Lungs: Restrictive Extrinsic Conditions - Kyphoscoliosis, Pleural Effusions, Pneumothorax, Tension Pneumothorax, Neuromuscular Disorders (GBS, MG)

Question 1

How does kyphoscoliosis affect lung function

Answer 1

Deviation of the normal curvature of the spine in the sagittal, coronal plane => restrictive lung problems

Question 2

Pleural effusions

-presentation, examination findings

Answer 2

No hemi diaphragm
Meniscus
Dense white shadowing
Locular effusions
Fluid sinks to the bottom, compresses lung above

Decreased expansion
Mediastinal shift to contralateral side
Stony dull percussion
Bronchial breathing at level of effusion
Decreased VF/TF

Question 3

What is the difference between a chest drain, pleural tap and thorascopy

Answer 3

Chest drain - drainage of air, blood, fluid, pus out of pleural space => reexpansion of lung
-Seldinger kit

Pleural tap - drainage of pleural fluid for sampling

Thorascopy - laproscopic technique to view lung and pleura, take lung biopsies and insert talc

Question 4

What info can you get from a pleural tap

Answer 4

Physical appearance

Protein and LDH often change together
-transudate < 25 LIGHTS CRITERIA 35 < exudate

AFB - TB culture
MCS - microbe culture
Cytology - cells

Glucose and pH often change together

• if low, likely
  
  • infection/empyema
  • malignancy
  • RA, TB, SLE

Question 5

What is the difference between transudate and exudate?

-what are the most common causes

Answer 5

Transudate

• due to increased hydrostatic pressure or low oncotic pressure
• low in protein and LDH
• systemic causes

Exudate

• due to inflammation and capillary permeability
• high in protien and LDH
• infection, inflammation, malignancy

Question 6

What is the Lights Criteria

Answer 6

Exudate if at least 1 of the criteria met

1. Pleural protein: Serum protein
   - ratio > 0.5
2. Pleural LDH: Serum LDH
   - ratio > 0.6
3. Pleural LDH greater than 2/3 upper limit of normal serum LDH

Question 7

How would you manage a

• parapneumonic effusion
• empyema
• malignant effusion
• bilateral effusion

Answer 7

Parapneumonic effusion - secondary to pneumonia

• no infection in transudate
• manage pneumonia, no need to drain

Empyema - pus from infection in pleural space
-drain exudate, identify microbe, ABx

Malignant effusion - cancer cells in exudate increase production of fluid and decrease absorption

• lung, breast, lymphoma mets
• mesothelioma
• pleurodesis with talc to prevent formation of effusions

Bilateral effusion - transudate due to systemic issues
-treat underlying cause

Question 8

Causes of

• primary pneumothorax
• secondary pneumothorax

Answer 8

No underlying pathology
Tall, thin patients
Presence of bullae on apices of lung
Often smokers

Trauma
Lung disease - asthma, CF, PCP, cancer, sarcoma, COPD
AI affecting lungs
Congenital - CF, Marfans, EDS

Question 9

Pneumothorax

• presentation
• investigation, diagnosis

Answer 9

Pneumothorax
Sudden onset SOB, pleuritic pain

TP -
Insp => air moves into PS
Exp => valve on lung closes
Increased air in PS => compress heart

Reduced chest expansion, reduce breath sounds on affected side

CXR => loss of lung markings on affected side

Question 10

Management of

• primary pneumothorax
• secondary pneumothorax
• tension pneumothorax

Answer 10

Primary
2cm+ / SOB?
-yes - aspiration & OPD => chest drain & admit
-no - OPD

Secondary
2cm+ / SOB?
-yes - chest drain & admit
No - 1-2cm?
-yes - aspirate & admit => chest drain & admit
-no - admit and observe

Tension

• needle decompression 5ICS MAL
• high flow O2, chest drain

Question 11

What neuromuscular conditions may cause a restrictive lung disease
-management

Answer 11

GBS, MG

-IVIG, plasmapheresis