Pleural Cavity

Question 1

What type of pleura is in the fissures of the lungs?

Answer 1

visceral only

Question 2

Inflammation of the lining of the lung (usually visceral pleura)

Answer 2

pleurisy

Question 3

What are the classic signs of pleurisy?

Answer 3

worsening pain with movement and deep breath

Question 4

What does pleural pain occur if the inflammation is in the visceral pleura, which does not have pain receptors

Answer 4

b/c it rubs the parietal pleura

Question 5

what is the most common cause of pleurisy?

Answer 5

viral infection

Question 6

what are other common causes of pleurisy?

Answer 6

pna, PE, pneumothorax, pericarditis,

Question 7

what is the treatment for pleurisy?

Answer 7

treat underlying cause, and provide anti-inflammatories like NSAIDS PRN

Question 8

pleura typically has about 14 cc’s of fluid in it all the time which is fed from systemic vessels. Typically this fluid is drained by the lymphatics. When this doesn’t happen appropriately, what happens?

Answer 8

pleural effusion

Question 9

What are some causes of pleural effusion

Answer 9

1. Interstitial pressure > Pleural pressure
2. Pleural membranes leaks liquid and
   protein
3. Inflammation and/or obstruction impair
   removal (lymphatics are obstructed, diseased)

Question 10

what is the most sensitive method to pick up a pleural effusion?

Answer 10

CT scan

Question 11

Is US ever used to detect pleural effusion? Why or why not?

Answer 11

Yes, because it can be done bedside in real time.

Question 12

You have definitively dx’ed pleural effusion. Now how can you figure out what caused it?

Answer 12

Thoracentesis! (drain the effusion and send to lab)

Question 13

When do you do a thoracentesis?

Answer 13

1) diagnose cause

2) symptom relief (evacuation)

Question 14

Which labs MUST be ordered for every thoracentesis?

Answer 14

1) cell count w/ diff 2) pH 3) glucose 4) protein 5) LDH. Other tests can be ordered based on suspicion

Question 15

What type of effusion forms by leakage of liquid across an intact
capillary barrier owing to increase in
hydrostatic pressure or reduced oncotic
pressure?

Answer 15

Transudate effusion

Question 16

What type of effusion causes leakage of of liquid and protein across
altered capillary barrier with increased
permeability.
(Think inflammation)

Answer 16

exudate effusion

Question 17

What are the 3 most common causes of transudate pleural effusion?

Answer 17

CHF, nephrotic syndrome, hepatic hydrothorax

Question 18

what are the 4 most common causes of exudative pleural effusion?

Answer 18

INFECTION, malignancy, hemothorax, chylothorax

Question 19

How would you treat a transudate effusion?

Answer 19

Treatment of underlying systemic process

Diuresis for CHF
Hemodialysis for uremia, volume overload
Liver transplant for Hepatic Hydrothorax
Decortication for trapped lung

Question 20

“Never let the sun set on______________”? Meaning, what kind of effusion cannot wait to be treated?

Answer 20

Parapneumonic effusion (exudative)

Question 21

There are 3 stages of parapneumonic effusion, simple, complicated and empyema. Which stage(s) can be treated with abx? Which stage(s) require chest tube drainage?

Answer 21

simple = abx

complicated and empyema = chest tube

Question 22

what is the most common cause of exudative pleural effusions in patients older than 60?

Answer 22

malignant pleural effusions

Question 23

What are some tx options for malignant pleural effusion?

Answer 23

1) Repeated thoracentesis (symptomatic tx)
2) Chest tube drainage and pleurodesis.
3) Pleurodesis with or w/o Thoracoscopy. (create scarring in the pleural space to limit spread of ca)
4) Small bore chest tube – destination device (Pleurex – catheter)
5) Palliative care

Question 24

What is the diagnostic criteria for hemothorax?

Answer 24

Pleural fluid Hct: serum hct > 0.5

Question 25

What condition results from blood accumulating in the pleural cavity?

Answer 25

Hemothorax

Question 26

What should you do to treat hemothorax?

Answer 26

1) chest tube drainage

2) VATS

Question 27

Rupture of thoracic duct causing leakage

into pleural space

Answer 27

causes chylothorax

Question 28

How do you treat chylothorax?

Answer 28

chest tube drainage, surgical ligation of the thoracic duct, medium chain triglycerides?

Question 29

when looking at a pleural effusion, what is the first things you should make note of?

Answer 29

How thick is the pleural effusion? <10mm can simply be observed

Question 30

your patient has a pleural effusion, and known CHF. When would you do a thoracentesis?

Answer 30

if they were also experiencing chest pain, fever, or effusion is asymmetrical

Question 31

Due to visceral pleural restriction, chronic
atelectasis, or endobronchial disease.

Lung Entrapment: visceral pleural restriction due to
active inflammation/infection or malignancy

Trapped lung: visceral pleural restriction with the
development of a fibrous pleural membrane in the
absence of active inflammation/infection or
malignancy.

Answer 31

unexpandable lung

Question 32

If the parietal or visceral pleura is breached and the pleural space exposed to postive atmospheric pressure, air enters the pleural space and the lung collapses inward towards the mediastinum. this is called a ___________

Answer 32

pneumothorax

Question 33

If you suspect______________, immediate decompression by transthoracic insertion of a needle attached to a syringe is indicated.
Waiting for radiographic confirmation may be fatal.

Answer 33

tension pneumothorax

Question 34

There are 3 general causes for pneumothorax. What are they?

Answer 34

spontaneous, traumatic (penetrating or blunt injury), iatrogenic (needle aspiration, cath placement, etc)

Question 35

if your pneumothorax is < 2cm in size, what will your treatment entail?

Answer 35

oxygen, observation

Question 36

If your patient has recurrent pneumothorax, what would you do?

Answer 36

VATS (video assisted thorascopic surgery) to identify air leaks

Question 37

What treatment would you use for a pneumothorax > 2cm?

Answer 37

Aspiration by needle or by small lumen catheter (least effective, may lacerate lung).
Insertion of a small chest tube or catheter attached to a one way flutter valve.
Insertion of a chest tube attached to water seal or suction drainage.
Traditional practice is to hospitalize pt for observation of complications or to insert a chest tube for 1-3 days or both.

Question 38

Your patient has a pleural effusion that is thicker than 10mm, what is the next thing you should ask yourself?

Answer 38

Does my patient have CHF? (because if they have CHF, the pressure in the lungs is going to be high, and these patients often have pleural effusions)

Question 39

What type of pleural effusion is caused by CHF!?! (and Nephrotic syndrome and cirrhosis)

Answer 39

Transudate effusion

Question 40

Your patient has a pleural effusion that is thicker than 10mm and he has CHF, what do you do?

Answer 40

Diurese and observe for improvement (if no improvement after 3 days, do a thoracentesis)

Question 41

your patient has a pleural effusion that is thicker than 10mm and he does NOT have CHF, what do you do?

Answer 41

Thoracentesis

Question 42

Ok, you’ve got the results from your thoracentesis on your pleural effusion patient. There are 2 criteria that would allow you to conclude that the pleural effusion is an exudate effusion. Either criteria will allow you to draw this conclusion, you don’t need both. What are they?

Answer 42

1) Is the ratio of pleural fluid protein to serum protein > 0.5?
2) Is the ratio of pleural fluid LDH to serum LDH > 0.6? (or you could say–is the LDH of the pleural fluid more than 2/3rds the normal serum level?)

Question 43

You’ve done a thoracentesis for pleural effusion. If neither of these criteria are met: 1) Is the ratio of pleural fluid protein to serum protein > 0.5?
2) Is the ratio of pleural fluid LDH to serum LDH > 0.6? (or you could say–is the LDH of the pleural fluid more than 2/3rds the normal serum level?)………..what is wrong with your patient? What should you do?

Answer 43

Patient has a transudate effusion. Treat underlying cause (most likely CHF, renal, liver dz) and provide palliation.

Question 44

Ok, your pleural effusion patient has an exudate effusion. Now what?

Answer 44

order additional labs to narrow down differential, make sure to include TB and PE in said differential.

Question 45

visceral pleural restriction DUE TO

active INFLAMMATION/INFECTION or MALIGNANCY

Answer 45

Lung entrapment

Question 46

visceral pleural restriction with the
development of a fibrous pleural membrane in the
ABSENCE of active INFLAMMATION/INFECTION or
MALIGNANCY

Answer 46

Trapped lung

Question 47

In a healthy person, where does the pleural fluid come from? Where does it go?

Answer 47

Normal pleural fluid flows from systemic
vessels feeding both pleura–>across leaky
membranes into the pleural space–>exits
via the parietal lymphatics

Question 48

So what’s really happening on a pathopysiologic level, in patient’s with a pulmonary effusion?

Answer 48

Inflammation and/or obstruction is impairing the removal of the pleural fluid

Question 49

What type of cancer is a malignancy of the pleura

Answer 49

mesothelioma

Question 50

What is the biggest risk factor for developing mesothelioma?

Answer 50

asbestos exposure

Question 51

What is the prognosis for mesothelioma? What is the general disease course?

Answer 51

Very poor, <3 years. Tumor eventually entraps the lung and spreads to mediastinal structures. Respiratory failure typically leads to death.

Question 52

Are there any treatments aside from palliative care for mesothelioma patients?

Answer 52

Radical pneumonectomy (removal of entire lung and both visceral and parietal pleura) OR pleurodesis (sclerosing the pleural space to prevent accumulation of pleural fluid)