Pleural Diseases (Effusion/Mesothelioma) Flashcards Preview

Year 3 - CR > Pleural Diseases (Effusion/Mesothelioma) > Flashcards

Flashcards in Pleural Diseases (Effusion/Mesothelioma) Deck (58)
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1

What is the pleura

A layer that covers the chest wall and the lung
- made out of the parietal pleura and visceral pleurae

2

What is the pleural space

- the potential space between the visceral and the parietal pleura

3

What is usually in the pleural space

- usually there is a small amount of pleural fluid
- sub atmospheric pressure normally allowing lungs to remain inflated

4

What is the pleural space lined with

mesothelial cells

5

What goes through the parietal pleura

blood vessels

6

what goes through the visceral pleura

blood vessels

7

What is on either side of the pleural space

- Next to the parietal pleura is the extra pleural parietal interstitial
- next to the visceral pleura is the pulmonary interstitial
- in the middle in the pleural space

8

What are local factors (exudates) that cause pleural effusion

- increase in capillary permeability = caused by trauma, malignancy, inflammation, infection, pancreatitis
- increase in pleural permeability = inflammation, malignancy, pulmonary embolus
- decrease in lymphatic drainage = malignancy, trauma
- increase in negative pleural pressure (usually negative but becomes even more negative) = atelectasis, mesothelioma

9

What are the systemic factors (transudates) that cause pleural effusion

- increase in capillary hydrostatic pressure = due to heart failure
- increase in pulmonary interstitial fluid = due to heart failure
- decrease in intravascular oncotic pressure = hypoalbuminaemia, cirrhosis
- increase in flow of fluid from other cavities = peritoneal dialysis, cirrhosis

10

What are the symptoms of pleural effusion

• Asymptomatic
• Dry cough
• Breathlessness
• Pleuritic chest pain
• “Shoulder pain”/ “Heaviness"

11

What are the clinical examination signs of pleural effusion

Inspection
- decrease chest expansion

Palpation
- decrease chest expansion
- decrease tactile vocal fremitus
- decrease tracheal deviation

Percussion
- stony dull

Auscultation
- decrease or absent breath sounds, bronchial breathing

12

What is bronchial breathing

- hollow sound

13

What is classification of pleural effusion

- Pleural fluid protein
- then use Light's criteria if borderline

14

describe the pleural effusion types due to pleural fluid protein

Pleural fluid protein
- exudate - greater than 30g/L
- transudate - less than 30g/L

15

Describe how lights criteria works and what case you use it in

- use light's criteria in those with borderline pleural protein (25 to 30g/L) or abnormal serum protein

Lights criteria - pleural fluid is an exudate if one of the following criteria are met:
- pleural fluid protein divided by serum protein > 0.5
- pleural fluid LDH divided by serum LDH > 0.6

16

using Lights criteria what makes a pleural effusion an exudate

Lights criteria - pleural fluid is an exudate if one of the following criteria are met:
- pleural fluid protein divided by serum protein > 0.5
- pleural fluid LDH divided by serum LDH > 0.6

17

what are the common causes of exudate pleural effusion

• Para pneumonic effusion
• Malignancy
• Pulmonary embolism
• Rheumatoid arthritis
• Mesothelioma

18

What are the less common causes of exudate pleural effusion

• Drugs
• TB
• Pancreatitis
• Oesophageal rupture
• Post cardiac injury (Dressler’s syndrome)
• Post-CABG
• Benign asbestos-related effusions
- empyema

19

What are the two types of pleural effusion

- exudate
- transudate

20

What are the common causes of transudate of pleural effusion

- left ventricular failure
- cirrhotic liver disease
- peritoneal dialysis
- nephrotic syndrome

21

What are the less common causes of transudate pleural effusion

- constrictive pericarditis
- hypothyroidism
- Meig's syndrome

22

What are the investigations that you need for pleural effusion

• Chest x-ray (CXR)
• Pleural fluid analysis
• Chest Ultrasound scan
• Chest CT scan
• Pleural biopsy (image-guided or Medical thoracoscopy)
• Video-assisted thoracic surgery (VATS)

23

Where do you aspirate pleural fluid from

Triangle of safety
- lateral border of pec major, lateral edge of lat doors, line along 5th intercostal space, axilla

24

What do you remove pleural fluid from the triangle of safety

- triangle of safety - minimise the complications and puncturing of internal organs

25

what do you analyse in the pleural fluid

• Appearance
• pH
• Protein
• Glucose
Pleural Fluid Analysis
• LDH
• Cytology (malignant cells, differential cell counts)
• Microbiology (Gram stain and culture, AFB)

26

What is the diagnostic algorithm for pleural fluid

- History, examination, CXR
- if yes to clinically transudate - treat cause and if it doesn't resolve then refer to a chest physician
- chest physician will do a pleural aspirate ultrasound guided
- then if still transudate - treat cause
- if not transudate has the fluid analysis and clinical features given a diagnosis
- if yes treat appropriately
- if no request a contrast enhanced CT thorax
- consider medical thoracoscopy or surgical VATS and consider radiologically guided pleural biopsy +/- chest tube drainage if symptomatic
- if the cause is found then treat appropriately
- if not then reconsider treatable conditions such as PE, TB, chronic heart failure, lymphoma

27

how does pleural infection present

Fever, sputum, chest pain, breathlessness

28

Who should you consider a diagnosis of pleural infection in

• Slow to respond pneumonias
• Pleural effusion with fever
• Malaise/weight loss

• High risk groups
o Diabetes
o Excess ETOH intake
o GORD
o IVDU
o Aspiration and poor dental hygiene

29

How is at high risk of developing a pleural infection in

o Diabetes
o Excess ETOH intake
o GORD
o IVDU
o Aspiration and poor dental hygiene

30

What are the investigations for pleural infection

• Diagnostic pleural tap
• Blood culture
• Chest ultrasound
• Chest CT chest