SCE > Pleural - General > Flashcards

Pleural - General Flashcards

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1
Q

What proportion of LVF effusions are unilateral

A

40%

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2
Q

Causes of Lights misidentified transudate as exudate

A

Diuretics

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3
Q

Rare causes of transduative effusion

A

Urinothorax - kidney malignancy/biopsy etc
Meigs
Subclavian catheter and fluids
Duropleural fistula eg shunt
Ovarvian hyperstimulation eg IVF

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4
Q

What % of PE get effusion

A

30% contralateral

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5
Q

Rare causes exudate effusion

A

RA/SLE/CT
BAPE
Pancreatitis
Esophageal rupture
CABG
Yellow nail syndrome
Drugs
Fungal
Chylothorax/pseudochylothorax
Ruptured hydatid cyst

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6
Q

Mortality fungal empyema

A

90%

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7
Q

Effusion:

Entrapped lung
Low glucose
Low pH
High LDF
visceral and pleural thickening
Pseudochylothorax biochem
Painless

A

RA

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8
Q

Effusion:

Raised triglycerides and normal cholesterol

b/g
trauma
line insertion
malignancy

A

Chylothorax

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9
Q

Causes of chylothorax

A

LAM
Sarcoid
TB
Filliaris
RA

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10
Q

Effusion:

RA
TB
normal triglycerides
Raised cholesterol

A

Pseudochylothorax

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11
Q

When to intervene in post CABG effusion

A

If still present after 3 months

early < 30 days

Left >R

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12
Q

Pleural fluid sensitivity for mesothelioma

A

10%

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13
Q

Pleural fluid sensitivity for breast cancer

A

60%

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14
Q

Pleural fluid sensitivity for lung adenocarcinoma

A

80%

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15
Q

What type of CT to visualise pleural esp malignancy

A

Late venous phase 60-90s contrast

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16
Q

Pick up rate malignancy thoracoscopy

A

90%

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17
Q

Common organisms pleural infection community acquired

A

Strep Milleri

then

Strep pneumoniae

then

staph aureus

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18
Q

When can you dive after PTX

A

Never

Unless bilateral surgery

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19
Q

Who gets PTX

A

Men 5:1

Tall

20-40

Primary incidence is 9/100,000

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20
Q

How much does smoking increase your risk of PTX

A

x22 men

x9 women

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21
Q

What % PTX have familial clustering

A

10%

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22
Q

Genetic causes PTX
(6)

A

Birt Hogg Dube
TCS-LAM
Marfans
Ehlers-Danos
Loeys-Dietz
Homocystinuria

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23
Q

Causes of secondary PTX

A

COPD (60%)
Asthma
ILD
Necrotising pneumonia
TB
PCP
CF
LCH
LAM
Marfans
Esophageal rupture
Lung Ca
Catamenial PTX
Pulmonary infarct

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24
Q

Why do taller pt’s get PTX

A

Negative intrapleural pressure increases the higher up in lung you go

taller peoples go up higher, so higher pressures cause distension –> blebs –> PTX

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25
What is Hamman's sign
Mediastinal crunch EW clicking in time with heart sounds in PTX
26
Deep sulcus sign PTX
27
Who can be classed as secondary PTX even if no diagnosed lung disease
>50 and smoking hx
28
BTS PTX Guidelines: How do you treat asymptomatic PTX
Conservatively
29
BTS PTX Guidelines: What are the 6 high risk characteristics for the PTX guideline
Haemodynamic compromise inc tension Significant hypoxia Bilateral pneumothoraces Underlying lung diease > 50 with significant smoking hx Haemopneumothorax
30
BTS PTX Guidelines: What to do is symptomatic PTX with no high risk features? and safe to intervene
Choose pt priority Procedure avoidance vs Rapid sx relief ambulatory vs Rapid sx relief short term drainage
31
BTS PTX Guidelines: What to do is symptomatic PTX with no high risk features? and NOT safe to intervene
Conservative Rx
32
BTS PTX Guidelines: What to do if high risk PTX and not safe to intervene
CT
33
BTS PTX Guidelines: What to do if high risk PTX and safe to intervene
Drain
34
BTS PTX Guidelines: What are the 3 patient managent options to choose from
Procedure avoidance = Conservative Rapid ambulatory sx relief = Ambulatory device Rapid non ambulatory sx relief = Needle aspiration or chest drain
35
BTS PTX Guidelines: What's considered a safe size to intervene
2cm+ laterally or at apex, or any size on CT
36
BTS PTX Guidelines: Which patients can be considered for talc pleurodhesis in their first episode of PTX
High risk pt's who a repeat PTX would be hazardous for eg severe COPD
37
BTS PTX Guidelines: If opting for conservative Rx, how often should pt's be reviewed
PSP = OP review every 2-4 days SSP = inpatient review
38
BTS PTX Guidelines: If opting for ambulatory device, how often should pt's be reviewed
OP review every 2-3 days Remove device when resolved
39
BTS PTX Guidelines: How often should a chest drain be reviewed
Every day
40
BTS PTX Guidelines: When should PTX have OP FU
2-4 weeks
41
What % patient have complications after IPC or talc
25%
42
What's the difference in outcomes in talc and IPC
Longer initial procedure and IP stay for talc Higher need for reintervention with talc
43
When can thoracic surgery for PTX be considered at 1st presentation
Prevention v important eg presented with tension High risk occupation
44
How often do pneumothoraces recur
32% PSP 12-39% SSP
45
When should elective surgery be considered for PTX
High risk profession 1st presentation tension 2nd ipsilateral 1st contralateral
46
How soon can you fly after a PTX
7 days after complete resolution
47
VATS vs thoracotomy evidence
VATS - shorter LOS - less complications - less painful - higher recurrence and need for further intervention
48
BTS PTX Guidelines: Indications for surgical advice (7)
1st presentation with tension or sever physiological compromise 2nd ipsilateral bilateral (synchronous or different times) Persistent air leak despite 5-7 days drainage or lung not re-expanding Spontaneous haemothorax At risk profession Pregnancy
49
Benefits of bullectomy vs surgical pleurodhesis for PTX
No difference
50
When can pregnant PTX be managed conservatively (3)
<2cm No SOB No foetal distress
51
Best birth approach if PTX
regional > epidural > GA 02 req goes up in labour valsalva manouevres can increase size
52
How does catamenial PTX present
Chest pain Dyspnoea Haemopytsis with 72 hr before or after menstruation Usually small Right sided PTX ax with endometriosis
53
Tx catamenial PTX
Hormone tx Surgery
54
Failure rate talc pleurdohesis
20%
55
Risk of recurrence of PSP
30% in first 2 years after 1st 40% after 2nd 50% after 3rd etc
56
Ax with weight and PTX
Low body weight = higher risk recurrence
57
Mortality SSP
10%
58
CT features which infected pleural effusion (5)
Lentiform shape Visceral pleural thickening "split pleura sign" Hypertrophy extrapleural fat >2mm Increased density of extrapleural fat Consolidation
59
Imaging features to suggest pleural effusion is TB
Heavily septated Often has pleural thickening and nodularity so can look like malignancy
60
61
How much pleural fluid should you send off
25-50ml Ideally 50ml for cytology
62
Additional pleural fluid tests for TB
IFN-gamma ADA
63
Pleural fluid test for lupus pleural effusion
ANA
64
12 month mortality pleural infection
20%
65
RAPID score for pleural infection
uRea - <5 = 0 - 5-8 = 1 = >8 = 2 points Age - <50 = 0 - 50-70 = 1 - >70 = 2 points Purulent fluid + 1 point Infection source HAP = 1 point Serum albumin >27 = 1
66
What does RAPID score pleural effusion show
3 month mortality
67
How to interpret pleural fluid pH
=< 7.2 - high risk infection - should have chest drain 7.2 - <7.4 - intermediate risk - if pleural fluid LDH >900, should have drain +- supporting factors suggesting infection 7.4+ - low risk - no indication for drain
68
How to interpret pleural fluid glucose
Advised if pH analysis not available <3.3 - high probability of infection
69
Evidence for streptokinase in pleural infection
Bad - no effect mortality, hospital stay, surgery or resolution - higher risk of complications
70
Evidence for urokinase in pleural infection
Decent - reduces need for surgery and time til resolution and hospital stay
71
Evidence for TPA + DNAse in pleural infection
Good - reduces length of hospital stay and time to resolution - but higher risk of complications
72
Evidence for saline washout pleural effusion
- reduces need for surgery but no mortality benefit
73
When do BTS recommend TPA + DNAse
Drain has stopped draining and leaves residual pleural infection
74
When do BTS recommend saline irrigation pleural infection
Pleural infection when TPA+DNase and surgery not suitable
75
What's the regime for TPA+DNase
10mg TPA + 5mg DNase BD for 3 days (can use 5+5 if necessary)
76
Commonest causes of unilateral effusions, in order
CCF Pneumonia Malignancy PE
77
How to decide transudate vs exudate
Protein <30 transudate Protein >40 exudate If 30-40 use Lights criteria
78
What's Light criteria
Exudate/positive if any one of: Pleural protein: Serum protein >0.5 Pleural LDH: Serum LDH >0.6 Pleural fluid LDH >2/3 ULN
79
How to do/interpret total protein gradient
Serum protein - pleural protein >31 suggestive of CCF
80
How much fluid is needed to see pleural effusion on PA CXR
200ml
81
How much fluid is needed to make effusion visible on lateral CXR
50ml
82
How to do pleural phase CT and what's it useful for
Pleural contrast 60-90s post injection Helpful in distinguishing benign vs malignant
83
What's CT features of pleura look malignant
mediastinal circumferential thickening Nodular thickening Parietal pleura >1cm
84
Sensitivity and complication rate thoracoscopy
Major complications 2.3% Sensitivity 95%
85
Factors that can falsely affect pleural pH
air increases lidocaine decreases
86
Causes of low pH and low glucose effusions
complex effusion/empyema Rheumatoid pleuritis (glucose <2.8 in 80%) Malignant pleural effusion TB Esophageal rupture Lupus pleuritis
87
Which transudate can cause a low pH
Urinothorax
88
Cause of abnormally high pleural fluid pH
proteus infection
89
What causes a chylothorax
Disruption of thoracic duct
90
How to confirm chylothorax
Presence of chylomicrons Triglycerides >1.24
91
Causes chylothorax (5)
Trauma Post thoracotomy Malignancy (particularly lymphoma) P-LAM TB
92
What is a pseudochylothorax and what conditions cause them
Cholesterol crystal deposits in chronic effusions RA TB
93
How to diagnose pseudochylothorax
Cholesteral >5.17 Cholesterol crystals on polarised light microscopy
94
What is considered an abnormal pleural fluid amylase
>ULN or pleural:serum amylase ratio >1
95
Causes high pleural fluid amylase
Pleural malignancy (particularly adenocarcinoma) Esophageal rupture (raised salivary amylase) Pancreatic disease
96
Pleural effusion Protein <10 Glucose > 17
Peritoneal dialysis effusion
97
When does a urinothorax occur
Obstructed kidney causes retroperitoneal urine leak Resolves after relief of obstruction pH low pleural creatinine >serum transudate
98
What is Meigs syndrome
Benign ovarian tumour + ascites + pleural effusion TRANSUDATE
99
What % pneumonias get parapneumonic effusion
40%
100
How often is pleural fluid cytology +ve in malignancy
60%
101
Which type of cancer is more commonly picked up on pleural fluid cytology
Adenocarcinoma
102
What type of effusion does TB cause
lymphocytic can also be pseudochylothorax and TB empyema small/mod
103
What's the AFB and culture pick up rate for TB in pleural fluid
AFB smear <5% Culture 10-20% Parenchymal infiltrates 1/3 Skin test 2/3 IGRA 90%
104
Pick up rate TB thoracoscopic biopsy
100%
105
What type of effusion does PE cause
80-90% exudates
106
What type of pleural effusion does RA cause
Low glucose <1.6 Low pH <7.2 Low complement Pseudochylous/serous/haemorrhagic
107
What type of effusion does esophageal rupture cause
Initially sterile exudate then empyema with raised salivary amylase
108
How long can a post radiotherapy effusion last for
6 months
109
What drugs can cause pleural effusion (6)
Amiodarone Beta blockers Bromocriptine Methotrexate Nitrofurantoin Phenytoin Usually resolves with drug discontinuation
110
Features of yellow nail syndrome
Yellow nails Resp issues - bronchiectasis, exudative effusion Lymphedema
111
Definition haemothorax
Pleural fluid haematocrit >50% blood haematocrit
112
Causes haemothorax
Trauma Malignancy Pulmonary infarct Pneumonia Post cardiac injury syndrome Benign asbestos Aortic dissection
113
Causes black pleural effusion
Aspergillus Melanoma
114
Causes of neutrophilic effusion
Any acute causes eg parapneumonic, PE
115
Causes of mononuclear cell pleural effusion
Any chronic Malignancy, TB
116
Causes lymphocytic effusion
TB esp if >80% CCF Malignancy Sarcoid Lymphoma RA CABG Cylothorax Uraemic pleuritis Yellow nail
117
Causes eosinophilic pleural effusio
Blood/air pleural space Malignancy Infecion Drugs Asbestos EGPA Idiopathic
118
What to do differently if you're suspecting a malignant effusion
CT TAP Consider TUS guided cutting needle biopsy If asbestos exposure, consider straight to thoro
119
What % TB effusion go on to develop pulmonary TB within 5 years
2/3 so has to be treated
120
TB effusion prognosis
can increase in size during tx should resolve as TB treated can cause thickening and calcification
121
Which CTDs most commonly cause effusion
RA SLE Either through autoimmune pleuritis or cardiac/renal/thromboembolism
122
Who tends to get RA effusions
5% More common in men Can last months-years
123
What type of effusion does SLE cause
Can be small BL pleuritis, v painful Can be 1st presentation
124
When do benign asbestos related effusions tend to occur
1st 2 decades after exposure Dose related
125
Features benign asbestos effusions
Small Asymptomatic Haemorrhagic Often resolve in 6 months and leave thickening behind Often need pleural biopsy to exclude mesothelioma
126
What type of effusion does ovarian hyperstimulation syndrome cause
Exudative
127
What is ovarian hyperstimulation syndrome
Life threatening reaction to HCG or clomiphene Can be just pleural effusion (usually right) Or whole body massive ascites. renal and hepatic failure, VTE, ARDS
128
Features of lymphoma related pleural effusion
Exudate Lymphocytic Chylothorax 40% cyto +ve flow cyto can be useful
129
Median survival time from diagnosis MPE
3-12 months Shortest in lung, longest in ovarian
130
Most common cancers to metastasise to pleural
Lung men Ovarian women
131
What cancers cause MPE
Lung, breast 50-60% Lymphoma, urothelial, GI 25%
132
When is therapeutic aspiration not recommended in MPE
if life expectancy >1 month as high risk of recurrence
133
When can you attempt pleurodhesis
When over half pleural is apposed
134
What's the best predictor of talc pleurodhesis success
Whether lung has expanded
135
What level of drain output can you do talc pleurodhesis
<150ml/day
136
What dose of intrapleural lidocaine should you give pre talc
3mg/kg max 250mg
137
Rate of significant pain in talc
7%
138
SEs talc pleurodhesis
Pain, fever
139
When to clamp and remove drain post talc insertion
Clamp for an hour after Remove after 24-48hr should be draining <250ml/day
140
Perioperatively mortality thoracoscopy
<0.5%
141
What does the LENT score for MPE show
Median survival
142
What are the parameters for LENT score MPE
LDH ECOG PS Neutrophil:lymphocyte ratio Tumour histo
143
LENT score
144
What % empyema end up needing surgery
20%
145
Risk factors empyema (5)
Diabetes Immunosuppresion IVDU GORD ETOH M>F Can be related to poor oral hygiene
146
Normal volume pleural fluid
10-20ml
147
Normal pH pleural fluid
7.6
148
Stages of empyema development
Simple exudative phase Fibrinopurulent Organising Peel formation
149
How often is pleural fluid culture +ve in empyema
60%
150
How often is blood culture +ve in empyema
14%
151
Risk factors for pneumonia progressing to empyema (7)
On-going sepsis/high CRP day 3 pneumonia on ABx Low albumin CRP >100 Platelet >400 Sodium <130 IVDU ETOH CIOD
152
When to consider DIRECT REFERRAL to surgeons for empyema
clinically unstable profound pleural thickening/solid collection
153
When to consider referral to surgeons in empyema
review @ 48hr If poor prognosis - persistent pleural shadowing - static worsening inflammatory markers (plus CT and pt suitable)
154
When does the algorithm suggest TPA + DNAse
No improvement 48hr and either not surgical candidate or >48hr wait til surgery
155
What does the algorithm suggest if no response to TPA-DNAse in empyema (4)
Switch ABx Prolonged ABx Non intubated surgery eg rib resection IPC
156
What nerve supplies the parietal/mediastinal pleura
Phrenic nerve and intercostal
157
What nerve supplies the visceral pleura
Pulmonary plexus from sympathetic chain
158
What's the effect of longer asbestos exposure on pleural plaques
Longer exposure is higher incidence but not related to extent of plaques
159
Are pleural plaques pre malignant
No
160
What stage of lung cancer do you have if you present with a malignant effusion
Stage 4
161
What is the survival for lung cancer presenting with a malignant effusion NOT MESOTHELIOMA
74 days
162
What's the survival for a mesothelioma presenting with malignant effusion
>300
163
What type of effusion does valproate cause
Eosinophilic effusion inc blood eosinophilia
164
What type of effusion does phenytoin cause
Drug induced lupus Ie lymphocytic
165
What's the next step is Light's criteria says exudate but clinically seems like transduate eg diruetics
Serum pleural >albumin gradient >12 means transduate
166
How much pleural fluid does BTS suggest for pH
0.5-1ml
167
How much pleural fluid does BTS suggest for micro
5ml
168
How much pleural fluid does BTS suggest for biochem
2-5ml
169
How much pleural fluid does BTS suggest for cyto
20-40ml
170
Contraindications to TPA-DNase (9)
Anticoagulants (INR should be <1.5) Hypersensitivity to either Age <18 Previous fibrinolytics same ep Pleural bleeding/major haemorrhage Stroke Surgery <5 days ago Pregnancy/breastfeeding Severe hepatic/renal impairment
171
What settings should you start chest drain suction at pressure/volume
-10cm to -20cm H20 Low pressure high volume
172
What size particles medical grade talc
25 um
173
What % IPC pts spontaenously pleurodhese
45%
174
What's the average LOS for talc pleurodhesis
4 days
175
Lemierres vs necrotising mediastinitis
Lemierres always starts w sore throat Usually young healthy ppl NM tend to have peridontal abcess
176
Cystic/fluid anterior mediastinal mass
Thymic cyst
177
Cystic and solid mixed anterior mediastinal mass
Lymphoma cystic thymoma germ cell tumour
178
Solid anterior mediastinal mass
thymic tumour, germ cell tumour goitre
179
Fat anterior mediastinal mass
germ cell tumour thymomlipoma fat pad
180
Cystic/fluid middle mediastinal mass
eosphageal duplication cysts bronchogenic cyst necrotic lymph nodes
181
Solid middle mediastinal mass
Lymph nodes
182
Fat middle mediastinal mass
Lipoma Fibrovascular eosophageal polyp
183
Cystic/fluid posterior mediastinal mass
Neuroenteric cyst Schwannoma Meningoceles
184
Solid posterior mediastinal mass
Lymph nodes Neuroblastoma Schwannoma Neurofibroma
185
Fat posterior mediastinal mass
extramedullary haemopoesis
186
RAPID score Low/medium/high
Low 0-2 Medium 3-4 High 5-7
187
LENT Score LDH
LDH <1500 = 0 LDH > 1500 = 1
188
LENT Score ECOG
0 = 0 1= 1 2 = 2 3-4 = 3
189
LENT Score Neutrophil:lymphocyte ratio
<9 = 0 >9 = 1
190
LENT Score Type of tumour
0 = Mesothelioma Haem malignancy 1 = Breast Gynae Renal 2 = Lung Other
191
LENT Score Low/med/high
0-1 = Low 2-4 = Moderate 5-7 = High
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