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01. Respiratory System - HP > Pleural Disease > Flashcards

Pleural Disease Flashcards

1
Q

What is pleura composed of?

A
  • Single layer of mesothelial cells

- Sub-pleural connective tissue

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2
Q

What is found between the visceral and parietal pleura?

A
  • The pleural cavity

- Lubricated by 2-3ml of pleural fluid which has a 30-75% turnover per hour

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3
Q

What pressure moves fluid from the chest wall to the pleural cavity?

A

Systemic arterial pressure (4kPa), negative intra pleural pressure

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4
Q

What pressure moves fluid from the pleural cavity to the chest wall?

A

Plasma osmotic/oncotic pressure

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5
Q

What pressure moves fluid from the pleural cavity to the lungs?

A

Plasma osmotic/oncotic pressure

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6
Q

What pressure moves fluid from the lungs to the pleural cavity?

A

Pulmonary arterial pressure (1.5kPa), negative intra pleural pressure

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7
Q

Overall, what is the net movement of fluid due to pressure?

A

From systemic circulation through the pleura into the lungs

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8
Q

How high up does the pleura extend?

A

Above the 1st rib

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9
Q

How far down does the pleura extend?

A

Pleura found over the liver, spleen and kidneys

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10
Q

Pleural effusion

A

Abnormal collection of fluid in the pleural space

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11
Q

What are the symptoms of pleural effusion dependent on?

A

Depends on cause and volume of fluids

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12
Q

What symptoms can pleural effusion present with?

A
  • Asymptomatic
  • Increasing breathlessness
  • Pleuritic chest pain
  • Dull ache
  • Dry cough
  • Weight loss
  • Malaise
  • Fevers
  • Night sweats
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13
Q

What do you need to enquire about when asking about symptoms relating to pleural effusion?

A
  • Peripheral oedema
  • Liver disease
  • Orthopnoea
  • PND
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14
Q

What are the 2 reasons for pleuritic chest pain due to pleural effusion?

A
  • Inflammatory: early, may improve as fluid accumulates

- Malignancy: progressively worsening

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15
Q

What are the main signs of pleural effusion?

A

Chest on affected side:

  • Decreased expansion
  • Stony dullness to percussion
  • Decreased breath sounds with band of bronchial breathing
  • Decreased vocal resonance
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16
Q

What other signs might be present in pleural effusion?

A
  • Clubbing
  • Tar staining of fingers
  • Cervical lymphadenopathy
  • Increased JVP
  • Trachea deviated away from effusion
  • Peripheral oedema
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17
Q

What are the 2 ways the pleural effusions can be classed by cause?

A
  • Exudates

- Transudates

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18
Q

What causes transudate pleural effusions?

A

An imbalance of hydrostatic forces influencing the formation and absorption of pleural fluid

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19
Q

What are the characteristics of transudate pleural effusions?

A
  • Normal capillary permeability

- Usually but not always bilateral

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20
Q

What are the characteristics of exudate pleural effusions?

A
  • Increased permeability of pleural surface and/or local capillaries
  • Usually unilateral
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21
Q

For exam purposes how do you separate exudates and transudates?

A
  • Transudates have pleural fluid protein of <30g/l

- Exudates have pleural fluid protein of >30g/l

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22
Q

What are the ‘very common’ causes of transudates?

A
  • Left ventricular failure
  • Liver cirrhosis
  • Hypoalbuminaemia
  • Peritoneal dialysis
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23
Q

What are the ‘less common’’ causes of transudates?

A
  • Hypothyroidism
  • Nephrotic syndrome
  • Mitral stenosis
  • Pulmonary embolism
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24
Q

What are the ‘rare’ causes of transudates?

A
  • Constrictive pericarditis
  • Ovarian hyperstimulation syndrome
  • Meigs’ syndrome
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25
Q

What are the ‘very common’ causes of exudates?

A
  • Malignancy (lung, breast, mesothelium, metastatic)

- Parapneumonic (consider sub-phrenic)

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26
Q

What are the ‘less common’ causes of exudates?

A
  • Pulmonary embolism/infarction
  • Rheumatoid arthritis
  • Autoimmune diseases
  • Benign asbestos effusion
  • Pancreatitis
  • Post-myocardial infarction/ cariotomy syndrome
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27
Q

What are the ‘rare’ causes of exudates

A
  • Yellow nail syndrome

- Drugs

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28
Q

What drugs can cause exudates?

A
  • Amiodarone
  • Nitrofurantoin
  • Phenytoin
  • Methotrexate
  • Carbamazapine
  • Penicillamine
  • Bromocriptine
  • Pergolide
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29
Q

When is investigation not usually required for pleural effusion?

A

Transudates

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30
Q

When is investigation required regarding pleural effusion?

A
  • If there is unusual features

- Failure to respond to appropriate treatment

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31
Q

What is used to confirm presence of effusion?

A

Chest radiograph

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32
Q

How much fluid is required before it is detectable on a chest X-ray?

A

At least 200ml

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33
Q

What can a contrast enhance CT of the thorax usually differentiate between?

A

Malignant and benign disease

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34
Q

What can be seen on a contrast CT which can differentiate between malignant and benign disease?

A
  • Nodular pleural thickening
  • Mediastinal pleural thickening
  • Parietal pleural thickening >1cm
  • Circumferential pleural thickening
  • Other malignant manifestations in lung/liver
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35
Q

What is required for aspiration of pleural effusion?

A
  • 50ml syringe 21G needle
  • Lignocaine anaesthesia
  • Sterile universal containers
  • Blood culture bottles
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36
Q

What are the possible complications from aspiration/biopsy of pleural effusion?

A
  • Pneumothorax
  • Empyema
  • Pulmonary oedema
  • Vagal reflex
  • Air embolism
  • Tumour cell seeding
  • Haemothorax
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37
Q

What ward analysis can be carried out during pleural aspiration?

A

Look and sniff

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38
Q

What can you tell by looking and sniffing contents of a pleural aspiration?

A
  • Foul smelling: anaerobic empyema
  • Pus: empyema
  • Food particles: oesophageal rupture
  • Milky: chylothorax
  • Blood stained: malignancy
  • Blood: haemothorax, rupture
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39
Q

What does a pH of< 7.2 for the contents of pleural aspiration suggest?

A

Infection

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40
Q

What is the intervention required if contents of pleural aspiration are infected and have a pH of <7.2?

A

Chest drain

41
Q

What will the biochemists be looking at when testing samples of pleural aspirations?

A
  • Protein, LDH
  • Amylase
  • Glucose
42
Q

What does raised amylase suggest?

A

Pancreatitis

43
Q

What does glucose <3.3mM suggest?

A
  • Empyema
  • Rheumatoid arthritis, SLE
  • TB
  • Malignancy
44
Q

What tests will the microbiologists carry out on pleural aspiration samples?

A
  • MC&S
  • Gram stain
  • AAFB
  • Culture
45
Q

What are they looking for in cytology when testing pleural aspiration samples?

A
  • Malignant cells, lymphocytes (TB, lymphoma)

- Eosinophils (Churg-Strauss, asbestos, malignancy)

46
Q

When is a pleural effusion exudate?

A

If 1 or more of the following criteria apply:

  • Pleural/serum protein >0.5
  • Pleural/serum LDH>0.6
  • Pleural LDH >0.66 of upper limit of serum LDH
47
Q

What instruments can be used for pleural biopsy?

A
  • Abrams needle for blind biopsy

- Tru-cut for CT guided biopsy

48
Q

Where should the needle be inserted during biopsy?

A
  • Immediately above a rib.

- Do not biopsy with cutting edge upwards

49
Q

How many biopsy samples must be obtained?

A

At least 4

50
Q

Where are biopsy samples sent?

A
  • 3 in formaldehyde to histology

- 1 in saline to microbiology if TB suspected

51
Q

What investigations can be carried out if there remains no diagnosis after biopsy?

A
  • Thoracoscopy

- Video assisted thoracoscopy

52
Q

What can thoracoscopy be used for?

A
  • Direct inspection of pleura
  • Directed biopsies
  • Therapeutic
53
Q

What treatment can be directed at the cause of pleural effusion?

A
  • Chemotherapy
  • Antituberculous chemotherapy
  • Corticosteroids
54
Q

What palliative treatment options are there for pleural effusion?

A
  • Repeated pleural aspiration 1-1.5 litres at one time

- Pleurodhesis

55
Q

How is a pleurodhesis performed?

A
  • Patient lying on bed at 45 degree angle with arm above head.
  • Insertion of chest tube into 4th intercostal space mid-axillary line
56
Q

What rate should fluid be drained at with pleurodhesis?

A

Drain fluid no faster than 500ml/hr

57
Q

If after draining the lung it hasn’t re-expanded what should be done?

A
  • Apply suction for 24 hours

- Remove drain

58
Q

If the lung has re-expanded what should you do next?

A
  • Instill 3mg/kg lignocaine
  • Instill talc slurry, clamp drain after 1 hour
  • Remove drain after 12-72 hours if lung remains re-expanded
59
Q

When is surgical pleurodhesis usually performed?

A

At time of diagnostic thoracoscopy

60
Q

Pneumothorax

A

Presence of air within the pleural cavity

61
Q

What is pneumothorax caused by?

A

Breach of visceral or parietal pleura with entry of air, lung collapses away from chest wall because of elastic recoil of the lung

62
Q

How can pneumothorax be classed?

A
  • Primary spontaneous
  • Secondary spontaneous
  • Non-iatrogenic traumatic
  • Iatrogenic traumatic
63
Q

What is the key characteristic of tension pneumothorax?

A

Mediastinal shift away from affected side

64
Q

What is the difference between primary and secondary spontaneous pneumothorax?

A
  • Primary there is no underlying lung disease

- Secondary there is underlying lung disease

65
Q

What is the typical patient of primary spontaneous pneumothorax?

A

Tall, thin males

66
Q

What are primary spontaneous pneumothorax believed to be due to?

A

The weight of lung inducing development of apical blebs that rupture

67
Q

What pre-existing lung diseases can lead to secondary spontaneous pneumothorax?

A
  • COPD
  • Asthma
  • Pneumonia
  • TB
  • Cystic fibrosis
  • Fibrosing alveolitis
  • Sarcoidosis
  • Histiocytosis X
68
Q

What can cause non-iatrogenic traumatic pneumothorax?

A
  • Penetrating chest injury

- Blunt chest injury

69
Q

What can cause iatrogenic traumatic pneumothorax?

A
  • Pleural aspiration/biopsy
  • Sub clavian vein cannulation
  • Lung, liver, breast, renal biopsy
  • Acupuncture
70
Q

What are the symptoms of pneumothorax?

A
  • Asymptomatic
  • Acute breathlessness
  • Pleuritic chest pain
  • Extreme dyspnoea
71
Q

What are the signs of pneumothorax?

A
  • May be no signs

- Surgical emphysema

72
Q

What are the signs in non-tension pneumothorax?

A 
-Trachea deviated to affected side
Affected side:
-Decreased expansion
-Hyper resonant
-Absent or decreased breath sounds
73
Q

What are the signs of tension pneumothorax?

A
  • Trachea deviated away from affected side
  • Haemodynamic compromise
  • Increased JVP
74
Q

What decisions must be made in the management of pneumothorax?

A
  • Is it tension?
  • Is pneumothorax small or large?
  • Is patient breathless?
  • Is pneumothorax likely to be primary or secondary?
75
Q

What is the management for a tension pneumothorax?

A
  • Cannula 2nd intercostal space mid-clavicular line

- Then insert intercostal chest drain

76
Q

What is the management for a small primary pneumothorax, not breathless?

A
  • Observe overnight, repeat CXR, if no change, hole has sealed
  • Discharge
  • Advise no vigorous activity, to return if it becomes breathless.
  • Review with CXR clinic 2 weeks
77
Q

What is the management for a breathless primary pneumothorax?

A
  • Aspirate pneumothorax
  • Patient at 45 degree angle
  • Lignocaine to 2nd intercostal space, midclavicular line
  • 50ML syringe, venflon, 3 way tap, tube to water
  • If successful, CXR, observe 24 hours
  • If unsuccessful, chest drain
78
Q

In a breathless primary pneumothorax, when should you aspirate until?

A
  • Feel lung surface on tip of venflon just beneath surface of chest wall
  • Aspirate > 3 litres
79
Q

What is the management for breathless secondary pneumothorax?

A
  • May try to aspirate if small but less successful
  • Insert intercostal chest drain to 4th intercostal space mid-axillary line
  • Small bore 10-14F
  • If surgical emphysema use large 24-32F
80
Q

What is the ideal outcome of an intercostal chest drain?

A

-Lung inflates in 1-2 days
-Drain stops bubbling
-CXR confirms lung inflated
THEN
1) Clamp drain fro 24 hours, re CXR, no change, remove drain
OR
2) Re CXR after24 hours, no change, remove drain

81
Q

What are the less than ideal outcomes of a chest drain?

A
  • Lung fails to re-inflate after 48 hours

- Drain continues bubbling

82
Q

What can you do if the chest drain does not work?

A

Apply suction to drain (high volume, low pressure)

83
Q

What should you do if the lung fails to re-inflate even after suction?

A
  • Contact thoracic surgeons at 3 days
  • Thoracoscopic inspection if visceral pleura
  • Identification of blebs, tears, clipping and talc poudrage pleurodesis
84
Q

Who should be referred for surgical pleurodesis?

A
  • Second ipsilateral pneumothorax
  • First contralateral pneumothorax
  • Bilateral spontaneous pneumothoraxes
  • First pneumothorax in high risk professions (pilot, divers)
85
Q

Asbestos

A

Highly fibrous naturally occurring mineral

86
Q

What are the 3 main types of asbestos?

A
  • Chrysotile (white)
  • Amosite (brown)
  • Crocidolite (blue)
87
Q

What is the most dangerous to health type of asbestos?

A

Crocidolite

88
Q

What are the properties of asbestos?

A
  • High tensile strength
  • Fire resistant
  • Insulation to electrical charge
  • Resistant to chemical attack
  • Commonly found in building materials
89
Q

Who is at highest risk of exposure to asbestos?

A
  • Boiler men
  • Engineers
  • Electricians
  • Plumbers
  • Building trade
  • Ship building
  • Relatives who washed dirty overalls
90
Q

When does asbestos related disease occur?

A

20-40 years after exposure

91
Q

What is mesothelioma?

A

Pleural malignancy mainly due to asbestos exposure

92
Q

What is the clinical presentation of mesothelioma?

A
  • Breathlessness
  • Chest wall pain
  • Weight loss
93
Q

What is usually found on radiology of mesothelioma?

A
  • Usually unilateral

- Diffuse or localised pleural thickening

94
Q

What can be performed if asbestos related pleural malignancy is diagnosed early in a patient that is otherwise well?

A

Pleuropneumonectomy

95
Q

What are the palliative treatment options for mesothelioma?

A
  • Radiotherapy to drain biopsy sites
  • Chemotherapy being trialled
  • Pleuradhesis
  • Analgesia
96
Q

What is the life expectancy for mesothelioma?

A

18 months

97
Q

What must be done if there is a mesothelioma death?

A

Reported to Procurator Fiscal

98
Q

Why is mesothelioma regarded as a compensatable disease?

A

Legal compensation available

01. Respiratory System - HP (82 decks)

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