Name two diseases that affect the pleura
▪ Pleural effusion
Pneumothorax
Explain why pleural effusion occurs, and what is it?
Pleural effusion is a collection of fluid in the pleural cavity as a result of too much fluid formation or too little fluid reabsorption
▪ List clinical features of pleural effusion.
▪ SOB (the accumulation of fluid will apply pressure to the lung reducing its volume)
▪ Reduced OR ABSENT breath sounds
- Dullness
- No crackles or wheeze
- Tracheal deviation away from effusion if it is massive
Describe typical radiographic features and examination findings of pleural effusion
▪ Blunting of the costophrenic angle
▪ Fluid in the lung fissures
▪ Larger effusions have a meniscus
Tracheal and mediastinal deviation
What is the difference between exudative and transudative causes of pleural effusion?
▪ ▪ Exudative = >3g/dL (or 30 per Litre) of protein (This is because there is inflammation leading to protein leaking out of tissue) - inflammation (E.g. RA,SLE, Pulmonary Infarct), malignancy, infection (Acute like empyema, or chronic like TB)
Transudative = <3g/dL of protein
List causes of exudative pleural effusion.
▪ Lung cancer ▪ Pneumonia ▪ Rheumatoid arthritis ▪ Tuberculosis Less Common: ▪ PE ▪ Drugs: • Methotrexate • Amiodarone • Phenytoin • B-Blockers
List causes of transudative pleural effusion
Very common: ▪ Congestive cardiac failure (LVF) ▪ Liver cirrhosis Less Common: ▪ Hypoalbuminemia ▪ Hypothyroidism ▪ Nephrotic syndrome ▪ Mitral stenosis Rare: ▪ Meig's syndrome (right sided pleural effusion with ovarian malignancy) Constrictive pericarditis
A) Describe Investigations
B) Describe Tx of pleural Effusions.
A)
- Diagnostic aspiration guided by ultrasound to reduce complications
- Use the Light Criteria for decisions of whether it is Exudate or Transudate as the value is usually close to 30g/L:
Fluid total protein: serum total protein > 0.5
Fluid LDH: serum LDH >0.6
Fluid LDH >2/3 upper limit of normal range for serum LDH
B)
▪ Conservative management - small effusions resolve with the treatment of the underlying cause
▪ Pleural aspiration to relieve the pressure
- Chest drainage if big effusion (if there is severe symptoms)
A) What is a pneumothorax?
B) List the common causes of pneumothorax.
C) What is common presentation?
D) What are the investigations of Pneumothorax?
A) ▪ When air gets into the pleural space separating the lung from the chest wall.
▪ Can occur spontaneously or secondary to trauma medical intervention (iatrogenic) or lung pathology
▪ Typical patient = tall, thin young man presenting with sudden breathlessness and pleuritic chest pain, possible while playing sports.
B)
▪ Spontaneous
▪ Trauma
▪ Iatrogenic (e.g. lung biopsy, mechanical ventilation or central line)
▪ Lung pathology (infection, asthma, COPD)
C)
▪ Sudden chest pain (unilateral)
– Sudden shortness of breath
D)
▪ Chest X-RAY
○ Erect Chest X-ray - will show the area between the lung tissue and the chest wall where there are no lung markings
○ Measurement Is from the lung markings to the chest wall on the level of the hilum horizontally
– CT Thorax - detects small pneumothorax that is too small to see on a chest x-ray
A) What is a tension pneumothorax?
B) What are the red flags of a tension pneumothorax?
C) How do you manage a tension pneumothorax.
A)
▪ Caused by a trauma to the chest wall which creates a one way valve that lets air in but not out of the pleural space
▪ During inspiration air drawn in, and during expiration air is trapped
▪ Dangerous as pressure will build up continuously
▪ Pressure will push the mediastinum
▪ Can kink the big vessels –> cardiorespiratory arrest
B)
E.g. Sweating, Tachycardia >135, Tachypnoea, Hypotension, Raised JVP
C)
▪ Insert large bore cannula into the second intercostal space in the midclavicular line (this is aspiration)
▪ Once pressure is relieved do a chest drain
▪ Give oxygen and IV Fluids
?? How do you carry out a chest drain?
▪ Inserted into the ‘triangle of safety’ (between the 5th intercostal space, mid axillary line and anterior axillary line)
▪ Needle inserted just above the rib to avoid neurovascular bundle
▪ Once inserted, confirm position with chest x-ray
What is the management of a normal pneumothorax?
- If no SOB and <2cm rim of air on the chest x-ray then no treatment
- If SOB and/or >2cm rim of air on the chest x-ray then it will require aspiration and reassessment
- If aspiration fails twice then chest drain
- Unstable or bilateral = chest drain
What are possible causes of T Lymphocyte deficiency?
- Bone marrow disease/transplant
- HIV
- Lymphoma or cancer therapy
(Watch out if thymus is affected)
what are possible causes of neutropenia?
- Chemo
- Bone marrow transplant
- Chronic Granulomatous disease
(Bone marrow dysfunction)
What are possible causes of B Lymphocyte deficiency?
- Primary humoral immune deficiency
- Myeloma
- CLL
Give an example of Primary T Lymphocyte deficiency.
- Di George Syndrome
- Autosomal Dominant
- Parathyroid, thymus, and aortic arch dont develop
- Increase in fungal and protozoan infections
Tx:
- Calcium supp
- Correction of cardiac abnormalities
- Prophylactic antibx
- Thymic transplantation
Give an example of Primary T and B Lymphocyte deficiency.
Severe Combined Immunodeficiency (SCID)
- X-Linked
- Treatment is stem cell
Give an example of Primary B Lymphocyte deficiency.
- Selective IgA Deficiency (Most common primary immune deficiency - treat with AbX, and caution with blood transfusions)
- X-Linked agammaglobulinaemia (XLA) - presents soon after maternal IgG protection falls, X chromosome loss of function mutation preventing B cell development)
What type of immunodeficiency is HIV?
Secondary Immunodeficiency
HIV
A) Under what value of CD4 cells does it count as low?
B) What is the organism that causes pneumonia in HIV patients and how do you treat it?
A) 200
B)
- Pneumocystis Jirovecii
- High dose co-trimoxazole and cotricosteroids + start ART
What is the preventative therapy for TB in HIV?
- Isoniazid preventative therapy
Give an example of Neutrophil deficiency.
- Chronic Granulomatous Disease (you maek neutrophil but they dont work properly - onset is toddler)
- Leukocyte Adhesion Defect (Neutrophils cant enter site of infection but number is normal)
List common causes of Neutropenia?
- Post-chemo
- Post-radiotherapy
- Due to marrow infiltration by malignancy
Neutropenia and Febril?
- Sepsis!
Treat with Sepsis 6 (Abx = IV within first hour piperacillin-tazobactum + gentamicin)
What is the risk with removal of spleen?
- High risk of sepsis from capsulated organisms (you can get an OPSI = OVERWHELMING POST-SPLENECTOMY INFECTION)
- ensure vaccinations
- Preventative abx - for at least 2 years or maybe life-long
