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Respiratory Anatomy & Disease Mechanisms > Pleural Malignancy (DISEASE MECHANISMS) > Flashcards

Pleural Malignancy (DISEASE MECHANISMS) Flashcards

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1
Q

What is the plural cavity?

A

The space between the visceral and parietal pleura

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2
Q

How much fluid does the pleural cavity normally contain?

A

Approx. 4 ml

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3
Q

How much fluid is approximately needed, in the pleural cavity to be detected on plain CXR?

A

Approx 200 ml

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4
Q

The two layers of the pleura combine around the ______

A

hila (of the lung)

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5
Q

The layers of the pleural cavity combine to form the _________ _______ which runs inferiorly and attaches the lung root to the ______

A

pulmonary ligament

diaphragm

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6
Q

What is pleural effusion?

A

Abnormal collect not fluid in pleural space

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7
Q

Which type of pleural effusions are a particular cause of concern?

A

Large unilateral effusions

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8
Q

What tools can be used to diagnose pleural effusion?

A 
History + Examination
CXR
Pleural aspirate
Biochemistry (Exudate/Transudate) 
Cytology
Culture 
Contrast CT chest
Repeated pleural tap
Pleural biopsy (blind or thoracoscopy)
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9
Q

What can straw-coloured pleural fluid suggest?

A

Cardiac failure

Hypoalbuminaemia

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10
Q

What can bloody pleural fluid suggest?

A

Trauma
Malignancy
Infection
Infarction

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11
Q

What can turbid/milky pleural fluid suggest?

A

Empyema

Chylothroax

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12
Q

What can foul-smelling pleural fluid suggest?

A

Anaerobic empyema

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13
Q

What can food particles in the pleural fluid suggest?

A

Oesophageal rupture

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14
Q

If pleural effusion is bilateral the likely causes include?

A

LVF
PTE
Drugs

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15
Q

What distinguishes transudate and exudate?

A 
Transudate = < 30 g/L of protein
Exudate = > 30 g/L of protein
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16
Q

Why can transudate pleural effusion occur?

A 
Heart failure 
Hypoproteinaemia
Hypoalbuminaemia
Atelectasis
peritoneal dialysis 
Hypothyroidism 
Meig's syndrome (right pleural effusion + ovarian fibroma
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17
Q

What causes an exudate pleural effusion?

A 
Increased leakiness of pleural cavity secondary to: 
- infection
- Inflammation 
- Injury 
caused by: 
- pneumonia
- TB
- pulmonary infarct 
- RA
- SLE
- Bronchogenic carcinoma 
- malignant metastase
- lymphoma 
- mesothelioma
- lymphogitis carcinoma 
- Asbestos
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18
Q

What does a pleural fluid pH < 7.3 indicate?

A

Pleural inflammation (malignany / empyema / TB / RA / SLE)

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19
Q

A pleural fluid pH requires …?

A

Drainage in the setting of infection

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20
Q

Pleural fluid glucose level of <3.3 mmol/L suggest…?

A 
Empyema
Malignancy
TB
RA
SLE
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21
Q

What does SLE stand for?

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A

Systemic lupus erythematosus

22
Q

What does an increase in lymphocytes in pleural fluid indicate?

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A

TB
Malignancy
SLE
Sarcoidosis

23
Q

What does an increase in neutrophils in the pleural fluid indicate?

Study These Flashcards
A

Para-pneumonic effusion

PE

24
Q

How can microbiology be used to analyse pleural fluid?

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A

Gram stain + microscopy
Culture
PCR, AFB stain + liquid culture
Put in blood culture bottles for greater yield

25
What are the signs of pleural effusion?
Decreased chest expansion Stony dull percussion note Reduced breath sounds on affected side Decreased tactile vocal remits and vocal resonance Above effusion where lung is compressed there may be bronchial breathing Possible tracheal deviation if large effusion Look are aspiration marks Look for signs of associated disease
26
What are the associated diseases of pleural effusion?
``` Malignancy Stigmata of chronic liver disease Cardiac failure Hypothyroidism RA SLE (shows butterfly rash) ```
27
Which tests can be used to investigate pleural effusion?
CXR US Diagnostic Aspiration Pleural Biopsy
28
What is a mesothelioma?
Uncommon tumour of mesothelial cells that usually occurs in the pleura and rarely in the peritoneum or other organs
29
What is the risk of developing a mesothelioma linked to ?
Asbestos exposure - often takes 30-45 yrs to develop
30
What are the symptoms of a mesothelioma?
``` Chest pain Dyspnoea Weight loss Finger clubbing Recurrent pleural effusions Fever Sweating Cough ```
31
Which investigations are possible for mesothelioma?
Imagina (plural nodularity / circumferential pleural thickening / lung invasion/ lung entrapments) Pleural fluid aspiration ( low cytological yield / avoid repeated aspiration / biopsy (thoracoscopy or CT-guided)
32
How can mesotheliomas be treated?
``` Pleurdodese effusions Radiotherapy Surgery Chemotherapy Palliative care Report deaths to fiscal (compensation if occupational asbestos exposure) ```
33
What are the treatment options for malignant pleural effusion?
``` Palliative treatment of symptoms Repeated pleura leaps Drain and/or pleurodesis (TALC) Long-term pleural catheter Surgical: abrasions/pneumectomy ```
34
What are the advantages of TALC: sclerosing agent?
Success of 60%
35
What are the disadvantages of TALC: sclerosing agent?
``` Involves stay in hospital Common Complications - minor pleuritic pain & fever Rare Complications - Pneumonia - Respiratory failure - Talc pneumonitis/ARDS ``` - Secondary empyema - Local tumour implantation at port site in mesothelioma
36
Malignant pleural effusions are due to ______ of many cancers to the _____
metastasis | pleura
37
What does a long-term pleural catheter involve?
Drain designed to stay for life Vacuum in drainage bottle produces vacuum providing suction to drain Drain fluid by demand
38
What is the maximum amount of a fluid a patient should drain using a long-term pleural catheter?
1 L a day
39
How is the prognosis of a patient with a malignant pleural effusion calculated?
``` LENT Score LDH level in pleural fluid (<1500 = 0 / > 1500 = 1) ECOG PS (0 = 0 / 1 = 1 / 2= 2 / 3-4 = 3) (serum) Neutrophil to Lymphocyte ratio (<9 = 0 / >9 = 1) Tumour type (Low risk: mesothelioma/haematological malignancy = 0 // Moderate risk: Breast / gynaecological / renal cell = 1 // High risk: lung cancer / other tumour types = 2) ```
40
How is the LENT score interpreted?
``` 0-1 = low score 2-4 = Moderate risk 5-7 = Higher risk ```
41
Treatment for malignant pleural effusion depends on ________
underlying cause
42
How would each of the malignant pleural effusions be treated considering the underlying cause: LVF Infection Malignancy
LVF - Diuretics Infection - drain/antibiotics/maybe surgery Malignancy - pleurodesis / long-term pleural catheter
43
What distinguishes primary and secondary pneumothoraces?
``` Primary = normal lungs; occurs due to apical bullae rupture / often asymptomatic Secondary = due to underlying lung disease / usually symptomatic ```
44
Under which patient category are pneumothoraces more common in?
Tall thin men Smokers Cannabis Underlying lung disease
45
What are the symptoms of a pneumothorax?
Acute onset of pleuritic chest pain Dyspnoea Hypoxia
46
What are the signs of a pneumothorax?
Tachycardia Hyper-resonant percussion notReduced chest expansion Quiet breath sounds on auscultation Herman's sign - click on auscultation of left side
47
How can a pneumothorax be investigated?
``` CXR usually sufficient CT chest (differentiation between bullous lung disease and small pneumothorax) ```
48
How is a pneumothorax managed?
``` Oxygen even if no drain If small & asymptomatic = no treatment 1st line is aspiration in PSP Chest drain - may need suction Surgical intervention ```
49
What causes a tension pneumothorax?
One-way valve causing progressive increase in pleural space pressure
50
What are the clinical signs of a tension pneumothorax?
Trachea deviated to opp. side Hypotension Increased JVP Reduced air entry on affected side
51
Why/when would a tension pneumothorax occur?
``` Patient ventilated Trauma CPR esp. PEA Blocked, kinked or misplaced drain Pre-existing airways disease Patients undergoing hyperbaric treatment ```
52
How is a tension pneumothorax treated?
Needle decompression usually with a large bore venflon Insert at second intercostal space anteriorly & mid-clavicular line

Respiratory Anatomy & Disease Mechanisms (13 decks)

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