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PULMONOLOGY > Chapter 288 - Disorders of the Pleura > Flashcards

Chapter 288 - Disorders of the Pleura Flashcards

1
Q

Plural fluid enters the pleural space from?

A
  1. Capillaries in the parietal pleura
  2. Interstitial spaces of the lung
  3. Peritoneal cavity via small holes in the diaphragm
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2
Q

2 mechanism by which pleural effusion may develop

A
  1. excess pleural fluid formation

2. decreased removal by the lymphatics

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3
Q

Diagnostic gold standard in detecting pleural effusion

A

Ultrasound of the hemithorax

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4
Q

Enumerate the Light’s criteria

A
  1. Pleural fluid protein/serum protein >0.5
  2. Pleural fluid LDH/serum LDH >0.6
  3. Pleural fluid LDH more than two-thirds the normal upper limit for
    serum
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5
Q

Light’s criteria can misidentify transudates as exudates by how many percent?

A

25%

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6
Q

When can exudative categorization be ignored?

A

When patient iOS clinically thought to have a transudative effusion, and the serum-PF protein gradient in >3.1 g/dL

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7
Q

The most common cause of pleural effusion

A

Left ventricular failure

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8
Q

In patients with heart failure , what are the instances when diagnostic thoracentesis is performed?

A
  1. febrile
  2. pleuritic chest pain
  3. effusions are not bilateral and comparable in size
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9
Q

What is virtually diagnostic of an effusion secondary to CHF?

A

[pleural fluid NT proBNP >1500 pg/mL

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10
Q

How many percent of patients with cirrhosis and ascites develop pleural effusions?

A

5%

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11
Q

Describe the pleural effusion in patients with hepatic hydrothorax

A

usually right sided

large enough to produce severe dyspnea

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12
Q

Most common cause of exudative pleural effusion in the US

A

Parapneumonic effusion

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13
Q

Refers to grossly purulent effusion

A

empyema

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14
Q

Differentiate bacterial pleural effusions caused by aerobic vs anaerobic bacteria.

A

aerobic: acute febrile illness with chest pain, sputum production, leukocytosis
anaerobic: subacute illness w/ weight loss, brisk leukocytosis, mild anemia, hx of aspiration

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15
Q

When is a therapeutic thoracentesis performed in parapneumonic effusion?

A

when free fluid separates the lung from the chest wall by >10 mm

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16
Q

Factors indicating the likely need for a procedure more invasive than a tho- racentesis (in increasing order of importance)

A
  1. Loculated pleural fluid
  2. Pleural fluid pH <7.20
  3. Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
  4. Positive Gram stain or culture of the pleural fluid
  5. Presence of gross pus in the pleural space
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17
Q

If the fluid recurs after the initial therapeutic thoracentesis, what is done first?

A
  1. Repeat thoracentesis
  2. CTT and tPA 10mg + deoxyribonuclease 5mg if still cannot be completely removed
  3. Decortication
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18
Q

Considerations of pleural fluid glucose <60

A

Malignancy
Bacterial Infections
Rheumatoid pleuritis

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19
Q

Second most common type of pleural effusion

A

Effusion secondary to metastatic disease

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20
Q

tumors causing malignant pleural effusion (occurs in 75%)

A

Lung
Breast
Lymphoma

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21
Q

If malignant is suspected and initial cytology is negative, what is the next best step?

A

Thoracoscopy

alternative: CT- or ultrasound-guided needle biopsy of pleural thickening or nodules

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22
Q

If the patient’s lifestyle is compromised by dyspnea and if the dyspnea is relieved with a therapeutic thoracentesis, what interventions are considered?

A
  1. insertion of a small indwelling catheter or

2) tube thoracostomy with the instillation of a sclerosing agent such as doxycycline (500mg).

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23
Q

Mesothelioma is associated with exposure to which chemical?

A

asbestos

24
Q

Diagnosis most commonly overlooked in the differential diagnosis of a patient with undiagnosed pleural effusion

A

pulmonary embolism

25
Q

Most common cause of exudative pleural effusion in many parts of the world

A

TB effusion

26
Q

Pathophysiology of TB effusion

A

hypersensitivity reaction to tuberculous protein in the pleural space

27
Q

markers of TB effusion

A

PF ADA >40 IU/L

PF IFN gamma >140 pg/ml

28
Q

Percentage of undiagnosed exudative pleural effusion and likely cause

A

20%

probably viral infections

29
Q

most common cause of chylothorax

A

trauma (most frequently thoracic surgery)

30
Q

Findings in the pleural fluid of chylothorax

A

milky fluid

triglyceride level >1.2 mmol/L or 110 mg/dL

31
Q

Diagnostic evaluation of patients with chylothorax with no obvious trauma

A

lymphangiogram

mediastinal CT scan

32
Q

Treatment of Choice for chylothorax

A
  1. CTT with octreotide

2. if fails, percutaneous transabdominal thoracic duct blockage

33
Q

Complications of patients with chylothorax on prolonged tube thoracostomy

A

Malnutrition

Immunologic incompetence

34
Q

Diagnosis of hemothorax

A

PF hematocrit more than one half of that in the peripheral blood

35
Q

Treatment of hemothorax

A

CTT - allows continuous quantification of bleeding

36
Q

When is angiographic coil embolization indicated?

A

pleural hemorrhage exceeding 200ml/h

37
Q

Diagnosis of an elevated pleural fluid amylase

A

Esophageal rupture

pancreatic disease

38
Q

Diagnosis of a febrile patient, has predominantly polymorphonuclear cells in the pleural fluid, and has no pulmonary parenchymal abnormalities

A

intraabdominal abscess

39
Q

Characteristics of Pleural effusion after CABG

A

first week: left-sided and bloody, with large numbers of eosinophils, and respond to one or two therapeutic thoracenteses.

after first week: left-sided and clear yellow, with predominantly small lymphocytes, and tend to recur.

40
Q

Seven causes of a transudative pleural effusion

A
  1. Congestive heart failure
  2. Cirrhosis
  3. Nephrotic syndrome
  4. Peritoneal dialysis
  5. SVC obstruction
  6. Myxedema
  7. Urinothorax
41
Q

Drug induced pleural disease

A

a. Nitrofurantoin
b. Dantrolene
c. Methysergide
d. Bromocriptine
e. Procarbazine
f. Amiodarone
g. Dasatinib

42
Q

Pneumonthorax occurring without antecedent trauma

A

Spontaneous

43
Q

Pneumothorax occurring in the absence of underlying lung disease

A

Primary

44
Q

pneumothorax in which the pressure in the pleural space is positive throughout the respiratory cycle.

A

Tension

45
Q

Most common cause of primary spontaneous pneumothorax

A

rupture of apical pleural blebs

46
Q

Primary spontaneous pneumothorax occurs almost exclusively among ____

A

smokers

47
Q

Percent of patients with an initial primary pneumothorax having recurrence

A

approx 50%

48
Q

initial recommend treatment for primary spontaneous pneumothorax

A

simple aspiration

49
Q

Indications of doing thoracoscopy with stapling of blebs and pleural abrasion

A
  1. lung does not expand after aspiration

2. recurrent pneumothorax

50
Q

Most common cause of secondary pneumothorax

A

COPD

51
Q

Treatment of patients with secondary pneumothorax

A

CTT

52
Q

intervention for hemopneumothorax

A

one chest tube placed in the superior part of the hemithorax to evacuate the air and another in the inferior part to remove the blood

53
Q

Leading causes of iatrogenic pneumothorax

A
  1. transthoracic needle aspiration
  2. thoracentesis
  3. insertion of central intravenous catheters
54
Q

Pathophysiology why tension pneumothorax is life threatening

A

positive pressure transmitted to the mediastinum –> decreased venous return –> reduced cardiac output

55
Q

Interventions for Tension pneuothorax

A
  1. needling in the second anterior ICS

2. CTT

PULMONOLOGY (10 decks)

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