Pleural Flashcards
How is spontaneous bacterial empyema diagnosed?
500 WBC or 250 WBC + positive culture
What are the lab values for a chylothorax and how is it managed?
Lymphocyte predominant (70+%) with total WBC 400-6800. TG >110 and cholesterol <200
Low flow (<1L/day) treated conservatively with symptomatic drainage. High flow is embolization vs surgical intervention
What are the features of pleural effusions due to Kaposi’s sarcoma?
Exudative, pH above 7.4, LDH 100-300, mononuclear predominant, large and bloody, usually bilateral. Fluid cytology and perc biopsies are nondiagnostic as the lesions are usually on visceral pleura. Histo shows spindle cells and endothelial cells with HHV8 on immunohistochemistry
When there is a malpositioned chest tube in the parenchyma, what is the next step?
Place a new chest tube before removing the old one as there will likely be resultant BPF/PTX and/or hemothorax
What are the features of a urinothorax?
pleural:serum Cr >1, transudative, low pleural pH. Leak identified on 99 technetium 99m renal scan. Iatrogenic vs traumatic vs obstructive
What are the common causes of eosinophilic pleural effusions?
Eos >10%
Trauma, surgery to the pleura, PTX/hemothorax.
Some drug reactions, inflammatory conditions (A/CEP, EGPA, RA), infections, pulm infarct, benign asbestos effusions, rarely malignancy.
How do pleural pressures change in different scenarios?
Normal- flat elastance curve with pleural pressures staying at 0 or above
Trapped lung- starts with negative pressure and rapidly falls further with suction
Entrapped lung- in between and has an infection point where the lung has expanded as far as it can with suction
What are the features of shrinking lung syndrome?
Pleuritic chest pain and pleural thickening, reduced TLC, elevated diaphragm bilaterally and low lung volumes
What are the ranges of Hounsfield units for different tissues?
What are the features of a Bochdalek hernia?
Congenital diaphragmatic defect with herniation through the posterolateral foramen of Bochdalek. More often the left side, can include the stomach, spleen, small intestine, colon. Surgical repair regardless of symptoms
How can you identify misclassified transudates?
serum-effusion albumin gradient above 1.2 or serum-effusion total protein gradient above 3.1 is heart failure, pleural:serum albumin ratio <0.6 is hepatic hydrothorax
In the setting of a pneumothorax, what defines large and what defines stable?
Large= >2cm from chest wall at the level of the hilum or >3cm to the apex
Stable= RR<24, 60<HR<120, RA sats >90%, ability to speak in full sentences, normotensive
What is empyema necessitatis?
Extension of purulent fluid through the parietal pleura into the chest wall
How is pleural TB evaluated?
Pleural fluid AFB sensitivity <5% and culture 10-20%. Pleural biopsy sensitivity >70% but increases with caseating granulomas.
High suspicion with lymphocytic:neutrophil ration >0.75, ADA above 40 or caseating granulomas on biopsy lead to presumptive diagnosis
What are the features of yellow nail syndrome?
Triad of lymphedema, chronic respiratory manifestations (effusion in 1/2, chronic cough, bronchiectasis, sinusitis) and nail abnormalities
Can have lymphocytic effusions, chylothoraces, chronic fibrosing pleuritis
