Pleural Disease - Pleural Effusion

Question 1

What is the pleura

Answer 1

A single layer of mesothelial cells with sub-pleural connective tissue

Question 2

What are the layers of pleura

Answer 2

Visceral

Parietal

Question 3

What is the space between the two pleura lubricated by

Answer 3

2-3ml of pleural fluid

Question 4

What is the dynamic turnover of pleural fluid per hour

Answer 4

30-75%

Question 5

Is pleura present above the first rib

Answer 5

Yes

Question 6

Is there pleura present over the liver, spleen and kidney

Answer 6

Yes

Question 7

What is pleural effusion

Answer 7

The abnormal collection of fluid in the pleural space

Question 8

What are the symptoms of plerual effusion dependent on

Answer 8

The cause and volume of fluid

Question 9

What are the symptoms of a pleural effusion

Answer 9

Asymptomatic - when there is a small amount which accumulates slowly
Increasing breathlessness (over days, weeks or months)
Pleuritic chest pain (due to inflammation or malignancy)
Dull ache
Dry cough
Weigh loss
MAlaise
Fever
Night sweats

Question 10

What should be enquired about in pleural effusion

Answer 10

Peripheral oedema
Liver disease
Orthopnoea
PND

Question 11

What signs will be present on the affected side

Answer 11

Decreased expansion
Stony dullness to percussion Decreased breath sounds (band of bronchial breathing)
Decreased vocal resonance

Question 12

What other signs will there be

Answer 12

Clubbing, tar staining of fingers
Cervical lymphadenopathy
Increased JVP
Trachea away from large effusion
Peripheral oedema

Question 13

What can the causes be classified into

Answer 13

Transudates

Exudates

Question 14

State the features of transudates

Answer 14

An imbalance of hydostatic forces influencing the formation and absorption of pleural fluid
Normal capillary permeability
Usually (not always) bilateral

Question 15

State the features of exudates

Answer 15

Increased permeability of pleural surface and/or local capillaries
Usually unilateral

Question 16

Name 4 very common causes of transudates

Answer 16

Left ventricular failure
Liver cirrhosis
Hypoalbuminaemia
Peritoneal dialysis

Question 17

Name 4 less common causes of transudates

Answer 17

Hypothyroidism
Nephrotic syndrome
Mitral stenosis
Pulmonary embolism (2/3rds exudates)

Question 18

Name 3 rare causes of transudates

Answer 18

Constrictive pericarditis (previous TB, connective tissue diseases)
Ovarian hyperstimulation syndrome
Meigs’ Syndrome (benign ovarian fibroma, ascites, R sided effusion)

Question 19

What must the pleural fluid level be for it to be considered a transudate

Answer 19

Below 30g/L

Question 20

What must the pleural fluid level be for it to be considered a exudate

Answer 20

Over 30g/L

Question 21

Name 2 very common causes of exudates

Answer 21

Malignancy (lung, breast, mesothelioma, metastatic)

Parapneumonic (consider sub-phrenic)

Question 22

Name 6 less common causes of exudates

Answer 22

Pulmonary embolism/infarction			
Rheumatoid arthritis
Autoimmune diseases (SLE, polyarteritis)
Benign asbestos effusion
Pancreatitis
Post-myocardial infarction/cardiotomy syndrome

Question 23

Name 2 rare causes of exudates

Answer 23

Yellow nail syndrome

Drugs: amiodarone, nitrofurantoin, phenytoin, methotrexate, carbamazapine, penicillamine, bromocriptine, pergolide

Question 24

Do transudates normally require investigation

Answer 24

No

Question 25

When should transudates be investigated

Answer 25

If there are unusual features present | There is a failure to respond to the appropriate treatment

Question 26

How can the presence of effusion be confirmed

Answer 26

Through a chest radiograph (at least 200ml is required before being detectable on a chest X-Ray)

Question 27

What can a contrast enhanced CT of the thorax differentiate between

Answer 27

Malignant and benign disease

Question 28

What equipment is required for a pleural aspiration and biopsy

Answer 28

50ml syringe 21G needle (green) Lignocaine anaesthesia Sterile universal containers Blood culture bottles

Question 29

What are the complications of a pleural aspiration and biopsy

Answer 29

``` Pneumothorax Empyema Pulmonary oedema Vagal reflex Air embolism Tumour cell seeding Haemothorax ```

Question 30

What can looking and sniffing of a pleural aspiration identify

Answer 30

``` Foul smelling – anaerobic empyema Pus - empyema Food particles – oesophageal rupture Milky – chylothorax (usually lymphoma) Blood stained -? malignancy Blood – haemothorax, trauma ```

Question 31

What can a blood gas analyser show

Answer 31

If the patient is infected and has a pH below 7.2 they require a chest drain

Question 32

What should be used if the protein is between 25-35g/L

Answer 32

Lights criteria

Question 33

How can you determine that the protein is an exudate using light's criteria

Answer 33

If one or more of the below is met: Pleural / serum protein >0.5 Pleural / serum LDH >0.6 Pleural LDH >0.66 of upper limit of serum LDH

Question 34

Where is a pleural biopsy taken from

Answer 34

Immediately above a rib

Question 35

What type of needles can be used for a pleural biopsy

Answer 35

Abram's needle | Tru-cut

Question 36

When conducting a pleural biopsy how many biopsies are required

Answer 36

4 3 sent sent in formaldehyde for histology 1 in saline sent to microbiology for suspected TB

Question 37

What other methods can be used if there is no diagnosis after previous more common investigations

Answer 37

Thorascopy | Video assisted thorascopy

Question 38

What does a thorascopy involve

Answer 38

Direct inspection of the pleura Direct biopsies Can be therapeutic

Question 39

What is the treatment administered directed at

Answer 39

The cause of pleural effusion

Question 40

What type of treatments are available

Answer 40

``` Chemotherapy Antituberculous chemotherapy Corticosteroids Palliative Pleurohesis ```

Question 41

When is palliative treatment normally used

Answer 41

For malignancy

Question 42

What does palliative treatment involve

Answer 42

Repeated plerual aspiration of 1-1.5L at any one time

Question 43

What is the life expectancy for patients requiring palliative treatment

Answer 43

Very limited life expectancy (tend to be hospitalised)

Question 44

What is pleurohesis

Answer 44

Procedure which helps to stick the 2 pleural surfaces together so there is no space present for fluid

Question 45

How is pleurohesis conducted

Answer 45

With the patient lying at 45˚ with there arm above their head The thoracostomy is conducted in the 4th intercostal space mid-axillary line and attached to an underwater seal

Question 46

What is the maximum amount that can be drained per hour using pleurohesis

Answer 46

500ml/hr

Question 47

How long does pleurohesis drain for

Answer 47

Until dry which is checked with a chest X-Ray

Question 48

What happens if the lung has not re-expanded after pleurohesis

Answer 48

Suction will be applied for 24 hours

Question 49

What happens if the lung still has not expanded 24 hours suction has been applied

Answer 49

Drain should be removed to prevent infection

Question 50

What should be done if the lung has re-expanded after pleurohesis

Answer 50

Chemical pleurodhesis should be conducted

Question 51

What does a chemical pleurodhesis involve

Answer 51

Instilling 3mg/kg of lignocaine 2-5g of talc slurry Drain should be clamped for 1 hour

Question 52

When should the drain be removed if the lung has re-expanded

Answer 52

12-72 hours if the lung remains expanded

Question 53

When is a surgical pleurodhesis normally preformed

Answer 53

At the time of diagnostic thorascospy