Pleural Diseases

Question 1

Define, in general, pleural disease.

Answer 1

Any conditions affecting the pleura/ pleural cavity.

Question 2

What are the layers of the pleura?

Answer 2

Question 3

What are 3 examples of pleural diseases?

Answer 3

Pleural Effusion
Pleural Malignancy
Pneumothorax

Question 4

Define a pleural effusion. Classify and list the causes of a pleural effusion

Answer 4

Accumulation of fluid in the pleural space

Causes:
Transudative: Increased hydrostatic pressure
Hypoalbuminemia: Cirrhosis, nephrotic syndrome
Cardiac: Congestive HF, Constrictive pericarditis
Iatrogenic: Fluid overload + TACO
Other: CKD

Exudative: Increased oncotic pressure
Infective: Tb, fungal, !parapneumonic, empyema)
Malignancy
Pancreatitis
Post-op (e.g. CABG)

Question 5

List 2 most common types of pleural malignancies.

Answer 5

Mesothelioma, metastasis

Question 6

Define a pneumothorax. Classify and list the possible causes.

Answer 6

the also classified as simple or tension

Question 7

fluid in the pleural space is considered to be pleural effusion if how many mls are present?

At what volume would symptoms most likely begin to be present?

Answer 7

25ml to be considered pleural effusion

300mls for sc

Question 8

What are the common symptoms of pleural diseases?

Answer 8

Question 9

What are ALL your exam findings for pleural disease?

Answer 9

Question 10

Is asymmetric chest expansion a common findings in significant pleural disease?

Answer 10

Yes

Question 11

What are your diagnostic investigations for pleural diseases? what are your expected findings?

Answer 11

Question 12

How would you grade a pneumothorax?

Answer 12

Question 13

What are the non-diagnostic investigations to support your dx of a pleural disease? Justify each.

Answer 13

Question 14

Describe this image.

Answer 14

right sided pneumothorax

Question 15

This is the CXR of the a patient with a pneumothorax. A was taken first and then B, both on the same day. What is a possible reason for the pneumothorax appearing different in image B?

Answer 15

Inspiration and expiration CXR in a case of right sided spontaneous pneumothorax. Note that the extension of pneumothorax is larger during expiration than inspiration and the expansion of the affected hemi-lung is more evident in the affected side.

Question 16

In total, what respiratory diseases cause clubbing?

Answer 16

Bronchiectasis/CF
IPF/pulmonary fibrosis (not neuromuscular ones)
Pleural diseases (Malignancy)
Empyema/Lung abcess (if long enough)

Question 17

While asterixes are typically due to CO2 retention, what does clubbing indicate?

Answer 17

chronic hypoxia

Question 18

What are the main causes of clubbing secondary to chronic hypoxia and not due to that?

Answer 18

Pulmonary Causes: (Most Common)
Lung cancer (especially non-small cell lung cancer)
Chronic lung infections (e.g., tuberculosis, lung abscess, bronchiectasis)
Interstitial lung disease (e.g., idiopathic pulmonary fibrosis)
Cystic fibrosis
Pulmonary AV malformations

Cardiac Causes:
Cyanotic congenital heart diseases (e.g., Tetralogy of Fallot, Eisenmenger syndrome)
Infective endocarditis (especially with right-to-left shunts)

Other Less Common Causes:
Liver cirrhosis (especially in biliary cirrhosis)
Inflammatory bowel disease (IBD) (e.g., Crohn’s disease, ulcerative colitis)

Question 19

You are performing a chest drain or needle thoracocentesis on a patient with massive pleural effusions. You note blood in the fluid escaping the thorax. What are the 3 most likely differentials?

Answer 19

PE
Malignancy
Trauma

Question 20

When you obtain pleural fluid, or any fluid in that case, What do you send it for?

Answer 20

Cytology/Microscopy (malignancy? Exudate)
Gram stain
Culture and sensitivity (infective? Exudate)
+ in pleural diseases: LDH and protein to compare to levels in the serum

Question 21

You perform a chest drain and send the fluid to microbiology for gram staining, culture, sensitivity and pathology for cytology and microscopy. The report from microbiology comes back noting a high level or neutrophils in the pleural fluid.

What are your top 3 differentials?

For these 3 differentials state if they are transudative or exudative

What if your found lymphocytes?

Answer 21

3 Ps:
Pneumonia (exudative)
Pulmonary embolus
Pancreatitis (extends into the pleural space)

Lymphocytes in the context of pleural fluid means a chronic process is there => every other diagnosis

Question 22

What is used to determine if pleural fluid is transudative or exudative?

Answer 22

Light’s criteria

Question 23

What is Light’s criteria?
What labs will you order for this?

Go through it

Answer 23

Set of guidelines used to distinguish between transudative and exudative pleural effusions.

It requires Serum protein and LDH + Pleural fluid protein and LDH

If one or more of the following are true then it is likely exudative:

1) PF protein/serum protein >0.5
2) PF LDH/Serum LDH >0.6
3) PF LDH >2/3 upper normal limit of Serum LDH

Question 24

What can cause both pleural and pericardial effusions? (2)

Answer 24

Tb
Constrictive pericarditis

Question 25

Is Tb transudative or exudative?

Answer 25

Exudative

Question 26

What is a parapneumonic pleural effusion?

Answer 26

Parapneumonic refers to any pleural effusion caused by pneumonia

Question 27

Is malignancy transudative or exudative?

Answer 27

Exudative

Question 28

A patient post op develops reduced breath sounds and bronchial breathing over their left lung. You ask the patient and they say it was a heart procedure. The patient is unstable. What procedure is the most likely one? What has occurred? Is it transudative or exudative

Answer 28

Post- CABG pleural effusion Exudative

Question 29

Is a PE transudative or exudative?

Answer 29

Can be either but mostly exudative due to the inflammation that ensues Remember anything causing inflammation or infection is exudative

Question 30

What are your differentials for a transudative pleural effusion vs exudative?

Answer 30

Transudative: Hypoalbuminemia: Cirrhosis, nephrotic syndrome Congestive HF Constrictive pericarditis SVC obstruction Exudative: Infective: Tb, fungal, !parapneumonic, empyema) Malignancy PE Pneumonia Pancreatitis Post-op (e.g. CABG)

Question 31

You notice this on the ward. What do you think this is? or at least what is it used for?

Answer 31

It is a PleurX catheter used to drain pleural or ascitic fluid from the pleural or peritoneal spaces. The bottle is iconic

Question 32

Pleurodesis is performed for a variety of reasons. Only tell me how it works (not full details)

Answer 32

It causes inflammation to allow the visceral and parietal pleura to stick together (adhesion)

Question 33

Malignancies typically cause exudative pleural effusions. There is, however, one exception. What is it?

Answer 33

Any cancer causing SVC obstruction => some lung cancers, oesophageal...

Question 34

"grading of pneumothorax" is based on size and clinical compromise. How do you assess the size of a pneumothorax? What size is considered small? Large?

Answer 34

Between lung margin and chest wall Small <2cm Large >2cm

Question 35

Outline the management of a pneumothorax.

Answer 35

Question 36

What is the treatment of a pleural effusion caused by 1) empyema 2) malignancy

Answer 36

Question 37

What are the complications of pleural diseases?

Answer 37

Question 38

Where is a chest drain inserted? Include the boundaries of the safety triangle.

Answer 38

4-5th ICS midaxillary line from above the rib (to avoid neurovascular bundle) Boundaries: Lateral border of Pec Major (Follow axillary fold Anterior border of Latissimus dorsi 5th ICS

Question 39

Where should the contents from a chest drain empty into? Explain the system briefly

Answer 39

Underwater seal used for one way flow of both fluid and air - Ventilation to prevent air ingress. This system is attached to wall suction.

Question 40

After performing a chest drain, how will you confirm it is properly performed?

Answer 40

Assessment involves checking for: 1) Oscillation -> Moving with breath (if not, blocked or dislodged) 2) Bubbling if pneumothorax 3) Repeat CXR shows improvement + clinical improvement

Question 41

After performing a chest drain for a patient with a pneumothorax, you assess to ensure it has been done correctly. you notie the oscillations moving with the breath and bubbling. After a few hours, the clinical status of the patient is improved. You perform a repeat X-ray to confirm this and see that it is now resolved. You look back at the underwater seal and its actually still bubbling. 24 hours pass and it is still bubbling. Whats going on? How will you manage?

Answer 41

If still bubblin but CXR shows that it has resolved, this suggests a persistent leak => Pleurodesis (VATS)

Question 42

What is this device?

Answer 42

CHEST DRAIN