Pleural and Chest Wall Disorders

Question 1

Inflammation of the pleura causes loss of lubricant between them,
inspiration causes the friction rub when the pleura rub together

Answer 1

Pleuritis

Question 2

What are some signs/symptoms of pleuritis?

Answer 2

Pain is localized, sharp, fleeting and made worse by coughing, sneezing, deep breath, or movement

Sharp pain like stabbing sensation – patient will be able to point out
exactly where it is felt

May hear a friction rub on inspiration

Question 3

What is contraindicationed in a rib fracture?

Answer 3

Constrictive brace is contraindicated

Question 4

Abnormal accumulation of fluid in pleural space

Answer 4

Pleural Effusion

Question 5

What are the two categories of pleural effusions?

Answer 5

transudative and exudative

Question 6

The most common cause of pleural effusion is what?

Answer 6

congestive heart failure

Question 7

What is the pathophysiology of pleural effusions?

Answer 7

Fluid enters the space through capillaries and exits through lymphatics in the visceral and parietal pleura

Pleural effusions occur when there is an excess formation of pleural fluid, decreased fluid removal, or both

Question 8

What is the difference between transudative and exudative pleural effusions?

Answer 8

Exudative: Increased production of fluid due to abnormal capillary permeability or decreased lymphatic clearance (Capillaries are damaged)

Transudative: Increased production of fluid in the setting of normal capillaries

Question 9

What are the most common causes of exudative pleural effusions?

Answer 9

Bacterial pneumonia

Cancer (decreased lymphatic drainage)

Question 10

What are the subtypes of exudative pleural effusions?

Answer 10

Empyema
Hemothorax
Chylothorax

Question 11

infection in pleural space (abscess in the pleural space)

Answer 11

Empyema

Question 12

bleeding in pleural space (gross blood from trauma)

Answer 12

Hemothorax

Question 13

lymphatic fluid in pleural space (cholesterol complex accumulation, appears white)

Associated with lymphoma and thoracic surgery

Answer 13

Chylothorax

Question 14

Exudative pleural effusions criteria: one or more of the following

Note: transudates have NONE of these features

Answer 14

Pleural fluid protein to serum protein ratio >0.5

Pleural fluid LDH to serum LDH ratio >0.6 and pleural fluid LDH greater than two thirds the upper limit of normal serum LDH

LDH = lactose dehydrogenase

Question 15

Transudates differentiated from exudates by what criteria?

Answer 15

Light’s Criteria

Looks at LDH and protein (compare to serum)

Question 16

What are the most common causes of transudative pleural effusions?

Answer 16

Congestive heart failure – one of the most common causes
Hypoproteinemia (Nephrotic syndrome)
Cirrhosis
Pulmonary embolism

Question 17

What is the gold standard treatment for pleural effusions?

Answer 17

Thoracentesis

Question 18

If the protein is <3gm%, which type of pleural effusion do you have?

Answer 18

Transudate

Question 19

If the protein is >/= 3gm%, which type of pleural effusion do you have?

Answer 19

Exudate

Question 20

Which two types of cancer commonly have malignant pleural effusions?

Answer 20

Lung cancer
breast cancer

Question 21

Accumulation of air in the pleural space

Answer 21

Pneumothorax

Question 22

What are the types of pneumothorax?

Answer 22

Primary spontaneous pneumothorax
Secondary spontaneous pneumothorax
Tension pneumothorax

Question 23

Type of pneumothorax that occurs in the absence of underlying disease?

Answer 23

Primary spontaneous pneumothorax

Question 24

Type of pneumothorax that occurs in the presence of underlying disease?

Answer 24

Secondary spontaneous pneumothorax

Question 25

What is the most common disease that can result in a secondary spontaneous pneumothorax?

Answer 25

COPD

Question 26

What is the classic patient demographic that you may see a primary spontaneous pneumothorax?

Answer 26

tall, thin males men between the ages of 18-40 smoking increases risk 20x

Question 27

Positive pressure in the pleural space throughout the respiratory cycle

Answer 27

Tension pneumothorax

Question 28

Spontaneous Pneumothorax is common in patients with which disorder?

Answer 28

Marfan’s Syndrome

Question 29

If you have severe tachycardia, hypotension, and mediastinal or tracheal shift, which type of pneumothorax should you suspect?

Answer 29

tension pneumothorax

Question 30

What therapy may hasten the resolution of pneumothorax?

Answer 30

Oxygen

Question 31

What imaging is diagnostic? What is the exception?

Answer 31

CXR Exception: tension pneumothorax

Question 32

What are some complications of a pneumothorax?

Answer 32

Subcutaneous emphysema Pneumomediastinum death

Question 33

Tension pneumothorax will result in what?

Answer 33

acute respiratory failure and potentially death

Question 34

What are the two common etiologies of a tension pneumothorax?

Answer 34

Traumatic Barotrauma (i.e. mechanical ventilation)

Question 35

What is the most common cause of a tension pneumothorax?

Answer 35

trauma

Question 36

In a tension pneumothorax, you'd see a tracheal +/or mediastinal shift toward which side?

Answer 36

the unaffected side (contralateral hemithorax)

Question 37

If a tension pneumothorax is suspected, a large-bore needle should be inserted immediately in the affected side for decompression at which site?

Answer 37

second intercostal space in midclavicular line

Question 38

A primary tumor predominately of pleural surface lining, arising from the mesothelial cells that line the pleural cavities or peritoneum known as the only pleural cancer “pleural-based mass”

Answer 38

Mesothelioma

Question 39

Malignant pleural mesotheliomas are commonly associated with what exposure?

Answer 39

asbestos exposure

Question 40

In mesothelioma, what percentage of patients will you expect to see extra-thoracic spread?

Answer 40

>90% of patients

Question 41

In mesothelioma, what percentage of cases are diffuse (malignant) v localized (benign)?

Answer 41

75% are diffuse (malignant) 25% are localized (benign)

Question 42

What is the most common first sign of mesothelioma we’ll come across?

Answer 42

Pleural effusions

Question 43

In mesothelioma, what is the median survival rate in localized disease?

Answer 43

16 months in localized disease

Question 44

In mesothelioma, what is the median survival rate in extensive disease?

Answer 44

4 months in extensive disease

Question 45

What diagnosis should you consider if you see the following clinical presentation: Insidious onset of SOB Non-pleuritic chest pain Weight loss

Answer 45

mesothelioma