

55
Q

What is the management of a patient after an intercostal chest drain?

A
  1. Clamp drain for 24 hours, re-xray, if no change remove drain

OR

  1. Re xray chest after 24 hours, no change, remove drain
56
Q

What should you do if the lung fails to re-inflate after 48 hours, and the drain continues bubbling?

A

Apply suction to drain (high volume, low pressure)

If lung fails to inflate contact thoracic surgeon at 3 days

Thosacoscopic inspection of visceral pleura identification of blebs, tears, clipping and talc poudrage pleurodesis

57
Q

What is the chance of getting a subsequent pneumothoroax within 4 years?

A

54%

58
Q

When should you refer someone for surgical pleurodhesis?

A

If it is the second ipsilateral pneumothorax

First contralateral pneumothorax

Bilaterl spontaneous pneumothoraces

First pneumothorax in high risk professions

59
Q

What can be used instead of talc poudrage?

A

Pleurectomy, removal of part of the pleura

60
Q

What is asbestos?

A

Highly fibrous naturally occuring mineral

61
Q

What are the three different types of asbestos?

A

Chrysotile

Amostile

Crocidolite

62
Q

What is the purpose of asbestos?

A

Woven into fabric or added to other materials

It has a high tensile strength

Fire resstance

Insulation to electrical charge

Resistant to chemical attack

Commonly foud in building materials

63
Q

What is mesothelioma?

A

Pleural malignancy

Mostly due to asbestos

64
Q

What is the clinical presentation of mesothelioma?

A

Breathlessness (pleural effusion)

Chest wall pain

Weight loss

65
Q

What are the radiological findings of mesothelioma?

A

Usually unilteral

Diffuse or localised pleural thickening

66
Q
A

01. Respiratory System - HP (82 decks)

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