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Pulmonology Board Review > Pleural Disease > Flashcards

Pleural Disease Flashcards

1
Q

Amount of pleural fluid in the pleural space normally

A

0.3 ml/kg

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2
Q

Location of lymphatics that drain the pleural space

A

Parietal pleura

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3
Q

Pleural filtration based on location of lung

A

Filtration decreases from apex to base

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4
Q

Flow of pleural fluid

A

Costal to mediastinal region along diaphragm and mediastinal surfaces

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5
Q

Pleural pressure at FRC

A

-3 to -5 cmH2O

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6
Q

Effects of air, time, and lidocaine on pleural fluid pH

A

Air and time in syringe will increase pH

Lidocaine will decrease pH

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7
Q

pleural fluid pH that is predictive of poor outcomes and failed pleurodesis in malignancy

A

< 7.30

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8
Q

Light’s criteria

A

Pleural/serum ratios

Protein > 0.5

LDH > 0.6

LDH > 2/3 upper limit of serum LDH

Any 1 positive means exudate

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9
Q

Reason for falsely classifying a transudate as an exudate via light’s criteria

A

Diuretic use (25% of cases)

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10
Q

Pleural fluid cholesterol threshold for exudate classification

A

> 55 mg/dl

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11
Q

Pleural protein gradient for classification of transudate or exudate

A

Serum to pleural gradient

> 3.1 is transudate

< 3.1 is exudate

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12
Q

Serum to pleural albumin gradient predictive of transudate

A

> 1.2 gm/dl

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13
Q

Serum or pleural NT pro BNP suggestive of transudate

A

> 1300 pg/ml

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14
Q

6 causes of common transudative effusions

A
  1. Congestive heart failure
  2. Hepatic hydrothorax
  3. Nephrotic syndrome
  4. Urinothorax
  5. Peritoneal dialysis
  6. Trapped lung
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15
Q

9 common causes of exudative effusions

A
  1. Benign asbestos effusion
  2. Chylothorax
  3. GI Disease
  4. Neoplastic
  5. Parapneumonic effusion
  6. PE after CABG
  7. TB
  8. Systemic diseases
  9. Vascular effusions
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16
Q

Percentage of hepatic hydrothorax where there is no ascites found

A

20%

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17
Q

Criteria for spontaneous infection of hepatic hydrothorax

A
  • Pleural fluid neutrophils > 250 and a positive culture

OR

  • Pleural fluid neutrophils > 500 with negative culture
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18
Q

3 diagnostic criteria for Urinothorax

A
  1. Low pH
  2. Low glucose
  3. Pleural fluid creatinine > serum creatinine

OR

  • Renal scintigraphy showing tracer going from urinary tract to pleural space
19
Q

3 most common malignancies for pleural effusion

A

Lung, breast, and lymphoma

20
Q

Lymphocyte count/neutrophil ratio for TB pleural effusion

A

> 0.75

AND

> 60% lymphocytes

OR

Adenosine deaminase positivity

21
Q

Triglyceride threshold for chylothorax

A

> 110 (Check chylomicrons)

22
Q

Exudative effusion associated with benign ovarian tumor

A

Meig’s syndrome

23
Q

Bleeding risk and thoracentesis guidelines based off 2013 and 2014 studies

A

Safe to do with INR > 1.5 or platelets <50,000

Can also do safely on heparin, coumadin, plavix, or DOACs

24
Q

Difference between lung entrapment and trapped lung

A
  • Lung entrapment
    • Inability of lung to re-expand
      • Thick visceral pleura, endobronchial obstruction, etc.
  • Trapped lung
    • Prior pleural inflammation and scarring
25
Q

Threshold for which reexpansion pulmonary edema is unlikely to develop if pleural pressure stays above

A

-20 cm H20

26
Q

3 classifications of parapneumonic effusion

A
  • Uncomplicated
    • Resolves with antibiotics alone
  • Complicated
    • Requires chest tube or surgery
  • Empyema
    • Presence of pus or bacteria (has to be drained)
27
Q

How many cultures of pleural infections grow no organisms

A

40%

28
Q

6 predictors of complicated effusion or empyema

A
  1. Albumin < 30
  2. Alcohol abuse
  3. CRP > 100
  4. IV drug use
  5. Platelets > 400K
  6. Sodium < 130
29
Q

3 ACCP & BTS indications for complicated effusion drainage

A
  1. Pleural fluid pH < 7.20
  2. Pleural glucose < 60 (< 40 in BTS)
  3. Pleural fluid > 1000 (only in BTS)
30
Q

RAPID clinical risk score for pleural effusions

A
  • Urea
    • <5 = 0
    • 5-8 = 1
    • > 8 = 2
  • Age
    • < 50 = 0
    • 50-70 = 1
    • > 70 = 2
  • Purulence
    • Present = 0
    • Not present = 1
  • Infection source
    • Community = 0
    • Hospital = 1
  • Dietary factors
    • Albumin > 27 = 0
    • Albumin < 27 = 1
31
Q

Low, medium, and high risk RAPID scores in pleural effusions and associated mortality

A
  • Low
    • Score 0-2
    • 1-3% risk at 3 months
  • Medium
    • Score 3-4
    • 9-12% risk at 3 months
  • High
    • Score 5-7
    • 31-51% risk at 3 months
32
Q

Trial that showed 14 french chest tube was better than surgical chest tube for effusions

A

MIST1

33
Q

Trial that showed TPA and DNase improved radiographic outcomes, lowered surgical referrals, and lowered mean hospital stay by 1 week

A

MIST2

34
Q

radiographic cut off for small to large pneumothorax

A

Small = < 3 cm apex-cupola distance

35
Q

Recommendations for management in small primary pneumothorax

A
  • Observe in ED for 3-6 hours
  • Can DC home if repeat CXR shows no progression
  • Follow up in 12-48 hours with repeat CXR
36
Q

Recommendation for CT imaging in first primary spontaneous pneumothorax

A

Do not order

37
Q

Surgical treatment for patients with pneumothorax and apical bullae

A

Staple bullectomy

38
Q

Prevention of pneumothorax recurrence in secondary pneumothorax

A

Medical or surgical thorascopy with or without staple bullectomy

39
Q

Diagnosis suggested by catamenial pneumothorax, chest pain, or hemothorax

A

Thoracic endometriosis

(May not have pelvic disease)

40
Q

Pleurodesis agent associated with ARDS

A

Doxycycline

41
Q

What frequency to drain IPC for malignant effusion to achieve pleurodesis

A

daily

(ASAP trial showed better than EOD)

42
Q

4 types of pleural reactions to asbestos

A
  1. Benign asbestos related pleural effusion
  2. Pleural plaques
  3. Diffuse pleural fibrosis
  4. Rounded atelectasis
43
Q

4 histologic subtypes of mesothelioma

A
  1. Epithelioid
  2. Sarcomatoid (Spindle cells)
  3. Desmoplastic (Patternless pattern)
  4. Biphasic (epithelioid and sarcomatoid combined)

Pulmonology Board Review (32 decks)

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