Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

So I'm a rest. Oh, recording in progress. Ok. Um So I'm a respiratory registrar. I'm working in North London and um in the next hour, hopefully, we shall discuss a bit of a about and pleural effusions and um maybe this might inspire you to consider respiratory as your future specialty as well. So, um this is your, let me see. Yeah, this is your syllabus um for the UK ML E or MLA I think the new thing now, um it's quite um wordy and quite long. Um So I've just summarized it for you. Um What you essentially need to know about pleural disease is um what bad things can happen. How do you know that they are happening and what are you going to do about it? So, that's what we're going to cover today. Um There will be some interactive bits that require a sliding um which will hopefully work and um that's on. So, um questions you can feel them um into the chat and um the team will um help us out with um questions and otherwise questions at the end as well. So, the pleural space, so the pleural itself is a fibrous ish layer that wraps around the lungs and also the uh the inside of the ribs um in a sort of um continuous way that doubles back on itself. So the pleura itself, it consists of five layers. So the outside is the mesothelium. There are two connective tissue layers and two elastic layers. So it's quite stretchy and it's quite fibrous. I usually tell patients that it's kind of like a thick cling film. But like if we're a bit like gen Z at the moment, it's kind of like, you know, those bees wax wrap that you can put with your lunch. Um It's kind of like that kind of thickness and um stiffness. So it wraps around the outside of the lungs and also the inside of the ribs. And as you know, probably from your anatomy process, the inside layer is called a visceral pleura. And the outside layer is called the parietal pleura pa parietal meaning wall. And that makes sense because it's on the outside. Now, there normally is fluid in the pleural space, which is the layer between the parietal and the visceropleural. So this little bit here, I don't know if you can see my cursor. Um Normally that's about 15 to 20 m of fluid that is there at any one time. It's kind of like a lubrication to allow the two layers of occur to slide nicely and smoothly over each other during inspiration and expiration over a 24 hour period. You are expecting about 200 mils of fluid to circulate through the fluid is produced um via the lung parenchyma and the pleura and then it's absorbed through the lymphatic system and drained out that way. So, if you have any disease to do with your lymphatic system, that will also affect your pleural space, so what can happen to your pleur? The pleura itself can be the problem. So you can have a build up of asbestos, you can have cancer there, whether that's a primary cancer, which is mesothelioma or metastases from other places, normally from the lung. Um It can be a site of infection. So, tuberculosis quite commonly can cause pleural disease or it can be infiltrated with a variety of other things such as aidos and sarcoidosis. So, the pleur itself can become thickened and diseased. You can also have stuff to accumulate in that pleural space um between the visceral pleura and the parietal pleura. Now, that can be fluid and that is called a pleural effusion. Um Hydrothorax is a bit of an older terminology. It can be blood um which is hemothorax and normally that is a result of trauma. It can be Kyle which is a milky kind of fluid that is consisting of mostly triglycerides and that is called a chylothorax or it can be air which is a pneumothorax. Now, for the purpose of your learning and your examination, you just need to focus on the effusions and the pneumothoraces, um hemothorax and chylothorax are rarer um relatively and you don't necessarily need to know so much about it for your syllabus. This talk is predominantly aimed at um sort of undergraduate at the end of their university slash F one and F twos. Um And that is what I would like. This kind of knowledge is what I would expect my F one and F two to have um when they come work with us. So um let's begin, why do things accumulate? So, physics and either you have an increased production of things or you can have a reduced absorption of things. When your production is greater than your absorption, then you have a build up of air or fluid in that space. Now, fluid or air can be produced um as a result of inflammation or injury and that can be inflammation and injury of the pleura or the underlying lung. The reduced absorption, as we said before, the pleural fluid is circulated by the lymphatic system. So if there is a blockage in the lymphatic system, for example, if you've got breast cancer that has metastasized to your axillary lymph nodes, you will have an impaired drainage and therefore your pleural fluid reabsorption will be slower. And that's why sometimes quite actually, quite commonly in metastatic breast cancer, you can get a malignant pleural effusion, the similar logic for air, um if you don't have anywhere for the air to go or be reapproved or escaped. You will have a buildup of air and the lung is essentially a track space because there are no holes in your rib cage and your chest will normally. So if there are no holes, air can't go out, even if there are holes, it's a two way process. So, unless you got a one way valve in your chest wall, air can go in as well as come out. And that is quite important when we manage pneumothoraces. Um as you will see that in the pool, um, am I going too fast? No, that's perfect speed doctor. Thank you. Ok, perfect. So let's um start with a case. So this is a case that you will see in uh emergency department or, you know, in ambulatory care. So it's a 25 year old gentleman who is quite tall and quite skinny. Now, I'm sure you all know from your history taking. You're gonna go through a presenting complaint, history, presenting complaint, past history, et cetera, et cetera. So I'm just gonna take you through it. So this is the demographic of the patient. He was at the gym when he suddenly developed pain on his right side. He then found it quite difficult to catch his breath. It's like a stabbing pain as soon as he starts to take a deep breath in and we call that chest pain. This has never happened before to him. This is quite new. He just thought, you know, he did something at the gym. He is normally, well, no medical history. He's not on anything. He's got no allergies. He's been smoking 10 a day. Um, from the age of 14, he's also recently started vaping and he used cannabis a little bit in university, but not so much. Now, only once in a while he worked as a plumber, he has got no family or travel history. Right. So, all of these things are quite important and that's why in history taking, we don't miss anything and even things that you think are completely unrelated, like they went to Saudi Arabia three years ago, that might also become relevant. So don't skip out any bits of your history taking when you're talking. Now you examined this gentleman obviously as you go and he looks quite clammy and he is struggling to take a breath. He is not some, you know, young, 25 year old who might just lie to you. He genuinely is a bit distressed. He's tachycardic. When you feel his pulse, his care is not moved to one side. When you palpate it, he's got reduced chest expansion on the right side. And when you percuss, it's quite hyper resonant to percussion on the right side. And this is associated with a reduced air entry, local pharmacist. We don't often do, but he has decreased local pharmacist. Now, let me see if this is going to work. So if you'll log in to slider.com um and put in that code or use the QR code that is on the screen that should take you through to slider, which would be this quiz. I'm just gonna move on to the next slide where all of this is still on there. Hopefully this will work. So what are your differentials at this point just to summarize um in case you know the too much information so young, tall and normally fit gentleman at the gym got sudden nonseparated chest pain, short of breath, hyperresonant on percussion and induced air entry on auscultation. He smokes, he vapes and he used to use cannabis and he's a plumber and he has no other associated symptoms like fever or productive cough or I don't know, back pain, abdo pain, things like that. It's gonna give you guys a minute or so, right? So you are very smart. And um given that the talk for today is pneumothorax and thorough eus it logically can only be one of those and you're very right. Um It in the top, the would be a pneumothorax. So now let's move swiftly on right now. Second quiz, what investigations would you then do next? If you think this gentleman has got a pneumothorax? Now, I think this is a ranking thing. So you have to then like move the options up and down. Um a bit of a tip, all of the options are correct. It just depends on what order you would do them in. I was like watching the stock market to see like how these things are. He's gonna wait for a couple more of you to put your answers in if you haven't answered already. Right. Any other takers? No. All right. So good. Um, right beside abs Blood x-ray, ABG, CT ultrasound and the ECG. So, as we said before, all of these options are correct and you must know from your um teaching that we start with bedside and easy to do things and then we will gradually on to more complicated and things that require requesting porting the patient et cetera. So yes, bedside observations. Absolutely. That is part of your examination. Then I would do the bloods, which would include clotting, which is important as we come on to later things. Um I would do my AB G probably at the same time if he's hypoxic. Um and then you will then follow through with some scans. So x-ray yes, is the most definitive investigation for a potential pneumothorax. CT is quite difficult to get what can be useful. We will come on to that later. An ultrasound also can be helpful um as we will also come on to later. But yes, this order is basically correct. ECG also important. If he's a bit tachycardic, you just want to rule out anything else that is contributing to his tachycardia. And we always always want to know when people are tachycardic. What kind of rhythm they're in. Is it sinus? Have they gone into af what do you need to do about it? Right next page. So you've done some of your investigations and you've got your results. He is a little bit hypoxic for a young fit man. And, um, BP, not too bad heart rate, not too bad, but in the context of him being a fairly fit gym goer, you'll be expecting that he normally has a low resting heart rate and a lower BP in general, he's not febrile. Um His bloods are fairly unremarkable and no raised inflammatory markers or stuff like that. You have obviously not done ad dimer in this situation because of low pre test probability. Hopefully, you would know that um d dimer date of my life. Um And you've done an ad he only has a reduced po two does not have a raised P CO2 to suggest type two respiratory failure. And um he's got a sinus R on his ecg. Now this is where the money is at, ok. This is his chest X ray. So you are all correct. He has got a pneumothorax on the right side and this is where you can see it. Hopefully, you can see my person moving and I can annotate it for you. OK? So this is the long edge if you follow this round and this is your pneumothorax on this side, you will see here that the trachea is centrum. So, ideally, what you would like to do is um do this quite systematically when you read the chest X ray. So that's the ABCD E. So chest X ray, uh it's for airway, you're looking for. If the trachea is central, it then bifurcates into the right main bronchus, left main bronchus. So if the trachea is deviated, that can mean several things in the context of pneumovax. If you're worried about tensioning, which means the, the trachea will deviate away from the side of the problem. I think. No to. Now, I'm getting confused. I think it'll be deviating a wave in the site of the problem because the air is pushing your mediastinum towards the other side. Now, um B is for lung fields. So B is for breathing, which is lung fields. Um So you're comparing side to side, essentially, you want to um encompass all the zones of the chest X ray. So the top, middle, lower part never has it a guess as to what kind of lobe you think it is? Just describe what you see. Um Don't miss the A PC, which is a common area that can be missed and pneumothorax is sometimes do tend to start off apical. Um You're looking for lung markings on both sides. Are they increased, are they reduced, are they absent in the case of the pneumothorax? And that is normally how you can tell um you're looking for lung markings also for signs of pulmonary edema. You're looking for masses consolidations and fluid as we will come on to discuss. Um it's got a bit of a blunted angle here actually, um C is for circulation. So you're looking at the heart of cardiomegaly and D is for diaphragm. So normally the right hemidiaphragm is slightly higher than the left hemidiaphragm, but not by much. Normally, if you measure it is about 3 to 4 millimeters higher, um you can have a raised hemidiaphragm and that is the top row separately and e is everything else. So you want to check all the soft tissue, all the bones, we wanna check the hila just so make sure you don't miss it the spine and also underneath the diaphragm. So you're looking for things like pneumoperitoneum and this is just a gastric bubble. Um And it's normal if it's on the left side. Normally, pneumoperitoneum comes as like a little slit, a crescent shaped slit. Um Sometimes you can have bowels overriding the liver, for example, when you can get on that side, but I'm sure you'll get radiology talks. Now, this is here because you want to measure the pneumothorax and that will impact on your management to some degree. And B is for British and A is for American. So, the American Thoracic Society recommends measuring from the apex um in the midclavicular line. So, like this and the British Thoracic Society recommends measuring at the level of the highland and you're going from the edge of the ridge to the lung. So that is the distance that you're measuring. And normally we would quite like the guest uh the measurements on the phone that will be useful. Now, next up, how do I? Here we go right here are some special scenarios where you might be caught up. Number one, this is a tension pneumothorax and this is the x-ray you should never see because on your examination, you should already have identified that the trachea is deviated and it sounds like there's a pneumothorax on that side. And therefore, you will already have a chest tube in before you do this x-ray. You can see here actually, the whole media spinum has been displaced to the right side. And this is because air is trapped in there with no way to escape. And um therefore you will tension and why is it so important is because if you get compression of the media spinal structures, in particular, the heart, your aorta, your IVC, your SPC that will cause hemodynamic instability and you can die from this. This is another thing where you might be caught out. So if you see the X ray on this side, it looks like there is an absence of lung marking, it looks like there is air in there and you might be tempted as many would do to put a chest strain in here. But actually, this is a bull up in the context of someone with COPD and when you see something like this and you're not entirely sure, just get a CT, um, before you stick a tube in. Otherwise, instead of fixing a pneumothorax, you'll be causing a pneumothorax. And it has happened before. Um, I have seen it, um, happened to other people. I have not done it myself, but it has happened to the best of us. So, just be cautious, right? Managing hemo things have changed um in 2023. So if you studied pneumothoraces before 2023 you will be well aware of the two centimeter rule. If the pneumothorax is bigger than two centimeters, you do something about it. If it's smaller than two centimeters, you don't do anything about it that has changed. So this is the newest BT S guideline from this year. And um essentially, you're asking, are they a high risk population? That means are they hemodynamically unstable? Are they hypoxic? Is the pneumothorax bilateral? Have they got significant underlying lung disease? Having a bit of asthma doesn't really count. But if they like high-risk asthma, then probably counts at the over 50 years of age with a significant smoking history, which means they probably at high risk of CO PD and therefore be prone to developing pneumopar and therefore slow to resolve. Or if you suspect that there is a hemopneumothorax and you can actually tell that from ultrasound, which is why ultrasound is so important. It is the point of care test, you can do it by the bedside. You don't have to wait for your patient to go to act and you can do it on really unwell. Patients. Ultrasounds are great. So if they are high risk, then you need to think about if it's safe to do something about it. So the pneumothorax big enough um in a safe place for you to intervene. Are you personally in a safe place to intervene? So, if I'm going to stick a chest drain in, I don't want to be on like some priority ward where they can't manage a chest drain. You need to be in a place where the patient is safely monitored and looked after and what does the patient want? So this is this bit of the algorithm. If they don't want a procedure that is completely OK. If they're completely fine, they're on oxygen. You know, the pneumotherapy is relatively small, you can just let them go home but bring them back every 2 to 4 days. We want to review them um in clinic normally via an ambulatory clinic with x rays on the day and just check that the pneumo arthritis is getting better over time if the patient wants to feel better because, you know, they've got pain, they're breathless, they're just a bit anxious about it. There are two ways about it. Number one, you can still ambulate them or number two, you can admit them and do something about it if you want to ambulate them. This is quite a fabulous device. It's called a um per event or a new event. Depending on your brain. It's essentially like a little portable chest strain with a one way valve at the end. And patients can just carry this around with them and they can go home with it. I put one in the other day and it's quite effective and then they come back, we can check that the pneumothorax is resolved, then you take it out and they can just continue living at home. You don't have to be in hospital. If they do decide they want to stay, you can either do a needle aspiration or chest strain depending on the size patient preference. Um Needle aspiration is actually more effective than people believe. Um it is effective in I think a third of cases, possibly. Um if it fails, obviously, then you have to go for chest drain. And um when you go for chest drain, we normally start from the smallest size um and then gradually upsize them. And with any of these things, you will have to manage them every 2 to 4 days until it's better follow up 2 to 4 weeks in outpatient department, normally with a repeat X ray. And then we also remind them again and again and again about things that they should not be doing. Scuba diving is forbidden for life. Ideally, um snorkeling is fine it's just scuba diving because of the changes in pressure flying should be avoided um for at least two weeks. Um after the pneumothorax has resolved, normally I tell people not to fly for six weeks, sometimes you can do like a fit to fly test. Um But that is if your hospital has that service, normally just avoid flying. And um they because because the change in pressure um when you're in higher altitude and cause your lung problem can cause the air leak to be great. So, um, and future risk of pneumothorax, um, once you have one, you are more likely to have another one. normally it's on the same side. If you're unlucky enough to have on both sides, then you're a very unlucky person. If you've had it more than once on the same side or if you've had it on both sides, then we will refer you for surgery because you need something done about the pleura that is not working particularly well, right? That is pneumothorax. Hopefully, that was straightforward enough. Now, case number two, slightly different. And we've got a 56 year old lady. She has been breathless for about six weeks and because you're a very good doctor, you take a very good history of presenting complaints. There is progressive breathlessness that is worse on exertion. She's got some inhalers at home and she's been like, you know, puffing the salbutamol like no tomorrow, but it's not helping. And like the first guy. She is also struggling to take deep breaths. She also has noticed that her coats are getting a bit looser and she thinks she's lost some weight. She's feeling tired all the time. But don, we, um, a couple of weeks ago she thinks she coughed up some blood but she's not really sure. It's like a little bit of streaks, like, you know, when you get a bit of a cold and then sometimes you get a bit of like streaky blood in your phlegm. Um, she thinks that happens, but she's not entirely sure. She's got a background history of CO PD and she's hypertensive and for this, she is on Trelegy inhaler. Um, you may, um, comment in the chat to, um, tell me what Trelegy is. Please don't cheat. Um, and she's on Ramipril for hypertension. She has no allergies. She works as a school teacher. She's quite a heavy smoker. She smoked 30 cigarettes a day since the age of 12. And, um, this will equate to a number of pack pack year history that I can't work out in my brain right now. So one pack year is 20 a day for one year. So I made it more difficult for myself by saying Betsy, but I'm not gonna work that out right now. She does not Vape or use cannabis and she has no asbestos exposure. Now, all of these are risk factors. That's why we always, um, mention these smoking is just a risk factor for anything and everything. So smoking is bad for you. POSTOP. If you currently smoke, don't vaping is also bad for you unless you're currently a smoker. In which case, we will allow you to have an electronic cigarette to help you quit, but we have no idea how bad it is for you and it probably is quite bad. Um So if you currently Vape also don't um cannabis can predispose you to having um schizophrenia and also pneumothorax. So if you use cannabis, no CBD oil is fine. Um smoked cannabis is not so fine. If you smoke cannabis, I would prefer if you bake into a brownie or something and eat it. Um asbestos is as we know, um related to cancer. Um her dad died of lung cancer, but then he was a heavy smoker. So she just blamed on smoking. She's not traveled anywhere. Now, you also examined this lady. She is breathless. She's got car staining on her fingers from all her cigarette smoking, but she is not cook. You felt a trick here and you think maybe it's deviated to the right side, but then you're not entirely sure because she just like kept moving and your percussive chest and still dull to percussion on the left side. And we know that this is associated with um she's got reduced air entry on the left side as you would expect, possibly some fine cracks on the left side. But then again, who's really sure she does look like she's lost some weight, you know, skin folds a bit looser. Her clothes look like they have loose on her. So again, what are your differentials? It still be the same slide though as before, I'm loving this. I'm loving the range of different shows you guys are coming up with. Pretty good. We'll maybe wait until 20 if you have replied. I'm really enjoying how specific some of these diagnoses are small cell lung cancer. Sounds like you need to come to my cancer talk on a Friday where we talk more about small cell lung cancer, lung cancer is my area of, um, interest. Um It's quite exciting familiarity. TB love that. Right. I think these are all very good and they're all equally valid. Um, but then again, you know, on the balance of probabilities and um, the type of the talk, uh, we are looking at pleion, we don't know yet the course of the pleion and therefore it could be any of these things that you guys have mentioned. Pneumonia, cancer, TB COPD exacerbation is possible. Um Sometimes they don't respond to um, inhaled therapy, but then she is only dull on one side. So there is something else going on. All right, let's move on. So you have done your investigations. Ok. No, we didn't do it that way. So, um, yeah, these are her investigation results because clearly you're going to work her up the exact same way you would work anybody out. So, she's largely hemodynamically stable and she is not hypoxic on her bloods. She's got a white cell count of 13 and she's got a CRP of 150. So something is happening in there. Does this make you think pneumonia? I'm not sure. ABG, we've not done one because she's not hypoxic. And you know, Ana is like, why would I do an ABG when you're not on oxygen? Um ECG she has enzyme rhythm and she's not tachycardic. Again, your first investigation that is going to be helpful um is going to be your chest X ray while you're looking at this, think about any other blood test that you think might be helpful in this situation as we continue to work this patient up. So you're correct. This is a pleural fusion on the left side and you notice because um it's a meniscus here. You can't see the left hemidiaphragm anymore. So you've lost that definition between air and soft tissue. So something that is of a greater density than air is filling that space. This is just a bit there with some poop. I think um trachea has been deviated to the right side um because there is um volume in here from an effusion. Um The rest of the lung looks fairly unremarkable, to be honest and this is where the money is and the right side is quite crisp. So you're not looking at a bilateral effusion. So you are thinking that this is a unilateral pleur effusion, which does change it ultrasound, as we said before, an incredibly useful test, um especially in ple effusions. So we don't routinely trust CT scans or X rays because they tend to overestimate the size of the effusion. Because if you think about it, your chest X ray is a two D scan, you're looking at someone from the face front and the lungs, the way the lobes are wrapped around and the way that the fluid can be distributed, you can just have like fluid here and it's superimposed on each other. And then it might look like a white out when it's actually just like pockets at different places. CT scan, you do it with the patient usually lying down. So all the fluid will pull to the back of the patient posteriorly and therefore, it might overestimate and fluid as we know is very possible. Um So where, how you position the patient and where you scan is very important. Um So this is um a bedside ultrasound that we normally would um perform for anyone with a pleuro fusion that we a bit suspicious about. So um this bright line here is the diaphragm and on the, so this is um patient's head is this way, patient's feet is this way with scanning cranial cord, the liver is on this side and you can tell because it's got that texture. That's the gray, gray fluid is black on ultrasound and this is all fluid and you've got an underlying lung here, that's a bit atoxic. These little strands here are septations and septations usually indicate the degree of infection or inflammation. It's kind of like, you know, in the abdomen. When you do surgery, you have adhesions, it's like that kind of vibe. Um So this is like a nice little pocket um forms this is called locule. Um Here, this is the pleura and you can see the pleura is a bit thick. Um Once you've seen a few of these, um we measure it normally and we see how thick the pleura is. Normally, we expect it to be less than one centimeter and we can measure the depth of the effusion. As you can see here, someone's very kindly done that for us and it's about seven centimeters and you measure it from the pleura to the lung. You scan what we scan from the diaphragm up or from the apex down and we measure how many rib spaces and we normally do it anteriorly laterally and posteriorly just to get an idea of a 3d picture of the fluid, you won't have to do this. But if you're interested in thoracic ultrasound, there is ABT S course. Um that is online is um 30 lbs for non-members and free for BT S members, which I think is quite cheap to join. If you're a student. Now, pe fusion. Number one, it's very important that we know what's causing the problem because it's all very well taking out fluid. But if you don't know how it's being produced and how quickly it's gonna be produced, you can't do very much about it. So what you need is a sample and you wanna send it for a PH biochemistry, microbiology and cytology, cytology, predominantly looking for cancer microbiology, looking for empyema and TB related effusions, biochemistry will then tell you whether it's uh more likely to be an exudate or a transudate. And whether or not you think it's infected and PH is a predominantly um infection um marker. So I'm sure you've all seen this um with regards to life criteria. So if you measure the protein concentration in the fluid, if it's less than 25 you are pretty happy that it's probably a trans and it is greater than 35. You might think it's going to be an exudate. Exudate tends to be inflammatory conditions, infection, malignancy, rheumatological conditions. If it's a transudate, then you're thinking of the failures. So, cardiac renal and hepatic, this is very common and usually translated effusions are bilateral but they can be unilateral or they can be much larger on one side compared to the other. For example, in the hepatic hydrothorax where your liver is not really working, you've got a bit of ascites, some of that spills over up um across the diaphragm and we get a lot of from the liver team and um, normally you need a definitive um, measure for the liver. So you drain the ascites or you do a tips or you sort out the liver disease. Um, but failing all of that, we can also do something about it from chest. Um, just to point out nigh syndrome is um, cancer. So, um, it's related to ovarian, um uh well, benign, benign ovarian fibroma correct me. Um So it's ovarian related. So you would think normally it should go under an exudate, but it is in fact, a trans uh yellow nail syndrome not to be missed. Um Sometimes it can cause a chylothorax if you fall in between of the 25 and 35 that is where your life criteria is going to be useful. It's a bit of a mouthful to say all out. So I'm not going to, you can get this anywhere on the internet. And um essentially, if the fluid has a lot of protein or LDH, um you are looking at more likely to be an accident. Um The tricky thing is once you've left the trans in for long enough or if you keep aspirating a trans, it can then turn into an accident which will then confuse things. So, um whilst we are all very happy to do procedures and um we love stabbing people with very sharp things, but we do try to avoid um poor procedures if we can because it is not without risk. The second thing you wanna do is get rid of it. So I've got some props here, um which we can um talk about in a bit. Um So you wanna find what's causing the fluid, get rid of the fluid and stop the fluid from coming back. If there's not much you can do apart from treating the underlying condition. If there's an accident, then you want to treat the infection. But sometimes if you've got an infected pleural space, you're gonna want to do source control. So you wanna get rid of that fluid if it's cancer, um treat the cancer. But then by the time you get a pleur infusion, you're looking at a metastatic cancer. Um So you want to do a bit more treatment and you can also do sort of like a palliative like chest strain um that sits inside the pleural space which we can cover on the Friday. Talk about lung cancer. Um Let me see. Uh Right. So let me stop sharing my screen because I've got some props, right? If you can all see me, OK. So to take a sample of the fluid, you can very well go in with like a 20 mil or 50 ml syringe and you can attach it to like the green needle and you just go inside the peral space between the visceral and the parietal pleural and you just ask for it. All right. Just aspirate and feel it will come out and the same you can do for air. Now, this sharp thing will always be inside. And if you're a bit unsteady with your hand, you can just wobble around and poke the lung and cause a neuro. So someone smart has come up with this contraction. This is called rocket pleural catheter. Uh My colleagues are very kindly named as an in and out catheter for the lung, which I think is quite accurate. To be honest, it works like a cannula. So when you're going in, you're aspirating as you go once you hit fluid or air, you know that you're in the right space and you can actually just untwist this slide this forward and it bends like a cannula. So the needle actually comes out and the plastic tubing stays in. So there are no things remaining inside the patient. And you can use this as like an ambulatory intervention. Takes about like 10 minutes to do start to finish. You will get good decent sample because you can like connect this to uh like a Catheer type bag and we normally can take out up to 1.5 L of fluid at one time and this is quite good. I quite like it. Um And also this edge is um blood, the needle is around the side of the blood thing. So it causes less damage. This is uh one of the newer models and it's eight French. Um Other things that you can do is a chest drain. So chest strain. Uh we put in uh medically with a singer technique. So you have your introduce a needle and you have a syringe that allows you to aspirate until you hit pleural space. And you can be like, ok, so now I'm in the pleural space and then you basically the guidewire, sorry, I used up my guidewire when I was doing a drink. But you essentially untwist this, you slide a wire inside through this hole and it comes at the end of the needle, then your needle comes out, the guidewire stays in. And then what you do is you then never receive the needle unless you're teaching. Um you then slide the strain um over the guide wire and you can see it's called a hole um at the end and basically the guide wire slides along here and then once the drain is out, the guide wire comes out, that's your technique. Now, the drain itself has holes um at the end. And these are the holes where your fluid or your air will come out of. And it's very important. All of these holes stay inside the pearl space because if they're not inside the peo space, as you can imagine if it's out in the open or if it's in a soft tissue and the stuff can come out of these holes and reaccumulate in the soft tissue area which you don't, you don't want, um, it has markings and it's always useful to know, ii, blurred my screen, but these are the centimeter markings always useful to know, um, what length you've inserted to. So people subsequent can, um, assess whether the drains come out. And, um, this is a 1212 French drain, which is quite small. You can upsize it to an 18 and, um, or you can use surgical drinks. Um I think that's all my choice and let's go back to sharing screen. Mhm. Mhm. Mhm. So uh again, this is in the new BTS pleural guidelines and this is what you do for suspected um infection. Um So this is um your fluid ph, if it's less than 7.2 it is very high risk for an empyema and you will have to put a drain in because that is source control without the drain, getting rid of the infected fluid, you're not gonna get better. If the ph is normal above 7.4 you can be relatively if it's somewhere in the middle, then it is recommended that you check a pro LDH and the cut off is 900. If it's greater than 900 it's more suspicious and you might want to do your drink if it's less than 900 less suspicious and you can just keep monitoring. Now, this is somebody I saw on Sunday. He came in with an X ray like this as you can see he's got a pacemaker for something and he's got this weird looking effusion on this side and it's a bit like like a low V here. It's not the nice meniscus that you normally see. So someone smart somewhere has done a CT scan. This is a CT scan with venous contrast. I cannot stress this enough. Then another reason why I hate D DIMER is because then it results in everyone doing AC TPA. And when you're looking at the pleural space, you ideally want contrast in the venous face or the pleural face, pleural face predominantly will be great, but then rarely happens. So venous face, I'll settle for. If you do it in the arterial face, it doesn't light up the pleura as well. And it's quite hard to see what I want to see on the CT. If I'm suspecting an empyema is a thickened and enhancing pleura on the outside, there might be an effusion underneath, there might be consolidated lung. And you can see actually this effusion, which is this like homogenous gray stuff here compared to lung which is slightly lighter and air which is black. Um It's in a weird curvy way and it's in pockets. So we call that loculations and a loculated infect uh effusion is very highly suspicious for. So this gentleman actually is about 70 years old. He went to a different hospital a couple of weeks ago and was treated for a left uh right, lower lobe community acquired pneumonia. So they all tracked. So he had a pneumonia on that side and now he's got an effusion. The question is, is it a parapneumonic effusion or is it an empyema? If there's a parapneumonic effusion, if you treat with antibiotics, it should get better. If it is not going to get better, you're gonna need to drain it. So this is why on Sunday I decided, you know what? Um even though this patient has a high inr, I'm just gonna do a drink. I do a tap first to see what the ph is like. I just told you. So I tested the PH with my 2020 mill syringe. Um And the PH was 6.6. So now I'm like, OK, I have no choice. I have to do a chest drain. So that is where the chest drain has gone in and it's been curled up in this little space here. And because there are so much septations in here, you can't fully drain all of it because it's form pockets. So if it's got pockets, your drain is only go into one pocket, it's not gonna get to the other ones because it's, you know, separated by that septation. And in that case, you're gonna have to put fibrinolysis through your chest ring, which is um to place and DNA dose Dornase Alpha. So, um then that breaks down DNA as the name suggests. And um it breaks down, soft tissue, breaks down protein to allow those patients to disappear. Everything becomes one big pocket and it can come out in your chest room with these empyema, the drains tend to get blocked because it's so like purulence and it's got all these like fibrin strains and stuff. That's why you try to use a bigger size strain. If you can, you should start off with an 18 in this patient. We use the 12 because it was quite difficult procedure with the inr of 1.4 which is for like, let's be safe and do a 12. He's now had some fibrillin license into his pleural space and it's getting better. His CRP has um gone from like 400 to like less than 100 in two days. So success. If it doesn't work fibrinolysis, we discussed about upsized, your discuss, discuss about and the other option is surgery. The same thing for pneumothorax and um pleural effusions. If things are not working, think about surgery earlier rather than later for pneumothorax. We're talking about if it within five days, they're not getting better, you can try suction, you can try using a bigger drone to get the pleura to come up. But if it's not happening, you might need surgery uh with pus pleural infections, in particular, if you're not getting out of control with your drain, refer them earlier because the later you refer the more complications they're going to have and people do die from this. So think about it earlier rather than later. If your bosses are not thinking about it, remind them to think about it. Um Other things that effusions could be. So um you can have on the ultrasound here. This is uh Atal lung you discussed before. This is the diaphragm right line. All of this is fluid, this is thickened, pleura. So if the pleura is thickened, we ideally want to take a sample of it. And in order to do that, you need a buffer of fluid. Otherwise you're just gonna hit lung directly if you get past the pleura. So we do that and this is really nice, loculated, pleural effusion on the right side. Um This is your liver, um very nice patients there, not for the patient, but good learning. Um This is a pet scan. So we're talking about malignant pleion and sometimes that can lead you to detecting cancer, which is the thing here which lights up right from the pet scan because of increased metabolic activity and glucose uptake. And you can do medical thoracoscopy as well, which is essentially you put a bronchoscope, which is like a camera on the flexible tube um into the pleural space and you can like look around with it. You can like do biopsies you can put in and stuff like that quite useful. And this is actually mesothelioma. So you can see all these wax here um is looking very nasty. Cancer looks like cancer. Like when it's malignant, you can usually tell it's malignant and it's usually quite bloody. Now, chest strings. Um, when you become junior doctors, you will see plenty of chest strains uh, on the water whenever you go and the nurses will call you being like chest strings, not working doctor. Now, whether the chest r is working, there are two questions you need to ask is the chest ring swinging is the chest ring bubbling. So you can see in here there's fluid in this bottle. Um There's a fluid level in this tubing, there is fluid in this tubing and there will also be fluid in the chest drain tubing that you put in. So all of this will be inside the patient, but this bit will be poking outside. So you're checking all of these places of tubing to see whether there's a swing. Because when you're breathing in and out, obviously, your intrathoracic pressure changes and then your fluid level will move up and down accordingly. So if your drain is in the pleural space, it should be swinging. If it's blocked, it will not swing. Sometimes when the pleura has come up a post, you're just tracking the drain in this position. So it will not swing, but usually it will, if you've got air in the space, you want to know if the drain is bubbling, that is both a measure of it working and also how well you have been draining your pneumothorax. If it's bubbling vigorously, even without you putting them on suction, then it probably means that there's to follow up air coming out. If the bubbling has died down, then either that means there is no more air inside the pleural space or it means your drain is not working. And that is why you go back to the first question. Is it swinging? So, drains are just like plumbing. You need to know at every single point that the connections are all right. It's not blocked, it's in the right place. So you just check every single point at the skin at the dressing, at the light. We connect the things um in this tube. Oh Go back in this tube in this tube in this tube is any of it blocked. And sometimes if the bottle is full, it doesn't drink very well. So that you might wanna change the bottle, take out all the gunk and block it. Um If any part of it kink. So if your tube is twisted like this and bent, it's not gonna work properly. And is it in the right place? You won't usually be able to tell if it's in the right place by the side. So you either do an X ray or you do a CT if you're not sure. Now this is a complication that we briefly mentioned before. This is your chest R and you can see the holes are in the soft tissue. And that is why you're getting surgical emphysema. And it might seem like, you know, like they, they will li literally puff up like a Michelin man. We have seen it quite a few times uh cause the drain is usually because when the lung re expands, it can push the drain out of the way. And if it's like loosely sutured, then it can move and the holes with the move and then you can get air accumulating in the subcutaneous tissue and then they'll puff up and then sometimes it's pretty bad and it can cause hemodynamic instability. And in that case, you need a much bigger drain um to go in and just relieve the uh pressure because as we said, rates of production rate of absorption slash escape. If you increase the rate of the air escaping um via a larger drain physics, um then you will be able to get rid of the air much quicker. But if your leak is very big or if it's ongoing and it's not getting better, then your rate of production is still very high. And in that case, no number of drain is gonna fix your problem. You need surgery, but you can get some really chunky like big surgical chest drains done. That is not a selling a method that is just you going in with your finger as a blunt dissection. Um but that will be for surgeons, other stuff you can do. So this is TALC pleurodesis. Once you've got rid of all the fluid or air, you can stick TALC in the pleural space. Talc is, uh, irritants your pleura, it generates some degree of inflammation and allow things to stick back together. And this is, um, vat surgery. So this is a two port vats. Um, you can have one port, two ports or three ports and um, it's basically laparoscopic surgery and, um, surgeons can do a wealth of things in there. They can do biopsies, they can cut things out, they can stick the pleur together, they can take bits of disease, pleur out, they can drain it, they can wash out out smart, smart people, you know, very skilled. Um I am aware that we just rattled through that. So have you got any questions? I think maybe the team can help us with the, the chat and stuff. Um So we actually got um a few questions um sent privately. So I'm just gonna read each of them out one by one and then you can answer them. Does that sound? OK. Yeah, that sounds great cause I can't see. Ok. Yeah. So the first question is how often do patients get recurrence of pleural effusion or a pneumothorax? So, pleural effusions, depending on the cause. They can recur quite a lot in situations where you've not dealt with the primary problem. So, in metastatic cancer, for instance, it can keep coming back. Um heart failure, renal failure. Hepatic hydrothoraces, they do just keep, keep, keep coming back. And in that case, if you've done everything you can and you tried everything and there is nothing else you can do. You will just want to put in the indwelling pleural catheter. And that is an ad for my Friday talk because we will have a picture of that on that day. Um, pneumothoraces. Um, usually once you've got rid of the first one, they don't tend to recur very often unless you have risk factors. So if you've got COPD or if you're a smoker, you smoke cannabis like that, um that will increase your risk of having another pneumothorax. Obviously, we said before, if you've got one, it's more likely that you'll have another. Um I think the risk is increased by 50%. Um But hopefully, if you do all the things that you're supposed to do and don't do the things that you're forbidden to do, then it should be OK. OK. That's great. Um So the next question that we sent privately and then we'll come to the questions in the chat afterwards was um please, can you explain the concept of septation and how we know that it's associated with pleural effusion. So, the concept of septation is that when you have active ongoing inflammation, um when you have inflammation, it produces lots of protein, protein mucinous material. So it's kind of like gunky GLU P and it can just form like this is the example I always give like adhesions like in abdomen, like they just form strands. And that is a suggestion of really good going inflammation and um sonographically it is associated more often with infection. But then again, you can never tell until you take a sample of it. Does that answer the question? I think so. Um So was the course that you had mentioned about x-rays? Um was that online Uh that's for ultrasound? And that is online and it is the BTS Thoracic Ultrasound online course. OK. Um Next question is, how would a transudate lead to an exudate in pleural effusion? The course is not well understood. Um But I think it's to do with sort of um when you poke on it repeatedly or if it's been sitting there for a longer time and then it generates a degree of inflammation and irritation and then you start to get a bit more protein and LDH in the fluid. I think that is the logic. OK, perfect. And what drain technique do you find the most beneficial? And why um we talk about selling or versus surgical? Or I think in regards to, I think in regards to the drain of pleural effusion when you were showing the props, uh which, which version you prefer. Uh I prefer normally. So ideally, you don't want to put plastic in plastic is usually bad. Um So normally if we just want a sample and quick symptomatic relief we use the rocket is really just fast and quick and it, especially if you're not suspecting infection or if you're not su su if you're not going to do anything with the drug. So if you're not, if you're not gonna pure these, if you're not gonna do fibrinolysis, this is usually sufficient. Um But if you are suspecting infection, cancer, that's going to require blood in your uh pleural space, then you probably need a drain. But uh it's a case by case basis and people often argue about it even amongst consultants. So, thank you very much for announcing that. So, um last question that was sent privately is how can you suspect there are cancerous cells in a pleural effusion by, by bloods or CT? And are these done before to ensure a chest drain is not put in that place? Very good? Um So if you suspect cancer, so that's from your history and your examination x-rays usually quite quick to get. So then we can just get that. And um if this uh lung mass, um it can sometimes be visible on the X ray, but not always can be obscured by your effusion. If you suspect cancer in any way, shape or form, just get a CT because then that will just tell you where the cancer is. Um for like for most cancers you can detect on CT, obviously, for some things you can't. Um But we start with a CT cap. Um then in that case, it will highlight to you where your targets will be. So, um we're going to talk about lung cancer on Friday. But um if you've got a better target somewhere else, for example, you've got liver Mets and you've got what looks like a lung cancer and you've got an effusion, pleural effusions are not actually very good um high yield um for diagnosing lung cancer, cytology is only positive in about a third of cases of malignant pleur effusions. And that is dependent on the fact that you send enough fluid, which is has to be at least 16 mils of fluid if you can, we send like giant pots of like 300 mil. Um But if you can get a diagnosis elsewhere and that would be good. Um It's also the case if, if you've got a malignant pleural effusion, once you treat the underlying cancer, it might just go away. So you don't, might, you might not always necessitate the chest strain. So you might just get away with doing this, get your sample for cytology, check that first and then decide what you want to do next. OK, perfect. So I'm just gonna move on to. There's a um a few questions in the chart. First question is, will we get the slides and recording? Yes, the slides and the recording will all be available on metal. Um As soon as this session is over, we'll be uploading them in the next couple of days. So they'll all be available to you. Then uh next question is, could you, could you please clarify the location of needle decompression in a pneumothorax and tension pneumothorax? Yeah. So needle decompression should only be used when you're suspecting a tension pneumothorax and the patient is unstable and you, if you think there's going to be a large enough um pneumothorax, then why not just put in a chest drain? If you've got one, obviously, if you're like, you know, in the middle of London with LA s, then yes, do a needle. But if you've got a drain in A&E, then just put in a drain. Um The convention is second intercostal space in the midclavicular line. I think there's some chat about doing the axilla. Um But I'm a bit a bit nervous about doing the axilla and we tend to like to stab people in the front because it's just easier than positioning them like this. And there are some newer um tech um called something called Pneumo Fix, which is what the trusts prefer to use nowadays. It's just a bit safer than like then like giant, great big cannula in your chest. Um They're just a bit more secure and a bit less um prone to risks and complications. You can google it. Pneumo. I think that's what it's called. Ok, great. So the next question is why aren't V ATS first fine in all hospitals if you can do everything with it. Why aren't what VA S or vs oh, vats. Why aren't they available in every hospital? Because we don't have the tech, we don't have the people, we don't have the expertise and they're not as commonly done. So it's like, you know, if you, you, you're not gonna get a plastic surgeon in every hospital, it's the same way. You're not gonna get a thoracic surgeon in every hospital. That's just the way resources is and your hospital is often not large enough or not serving a large enough population to warrant a whole thoracic surgery department. Right? So we have, why don't we send everyone for surgery? That's because surgery is also high risk. And ideally, we wanna deal with things noninvasively or, you know, the most conservative, least invasive way possible. Mhm. Sounds good. Um, we have a question saying, what's the difference between needle decompression and aspiration? Needle decompression is when you just stab them with a cannula and you just leave the cannula in place. It's an emergency measure. Needle aspiration is you use your needle and your s syringe to suck out as much air as possible. And that is less of an emergency thing and just more of a therapeutic thing. Great. And we have one more question which was sent privately. Um, is there a criteria of when to choose a needle aspiration versus a chest drain? No, I think in the beginning of, uh, BTS it says you should try a needle aspiration first before proceeding to a chest drain. And then again, it's personal preference and um what's best for the patient at the time? So no criteria. Ok. Ok, perfect. So, unless anybody else has any burning questions at the moment, I think we will round off the talk. Um I just wanted to say thank you so much, Doctor Maggie for such an interactive talk on pneumothorax and pleural effusion. I think we can all agree that the uh session was extremely enjoyable and interactive and we all learned quite a lot in this hour. Personally, I found the X rays and applying the content that we've learned during lectures to a case study was very helpful um especially when it came down to distinguishing between pneumothorax and pleural effusion. Uh Once again, on behalf of everyone at me, thank you so much, Doctor Maggie for giving up your time today to join this session and thank you everyone for joining as well. Um If I can ask everyone to fill out the feedback form that I've left in the chart, um that will give some feedback to Doctor Maggie about how the session was run today. And then also you guys will get certificates about the session that was held today. Um Our next session will be this Friday at 5 p.m. regarding lung cancer and it will also be held by Doctor Maggie again, which we are very much looking forward to. So unless everybody, anyone has any question. Yes, we will. You will get the slides. Could you send the feedback link again? Yes. Hold on one second. Ok. So I've just sent the feedback form once again in the chat. Um Will you get the slides? Yes. The slides will be posted on Medal along with the recording after the session. Thank you, everybody for joining. Thank you, Doctor Maggie.