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Pleural Disease - Coggle Diagram

- - - - No underlying lung disease
    - - Underlying lung disease
  - - - Icreases size of pneumothorax
      - Makes lung denser - better contract
  - - - Young tall thin male smokers
    - - SOB
      - Chest pain
  - - - Copd
      - TB
    - - Lung cancer
      - CF
      - PCP
    - - Mesothelioma
      - ILD
      - Catamenhial
      - Birth Hogg Dube
      - LCH
      - LAM
  - - - Conservative
    - - Chest drain
    - - Needle decompression
    - - Intercostal catheter insertion
        
        Drain siz
        
        8/12/18 Fr
        
        Methods
        
        Seldinger
        
        Blunt Dissection
        
        Monitoring
        
        Oscillation
        
        Bubblign
        
        Air leak
    - - Interventional
        
        Suction
        
        Argument ongoing for years - does it perpetuate the air leak or allow more rapid healing thoguh visc parietal pleural apposition?
        No evidence to support it - trial starting in UK
        
        Blood Patch
        
        60-100ml autologous
        
        Talc Pleurpdesis
        
        U-loop post instilation
        
        Endo-bronchial valve
      - Surgery
        
        VATS bullectomy and pleurodesis
        
        Some advocate for direct surgical referral if blebs on CT
        Surgeons should be consulted if PAL >3-5 days
- - - - Diaphram
      - Mediastinum
      - Chest wall
    - - Fluid exist pleural space
      - Formed by cap in continous mesothelial cells
  - - - Kung
      - Interlobar fissures
- - - - Chest Expansion - asymmetry
      - Tracheal deveiation
      - Tactile frematus - reduced with effusion
      - Respiration rate - Tachypnic
    - - Stony dullness
    - - Reduced air entry
      - Blowing breath sounds
      - Plerual rub
      - Reduced vocal fremitus
    - - Chest
        
        Shape - asymmetry
        
        Scars
  - - - Accessory Muscle use
      - Audible wheeze
      - Nasal flaring
      - Tripod breathing
      - Diaphragmatic breathing / abdominal breathing
      - Increased WOB
- - - - Likely to resolve with abx alone
    - - Highly inflammatory and need drainage
    - - Presence of bacteria / pus inspace
  - - - Paraneumonic
      - Primary pleural
    - - Post-procedural
      - IPC-related
    - - Parapneumonic
      - Primary pleural
    - - Oesophageal leak
      - Spontaeneous bacterial empyema (SBP)
      - Translocation from subdiaphragmatic infx
- - - - Anaemia in haemothorax
  - - - Airway
        
        Tracheal deviation
      - Breathing / Bones
      - The most obvious abnormality is X but I will proceed with a stepwise process to ensure I don't miss anything
      - Cardiac
      - Diaphram
        
        Costophrenic angles
      - Extremeties
      - Lung Fields
      - Gastric Bubble
      - Check 3
        
        Apices
        
        Behind heart
        
        Costophrenic angles
  - - - Assessment
        
        1. Gross appearance
        
        Colour
        
        Pale yellow (straw)
        
        Transudates
        
        Some Exudates (more amber)
        
        Red (bloody)
        
        Malignancy
        
        PE
        
        Benign asbestos effusion
        
        Post cardiac injury
        
        Haemothorax
        
        White (milky)
        
        Chylothorax (does not seperate)
        
        Pseudochylothorax
        
        Infection - empyema (seperates)
        
        Clear
        
        Normal
        
        2. Transudate vs exudate classification ⭐
        
        Transudates
        
        Mechanism
        
        Imbalances in hydrostatic and oncotic pressue in the chest - can't keep water in blood stream cause no proteins
        
        Causes
        
        Failures
        
        Hepatic failure
        
        Renal failure
        
        CCF
        
        5% malignant effusions
        
        Exudates
        
        Mechanism
        
        Inflammation / Infection causing increased entry of fluid and protein due to elevated capillary permeability
        
        Impaired lymphatic drainage
        
        Causes
        
        Inflammatory / immunogenic conditions
        
        Impaired lymph dainage - lymphatic abnormalities / malignacy
        
        https://images.squarespace-cdn.com/content/v1/5f28734698799b38264a113b/1596650247807-KSVFPMNRVUXAG4U39EAX/Pleural-Effusion-min.jpg
        
        Lights Criteria
        
        First Investigation of Effusion
        
        Error Rate
        
        ~10% malignant effusions are transudates
        
        ~30% CHF effusions are misclassified as exudate if pt on diuretics
        
        Check albumin gradinet (>12g/L)
        
        Criteria
        
        The ratio of pleural to serum protein is greater than 0.5
        
        The ratio of pleural to serum LDH is greater than 0.6
        
        The pleural fluid LDH is greater than ⅔ of the upper limit of normal serum value
        
        Initial fluid tests
        
        Pleural Protein
        
        Differentiates transudates form exuates
        
        Transudates - total protein concentrations <30g/L
        
        Pleural LDH
        
        Pleural glucose
        
        Exudate
        
        Transudate
        
        Pleural PH
        
        Alumin if on diuretics
        
        Microbiology
        
        Culture and Sensitivity
        
        Acid fast bacilli
        
        TB culture - leave for 8w until neg for TB
        
        Adenosine deaminase - highly specialised test for TB 📜
        
        Cytology
        
        Differential cell count
        
        Used to look for malignant cells
        
        Not disease specific
        
        Lymphocytosis
        
        Eosinophils
        
        Air / blood in pleural space
        
        Drugs
      - Exceptions
        
        Bilateral effusions & hx heart failure
        
        Coagulopathy / anticoagulants
- - - - Fluid recurs in 85% at 1 months
      - Indx - Very frail / likely to respond to chemo
    - - Talc Pleurodesis
        
        Success 75% at 30 days
        50% fluid free at 6months
      - IPC - Indwelling pleural catheter
- - - - Fibrinolytic agent : Streptokinase / Alteplase
      - Deoxyribonuclease (DNase)
  - - - Antibiotics
    - - Pleural aspiration
      - Chest drain
      - Tunnel indwelling pleural drain