Pleural Disease- Bootcamp

Question 1

A pneumothorax is defined as _ in the pleural space

Answer 1

A pneumothorax is defined as air in the pleural space

Question 2

A pneumothorax will present with symptoms like _

Answer 2

A pneumothorax will present with symptoms like sudden onset dyspnea, chest pain
* Chest pain may be described as unilateral, pleuritic, and sharp
* Pain may radiate to the ipsilateral shoulder
* Note that spontaneous pneumo in otherwise healthy adults may appear with minimal symptoms

Question 3

Spontaneous pneumothorax are normally caused by _

Answer 3

Spontaneous pneumothorax are normally caused by rupture of subpleural bleb

Question 4

The two populations most at risk of a spontaneous pneumothorax are _ and _

Answer 4

The two populations most at risk of a spontaneous pneumothorax are tall thin males (Marfan’s) and smokers

Question 5

What is a subpleural bleb?

Answer 5

Subpleural blebs are local defects in the lung that cause the lung to balloon out

Question 6

What happens in a spontaneous pneumothorax?

Answer 6

In a spontaneous pneumothorax bleb ruptures –> air rushes from the lungs into the pleural space –> lung collapses and pleural space expands

Question 7

A tension pneumothorax is more dangerous than a spontaneous pneumo; why?

Answer 7

In a tension pneumothorax, there is a progressive build up of air in the pleural space
* Air can only move unidirectionally, out of the lungs into the pleural space
* Air is accumulating with each breath and creating pressure on other structures

Question 8

Trauma from chest wall penetration or fractured ribs tend to cause the formation of a _

Answer 8

Trauma from chest wall penetration or fractured ribs tend to cause the formation of a unidirectional valve (tension pneumothorax)
* Fractured rib: air flows from lungs to pleural space
* Chest wall penetration: air flows from atmosphere to pleural space

Question 9

When air enters during a pneumothorax, it dissects through the liquid of the pleural space and disrupts the vacuum such that the intrapleural pressure is no longer _

Answer 9

When air enters during a pneumothorax, it dissects through the liquid of the pleural space and disrupts the vacuum such that the intrapleural pressure is no longer negative
* Transpulmonary pressure is no longer positive
* The lungs and chest wall are not held together

Question 10

Tension pneumothorax may cause the trachea to _ and vena cava to _

Answer 10

Tension pneumothorax may cause the trachea to deviate away from the affected side and vena cava to collapse –> drops venous return –> hypotension, tachycardia, JVD –> shock

Question 11

In a _ pneumothorax Pip = Palv

Answer 11

In a spontaneous pneumothorax Pip = Palv

Question 12

In a _ pneumothorax Pip > Palv

Answer 12

In a tension pneumothorax Pip > Palv

Question 13

When auscultating the lungs in a pneumothorax, we should expect to hear _ and _

Answer 13

When auscultating the lungs in a pneumothorax, we should expect to hear hyperresonance and decreased breath sounds

Question 14

X ray findings of a pneumothorax will show _

Answer 14

X ray findings of a pneumothorax will show collapsed lung with black/ air-filled lung field

Question 15

Management for pneumothorax includes _ or _

Answer 15

Management for pneumothorax includes needle decompression (tension pneumothorax) or chest tube placement

Question 16

A chest tube helps to treat a pneumothorax by creating a _

Answer 16

A chest tube helps to treat a pneumothorax by creating a unidirectional valve that allows air out of the pleural space but not in

Question 17

Answer 17

Tension pneumothorax
* Trachea is deviated

Question 18

Pulmonary edema is caused by an increase in hydrostatic pressure in the pulmonary _

Answer 18

Pulmonary edema is caused by an increase in hydrostatic pressure in the pulmonary capillaries
* This fluid gets pushed out and collects in the alveoli

Question 19

Pulmonary edema due to increased hydrostatic capillary pressure is often caused by_

Answer 19

Pulmonary edema due to increased hydrostatic capillary pressure is often caused by left heart failure

Question 20

_ are “heart failure cells” that may be seen in the alveoli

Answer 20

Hemosiderin laden macrophages are “heart failure cells” that may be seen in the alveoli
* These are macrophages that contain engulged extravasated RBCs

Question 21

Pulmonary edema can also occur from decreased oncotic pressure secondary to things like _ or _

Answer 21

Pulmonary edema can also occur from decreased oncotic pressure secondary to things like nephrotic syndrome or liver failure
* Less protein in the blood leads to fluid leaking from the pulmonary capillaries into the alveoli

Question 22

What happens to V/Q, DLCO, and lung compliance when we have pulmonary edema?

Answer 22

V/Q mismatch
Decreased DLCO
Decreased compliance (surfactant dilution)

Question 23

What does pulmonary edema sound like?

Answer 23

Pulmonary edema presents with bibasilar crackles, rales, dullness to percussion

Question 24

Pleural effusion can be defined as a collection of _ in the pleural space

Answer 24

Pleural effusion can be defined as a collection of fluid in the pleural space
* Often caused by an increase in inflow or a decrease in outflow

Question 25

The major contributors of the increased fluid in pleural effusions are the _

Answer 25

The major contributor of the increased fluid in pleural effusions are the pleural blood vessels
* These are intercostal microvessels
* Found in the parietal pleura

Question 26

We also have pulmonary capillaries in the _ that can cause contribute to pleural effusions in pathological states

Answer 26

We also have pulmonary capillaries in the lungs that can cause contribute to pleural effusions in pathological states

Question 27

The parietal pleura contains _ to drain excess fluid out of the pleural space

Answer 27

The parietal pleura contains pleural lymphatics to drain excess fluid out of the pleural space
* Sometimes malignant cells can block the pleural lymphatics

Question 28

Contributors to pleural effusions that should be considered:

Answer 28

1. Increased fluid from the pleural blood vessels
2. Increased fluid from the pulmonary capillaries
3. Thoracic duct rupture
4. Blockage of the pleural lymphatic system

Question 29

In very severe pleural effusions, we can see a deviated trachea (away from/ towards) the side of effusion

Answer 29

In very severe pleural effusions, we can see a deviated trachea away from the side of effusion

Question 30

Transudative pleural effusions are caused by _ or _

Answer 30

Transudative pleural effusions are caused by increased hydrostatic pressure or decreased oncotic pressure in the pleural vessels/ pulmonary capillaries

Question 31

Exudative pleural effusions are caused by _

Answer 31

Exudative pleural effusions are caused by increased vascular permeability whereby exudate is able to travel from the vessels to the pleural space
* Parapneumonic effusions
* Malignant pleural effusions

Question 32

_ effusions are pleural effusions that occur from pneumonia infection

Answer 32

Parapneumonic effusions are pleural effusions that occur from pneumonia infection

Question 33

Uncomplicated vs. complicated parapneumonic effusions

Answer 33

Uncomplicated: exudate is sterile
Complicated: bacterial seeding of the pleural space

Question 34

Exudative effusion contains fluid with a low pH, glucose, and high leukocytes; this is likely a _ effusion

Answer 34

Exudative effusion contains fluid with a low pH, glucose, and high leukocytes; this is likely a complicated parapneumonic effusion

Question 35

Malignant pleural effusions are (transudative/exudative)

Answer 35

Malignant pleural effusions are exudative
* Inflammation causes increased vascular permeability
* Also often have a blockage of outflow due to blocked lymphatics

Question 36

What does pleural effusion sound like?
_ percussion
_ breath sounds
_ tactile fremitus

Answer 36

What does pleural effusion sound like?
dullness to percussion
decreased breath sounds
decreased tactile fremitus

Question 37

_ is a procedure conducted for a pleural effusion for both diagnostic and therpeutic reasons

Answer 37

Thoracocentesis is a procedure conducted for a pleural effusion for both diagnostic and therpeutic reasons

Question 38

In order to determine whether a pleural effusion is transudative or exudative, we can remove fluid via _ and use the _ criteria

Answer 38

In order to determine whether a pleural effusion is transudative or exudative, we can remove fluid via thoracocentesis and use the Light’s criteria

Question 39

Three elements of Light’s criteria

Answer 39

Light’s criteria states that a pleural effusion is exudative if:
1. Pleural protein/serum protein > 0.5
2. Pleural LDH/ Serum LDH > 0.6
3. LDH is > 2/3 upper limit of normal serum LDH

Question 40

An increase in RBCs and atypical cells on thoracocentesis indicates _

Answer 40

An increase in RBCs and atypical cells on thoracocentesis indicates malignancy

Question 41

(Increased/Decreased) glucose levels indicate malignancy or infectious pleural effusions

Answer 41

Decreased glucose levels indicate malignancy or infectious pleural effusions
* Malignant cells take up all the glucose

Question 42

_ are direct communicators that exist between the pleural space and the underlying lymphatic network, allowing removal of large particles from the pleural space

Answer 42

Stromata are direct communicators that exist between the pleural space and the underlying lymphatic network, allowing removal of large particles from the pleural space

Question 43

The normal volume of fluid in the intrapleural space is _ mL

Answer 43

The normal volume of fluid in the intrapleural space is 15 mL

Question 44

Under normal conditions, the hydrostatic pressure is slightly _ than the oncotic pressure gradient in the lungs; this means that there is a net movement of fluid _

Answer 44

Under normal conditions, the hydrostatic pressure is slightly greater than the oncotic pressure gradient in the lungs; this means that there is a net movement of fluid into the pleural space

Question 45

What is the composition of normal pleural fluid?

Answer 45

< 1500 nucleated cells/ mm3

75% macrophages

23% lymphocytes

pH > 7.5

Low in protein

Question 46

Non-inflammatory fluid with low protein content describes (transudative/exudative) fluid

Answer 46

Non-inflammatory fluid with low protein content describes transudative fluid

Question 47

Transudative pleural effusions usually occur due to increased _ or decreased _

Answer 47

Transudative pleural effusions usually occur due to increased hydrostatic pressure or decreased plasma colloid oncotic pressure

Question 48

Exudative pleural effusions are usually due to _

Answer 48

Exudative pleural effusions are usually due to increased capillary and pleural membrane permeability via an inflammatory process
* Pleural disease, pneumonia, infection, cancer, obstruction to lymphatic channel

Question 49

Inflammatory proteinaceous fluid describes (transudative/exudative) effusions

Answer 49

Inflammatory proteinaceous fluid describes exudative effusions

Question 50

Answer 50

Right sided effusion

Question 51

Answer 51

Pleural effusion

Question 52

Transudative thoracentesis fluid should appear _

Answer 52

Transudative thoracentesis fluid should appear clear, straw colored, non-viscid, odorless

Question 53

Blood thoracentesis may indicate _

Answer 53

Blood thoracentesis may indicate cancer, pulmonary infarction, trauma, recent surgery

Question 54

A true hemothorax is indicated when pleural fluid hematocrit/ Blood hematocrit > _

Answer 54

A true hemothorax is indicated when pleural fluid hematocrit/ Blood hematocrit > 50%

Question 55

Turbid or milky thoracentesis fluid may indicate _

Answer 55

Turbid or milky thoracentesis fluid may indicate a chylothorax (thoracic duct injury)

Question 56

Light’s criteria

Answer 56

Question 57

High neutrophils in the pleural fluid may indicate _

Answer 57

High neutrophils in the pleural fluid may indicate acute inflammatory process

Question 58

High lymphocytes in the pleural fluid may indicate _

Answer 58

High lymphocytes in the pleural fluid may indicate malignancy or TB (if > 50%)

Question 59

High LDH may be indicative of _

Answer 59

High LDH may be indicative of malignancy, parapneumonic effusion

Question 60

Answer 60

R sided pneumothorax

Question 61

Answer 61

Pneumothorax