Chapter 288 - Disorders of the Pleura

Question 1

Plural fluid enters the pleural space from?

Answer 1

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

Question 2

2 mechanism by which pleural effusion may develop

Answer 2

1. excess pleural fluid formation

2. decreased removal by the lymphatics

Question 3

Diagnostic gold standard in detecting pleural effusion

Answer 3

Ultrasound of the hemithorax

Question 4

Enumerate the Light’s criteria

Answer 4

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

Question 5

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

Answer 5

25%

Question 6

When can exudative categorization be ignored?

Answer 6

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

Question 7

The most common cause of pleural effusion

Answer 7

Left ventricular failure

Question 8

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

Answer 8

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

Question 9

What is virtually diagnostic of an effusion secondary to CHF?

Answer 9

[pleural fluid NT proBNP >1500 pg/mL

Question 10

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

Answer 10

5%

Question 11

Describe the pleural effusion in patients with hepatic hydrothorax

Answer 11

usually right sided

large enough to produce severe dyspnea

Question 12

Most common cause of exudative pleural effusion in the US

Answer 12

Parapneumonic effusion

Question 13

Refers to grossly purulent effusion

Answer 13

empyema

Question 14

Differentiate bacterial pleural effusions caused by aerobic vs anaerobic bacteria.

Answer 14

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

Question 15

When is a therapeutic thoracentesis performed in parapneumonic effusion?

Answer 15

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

Question 16

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

Answer 16

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

Question 17

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

Answer 17

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

Question 18

Considerations of pleural fluid glucose <60

Answer 18

Malignancy
Bacterial Infections
Rheumatoid pleuritis

Question 19

Second most common type of pleural effusion

Answer 19

Effusion secondary to metastatic disease

Question 20

tumors causing malignant pleural effusion (occurs in 75%)

Answer 20

Lung
Breast
Lymphoma

Question 21

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

Answer 21

Thoracoscopy

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

Question 22

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

Answer 22

1. insertion of a small indwelling catheter or

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

Question 23

Mesothelioma is associated with exposure to which chemical?

Answer 23

asbestos

Question 24

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

Answer 24

pulmonary embolism

Question 25

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

Answer 25

TB effusion

Question 26

Pathophysiology of TB effusion

Answer 26

hypersensitivity reaction to tuberculous protein in the pleural space

Question 27

markers of TB effusion

Answer 27

PF ADA >40 IU/L | PF IFN gamma >140 pg/ml

Question 28

Percentage of undiagnosed exudative pleural effusion and likely cause

Answer 28

20% probably viral infections

Question 29

most common cause of chylothorax

Answer 29

trauma (most frequently thoracic surgery)

Question 30

Findings in the pleural fluid of chylothorax

Answer 30

milky fluid | triglyceride level >1.2 mmol/L or 110 mg/dL

Question 31

Diagnostic evaluation of patients with chylothorax with no obvious trauma

Answer 31

lymphangiogram | mediastinal CT scan

Question 32

Treatment of Choice for chylothorax

Answer 32

1. CTT with octreotide | 2. if fails, percutaneous transabdominal thoracic duct blockage

Question 33

Complications of patients with chylothorax on prolonged tube thoracostomy

Answer 33

Malnutrition | Immunologic incompetence

Question 34

Diagnosis of hemothorax

Answer 34

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

Question 35

Treatment of hemothorax

Answer 35

CTT - allows continuous quantification of bleeding

Question 36

When is angiographic coil embolization indicated?

Answer 36

pleural hemorrhage exceeding 200ml/h

Question 37

Diagnosis of an elevated pleural fluid amylase

Answer 37

Esophageal rupture | pancreatic disease

Question 38

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

Answer 38

intraabdominal abscess

Question 39

Characteristics of Pleural effusion after CABG

Answer 39

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.

Question 40

Seven causes of a transudative pleural effusion

Answer 40

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

Question 41

Drug induced pleural disease

Answer 41

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

Question 42

Pneumonthorax occurring without antecedent trauma

Answer 42

Spontaneous

Question 43

Pneumothorax occurring in the absence of underlying lung disease

Answer 43

Primary

Question 44

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

Answer 44

Tension

Question 45

Most common cause of primary spontaneous pneumothorax

Answer 45

rupture of apical pleural blebs

Question 46

Primary spontaneous pneumothorax occurs almost exclusively among ____

Answer 46

smokers

Question 47

Percent of patients with an initial primary pneumothorax having recurrence

Answer 47

approx 50%

Question 48

initial recommend treatment for primary spontaneous pneumothorax

Answer 48

simple aspiration

Question 49

Indications of doing thoracoscopy with stapling of blebs and pleural abrasion

Answer 49

1. lung does not expand after aspiration | 2. recurrent pneumothorax

Question 50

Most common cause of secondary pneumothorax

Answer 50

COPD

Question 51

Treatment of patients with secondary pneumothorax

Answer 51

CTT

Question 52

intervention for hemopneumothorax

Answer 52

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

Question 53

Leading causes of iatrogenic pneumothorax

Answer 53

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

Question 54

Pathophysiology why tension pneumothorax is life threatening

Answer 54

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

Question 55

Interventions for Tension pneuothorax

Answer 55

1. needling in the second anterior ICS | 2. CTT