Pleural Disease

Question 1

What type of cell make up the pleural membranes

Answer 1

• single layer of mesothelial cells

- sub-pleural connective tissue

Question 2

How is the pleural fluid maintained in the pleural space

Answer 2

inward pulmonary/systemic arterial pressure is greater than outward oncotic pressure

Question 3

What is a pleural effusion

Answer 3

abnormal collection of fluid in the pleural cavity

Question 4

What are the symptoms of pleural effusion

Answer 4

• asymptomatic in small amounts
• increasing breathlessness
• pleuritic pain
• dry cough
• weight loss/malaise/night sweats

Question 5

What are the clinical signs of pleural effusion

Answer 5

• decreased chest expansion/breath sounds/vocal resonance
• stony dullness on percussion
• clubbing/cervical nodes/tracheal movement/peripheral oedema

Question 6

What are transudates in pleural effusion

Answer 6

• imbalance of hydrostatic forces influencing the formation/absorption of pleural fluid
• bilateral

Question 7

What are exudates in pleural effusion

Answer 7

• increased permeability of pleural surface and local capillaries
• unilateral

Question 8

What is the pleural fluid protein content of transudates

Answer 8

less than 30g/L

Question 9

What are the causes of transudates

Answer 9

• left ventricular failure (increased pressure, pushing fluid out)
• liver scarring
• hypoalbuminaemia
• hypothyroidism
• PE
• mitral stenosis

Question 10

What is the pleural fluid protein content of exudates

Answer 10

greater than 30g/L

Question 11

What are the causes of exudates

Answer 11

• malignancy (lung/breast/metastatic)
• pneumonia
• PE
• rheumatoid arthritis
• autoimmune disease
• pancreatitis
• drugs

Question 12

When should transudates be investigated

Answer 12

• unusual features

- treatment failure

Question 13

What are the two main investigations used to diagnose pleural effusion

Answer 13

• CXR
• contrast enhanced CT (to differentiate between benign and malignant disease)
• pleural aspiration and biopsy

Question 14

Name some complications arising form a pleural aspiration and biopsy

Answer 14

• pneumothorax
• pulmonary oedema
• air embolism
• haemothorax

Question 15

What investigations should be carried out on the aspirated material

Answer 15

• look and sniff
• blood gas analysis
• biochemistry
• microbiology (suspected TB/infection)
• cytology (for malignancy)

Question 16

What investigation must be carried out if pleural effusion still cannot be diagnosed

Answer 16

thorascopy

Question 17

How is pleural effusion managed

Answer 17

• treat underlying cause
• give palliative treatment in malignancy
• pleurodhesis

Question 18

What is pleurodhesis

Answer 18

removal of the pleural cavity by surgical/chemical meands

Question 19

What is the procedure of pleurodhesis

Answer 19

chest tube in 4th intercostal space, midaxillary line

Question 20

What is pneumothorax

Answer 20

• presence of air in the pleural cavity leading to lung collapse

Question 21

What are the two main divisions of pneumothorax

Answer 21

• spontaneous primary/secondary

- traumatic (iatrogenic/non-iatrogenic)

Question 22

What is the cause of primary spontaneous pneumothorax

Answer 22

the weight of the lung inducing development of blebs that may spontaneously rupture

Question 23

What is the cause of secondary spontaneous pneumothorax

Answer 23

any underlying lung disease

Question 24

What is the cause of non-iatrogenic pneumothorax

Answer 24

• any penetrating/blunt lung injury

Question 25

What is the cause of iatrogenic pneumothorax

Answer 25

• pleural aspiration and biopsy
• subclavian vein cannulation
• lung/liver/breast biopsy

Question 26

What are the symptoms of pneumothorax

Answer 26

• asymptomatic if small breach
• acute, worsening breathlessness
• pleuritic pain

Question 27

What are the clinical signs of non-tension pneumothorax

Answer 27

• surgical emphysema (bubble wrap)
• tracheal deviation
• decreased chest expansion/breath sounds
• hyper resonance on percussion

Question 28

What are the additional clinical signs of tension pnemothorax

Answer 28

increased jugular venous pressure

Question 29

What is a tension pneumothorax

Answer 29

the breach is in the form of a flap, which forms a one way valve, allowing air into the pleural space but not back again

causes the lung to become smaller and smaller, and the pneumothorax to become larger and larger

Question 30

How can tension pneumothorax be managed

Answer 30

cannula in second intercostal space, midclavicular line followed by insertion of intercostal chest drain

Question 31

How is primary pneumothorax, no SOB managed

Answer 31

• overnight
• CXR
• dishcharge

Question 32

How is primary pneumothorax, SOB managed

Answer 32

intercostal chest drain, midaxillary line

Question 33

What is asbestos

Answer 33

a highly fibrous naturally occurring material historically used in the building industry due to its commercially profitable properties that has been shown to give rise to mesothelioma

Question 34

What is mesothelioma

Answer 34

pleural malignancy caused by exposure to aspestos, usually presenting up to 40 years after first exposure

Question 35

What is the clinical presentation or mesothelioma

Answer 35

• breathlessness

- chest wall pain

Question 36

What is the radiological presentation of mesothelioma

Answer 36

• unilateral

- diffuse/localised pleural thickening