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eearn Pneumothorax and Pleural Effusion MEDIC Dr Maggie Cheung, Respiratory Registrar edic earn Aims & Objectives 1. Understand the anatomy and physiology 1. What bad things can happen to your of the pneumothorax and pleural effusion. pleural space? 2. Explain the aetiology, clinical features and. How do I recognise these? common causes of pneumothorax and 3. What do I do about it? pleural effusion. 3. Describe the assessment and investigations for pneumothorax and pleural effusion. 4. Detail the indications for treatment of pneumothorax and pleural effusion. 5. Discuss the long-term management and preventive strategies of pneumothorax and pleural effusion. edic earn The Pleura • Comprises of 5 layers: mesothelium, connective tissue layers x 2, elastic layers x 2 • Folds back on itself to create 2 layers: visceral and parietal • 15-20ml fluid exists and circulates through the pleural space • Drained by the lymphatic system edic earn What can happen to the pleura? • The pleura itself can be diseased • Things can accumulate in the space – Asbestos plaques – Fluid (pleural effusion/hydrothorax) – Mesothelioma – Blood (haemothorax) – Pleural metastases – Chyle (chylothorax) – Infection e.g. TB – Air (pneumothorax) – Infiltration e.g. amyloidosis/sarcoidosis edic earn Why do things accumulate? • Increased production – Injury – Inflammation • Reduced absorption – Reduced drainage of fluid – Lack of escape route of air • When production >> absorption, you will begin to see build up of air/fluid edic earn Case 1 - History • 25y male, tall and skinny • At the gym when suddenly developed pain on his right side • Difficult to catch his breath, like stabbing pain when try to take a deep breath • This has never happened before • Normally fit and well • No medication, no allergies • Smoked 10/day from age 14, recently started vaping, cannabis use in university • Works as a plumber • No family or travel history edic earn Case 1 - Examination • Looks clammy and struggling to take a breath • Tachycardic • Trachea not deviated • Reduced chest expansion on the right • Hyper-resonant to percussion on the right • Reduced air entry on the right • Decreased vocal fremitisedic earn What are your differentials? www.slido.com #2063791What are your differentials? ⓘStart presenting to display the poll results on this slide.edic earn What investigations will you do next? www.slido.com #2063791What investigations will you do next? ⓘStart presenting to display the poll results on this slide. edic earn Case 1 - Results • Obs: – SpO2 92% RR 22 – BP 100/56 HR 95 – Afebrile • Bloods: – Unremarkable • ABG: – Type 1 respiratory failure • ECG: – Sinuseearn Don’t be caught out! edic earn Management • Are they high risk? • Is it safe to intervene? • What does the patient want? – Avoid procedure • Ambulate and review regularly – Rapid symptomatic relief (ambulatory) • Ambulatory device and review regularly – Rapid symptomatic relief (drainage) • Chest drainration • Follow up – 2-4 weeks OPD • Safety net – diving, flying, future risks edic earn Case 2 - History • 56y female • Breathless for 6 weeks • Progressive, worse on exertion, inhalers not helping, struggling to take deep breaths • Weight loss, lethargy, ?haemoptysis few weeks ago • COPD, hypertension • Trelegy & ramipril, no allergies • School teacher, smokes 30/day since 12, no vape/cannabis, no asbestos • Father died of lung cancer but he was a heavy smoker • No travel history edic earn Case 1 - Examination • Visibly breathless • Tar staining on fingers and no clubbing • Trachea ?deviated to the right • Stony dull to the percussion on the left • Reduced air entry on the left • Possible fine creps on the left • Looks like she’s lost weightedic earn What are your differentials? www.slido.com #2063791What are your differentials? ⓘStart presenting to display the poll results on this slide. edic earn Case 2 - Results • Obs: – SpO2 94% RR 24 – BP 135/84 HR 80 – Afebrile • Bloods: – Hb 95 WCC 13 CRP 150 • ABG: not done • ECG: sinus • Can you think of other blood tests which might be relevant?edic earn Ultrasound Liver Septations Lung Diaphragm edic earn Management Transudate Exudate 1. Find the cause Protein concentration < 25g/L >35g/L – pH Causes Common: Common: •“Failures” – cardiac, renal,•Infection (TB, pneumonia) – Biochem: glu, prot, ldh hepatic •Malignancy Less common: Less common: – Micro: AFB, MCS •Hypothyroidism •Autoimmune disorders (rheu •Meig’s syndrome* (benign matoid arthritis, SLE, – Cytology (>60ml) ovarian fibroma, ascites, Sjogren’s) right sided pleural effusion •Post-operative (e.g. CABG) 2. Get rid of it •Drugs* •Dressler’s syndrome •Yellow nail syndrome* 3. Stop it from coming back • If the pleural fluid protein concentration 25-35: Light’s criteria Fluid protein: serum protein > 0.5 Fluid LDH: serum LDH > 0.6 Fluid LDH > 2/3 of the upper limit of normal If 1/3 apply – exudative effusioneearn Management - 2edic earn Management - 2 • Fibrinolysis • Upsize drain • VATSeearn Management - 3 edic earn Chest Drains • 2 questions: – Is it swinging? – Is it bubbling • Just like plumbing… – Is it leaking – Is it blocked – Is it kinked – Is it in the right place?edic earn Other Interventions Talc pleurodesis Video-assisted Thoracoscopic Surgery (VATS)edic earn Any questions? maggie.cheung@nhs.net THANKYOU! eearn Dr Maggie Cheung < Insert Picture > Please contact ML member mediclearnenquiries@gmail.com mediclearnuk @MEDICLEARNUK Resources BTS Pleural Guidelines 2023! Sponsored by mysuture_ hello@mysuture.com www.mysuture.com