Pleural disease: pneumothorax and pleural effusions

Question 1

where does the blood and nerve supply to the pleura come from?

which pleura has sensation, parietal or visceral?

Answer 1

blood supply: intercostal vessels
nerve supply: intercostal nerves and vagus

Parietal pleura has sensation

Question 2

are the pleura covering the lungs connected? what does this mean for disease spread?

Answer 2

Right and left side are completely separate so disease should not spread

Question 3

how much pleural fluid is normal to be found in the pleural cavity? what is its function?

Answer 3

5-10mL to lubricate and make movements smooth during inspiration and expiration

Question 4

what is a pneumothorax? why can it cause a collapsed lung?

Answer 4

Presence of air in the pleural space. Intra-pleural pressure is negative (lower than alveolar and atmospheric pressure) so air gets sucked into cavity and can lead to partial or total lung collapse

Question 5

what is a tension pneumothorax and why is it an emergency? how do we treat it?

Answer 5

Air gets sucked into the pleural space but it is not expired so air build up. It can displace the mediastinum and cause cardiac compromise.

Treatment: urgent needle decompression in 2nd intercostal space to relieve pressure.
Leads to cardiac arrest if not treated.

Question 6

A 20-40 year old, male, tall, smoker with no underlying lung disease is at risk of what condition?

Answer 6

Primary spontaneous pneumothorax

Question 7

A secondary spontaneous pneumothorax occurs in who?

Answer 7

Those with underlying lung disease, majority COPD.

Question 8

Name some trauma induced causes of pneumothorax

Answer 8

penetrating chest wall injury
puncture from rib
rupture of bronchus or oesophagus

Question 9

Name some iatrogenic induced pneumothorax

Answer 9

pace makers, CT guided lung biopsy, central line insertion, mechanic ventilation, pleural aspiration

Question 10

A patient presents with sudden breathlessness and pleuritic chest pain which is worse on breathing. They are tachypnoeic and hypoxic with reduced breath sounds. What condition is likely?

Answer 10

pneumothorax

Question 11

how do we measure a pneumothorax? If there was a 2cm gap in the pleural space, approximately how much lung function would be lost?

Answer 11

measure across from the chest wall to the lung contour. 2cm across of pleural space means 50% of lung function is lost.

Question 12

how do we manage a pneumothorax?

Answer 12

depends on size and symptoms

• small <2cm = no intervention as can spontaneously resorb
• pleural aspiration = up to 1.5L of air can be aspirated
• chest drain = needed for most secondary pneumothoraxes, chest drain put into big bottle with liquid at the bottom to stop air flowing back in
• surgery = for persistent and recurrent pneumothorax
• general advice: smoking cessation, no air flight for 6 weeks after resolution, no scuba diving ever.

Question 13

what is a pleural effusion?

Answer 13

collection of fluid in the pleural space - common

Question 14

Differentiating between transudate and exudate effusions?

Answer 14

Transudate = <30g/L pleural protein. Transudate occurs when things fail (heart failure, cirrhotic liver disease, renal failure, myxoedema, ascites)

Exudate - >30g/L pleural protein. These are all related to inflammation, increased capillary permeability and impaired re-absorption (pneumonia is most common, cancer, TB, PE, benign asbestos effusion, pancreatitis, dressers syndrome, drug induced)

Question 15

A patient presents with breathlessness, cough, pain & fever. They have stony dull percussion, quiet breath sounds and reduced wall expansion as well as reduced tactile and vocal fremitus. What is the likely condition?

Answer 15

pleural effusion

Question 16

If there is blunting of the diaphragm, how much fluid can you say there must be in the pleural space?

Answer 16

300mL

Question 17

If you took a pleural sample and the appearance was turbid and foul smelling, what would you suspect?

• trauma
• empyema
• transudate
• oesophageal rupture

Answer 17

empyema

Question 18

If you took a pleural sample and the appearance was milky, what would you suspect?

empyema
chylothorax
trauma

Answer 18

chylothroax - fat in the fluid so can be due to damage to thoracic duct

Question 19

If you took a pleural sample and the appearance was blood stained, what would you suspect?

• empyema
• chylothorax
• trauma, cancer or PE
• oesophageal rupture

Answer 19

trauma, cancer or PE

Question 20

If you took a pleural sample and the appearance has food particles, what would you suspect?

• empyema
• chylothorax
• transudate or educate
• oesophageal rupture
• trauma

Answer 20

oesophageal rupture

Question 21

If you took a sample of pleural fluid and there was high levels of LDH, what is this a sign of?

Answer 21

Cancer

Question 22

If you took a sample of pleural fluid and there was high levels of amylase, what is this a sign of?

Answer 22

pancreatitis or pancreatic cancer if very high

Question 23

If you took a sample of pleural fluid and the pH was <7.2, what is this a sign of?

Answer 23

empyema meaning there is infection and acidic fluid.

Question 24

Treatment for an infected effusion?

Answer 24

antibiotics and chest drain if there is pus

Question 25

Treatment for a small effusion?

Answer 25

Normally none, treat underlying cause. Diuretics for HF Dialysis for renal failure NSAIDs or steroids for SLE effusion

Question 26

What is an empyema? | What are the most common causes of community acquired and hospital acquired empyema?

Answer 26

Pus in the pleural space Community acquired: s millers or s pneumoniae or s aureus Hospital: MRSA, s aureus or enterococcus

Question 27

A patient presents feeling unwell and not improving, swinging fevers or rigors and cough with chest pain. What do you suspect? How do you treat it?

Answer 27

``` Empyema Antibiotics (prolonged course), chest drain. ```

Question 28

what is a haemothorax. when can it happen? how do we manage it?

Answer 28

blood in the pleural cavity. usually caused by trauma, post-op, bleeding disorders, lung cancer PE, aortic rupture. management: large bore chest drain, vascular intervention might be needed or surgery.

Question 29

what is a hydropneumothorax? | causes?

Answer 29

air and fluid in the pleural space | causes: iatrogenic, gas forming organisms or thoracic trauma

Question 30

what is a pneumomediastinum and why can it occur?

Answer 30

air in the mediastinum which can enter from the lungs, trachea, oesophagus and get into the central part of the chest. Often seen with surgical empyema and pneumothorax.

Question 31

A young patient presents with vomiting and severe pleuritic chest pain and is becoming very unwell. They have had an endoscopy recently which could have caused trauma. What do you suspect has happened? How do you treat it?

Answer 31

Oesophageal rupture | Treatment: not eating, antibiotics and surgical intervention.