Pleural Effusion and Pneumothorax

Question 1

What does the visceral pleura cover?

Answer 1

surface of lungs and interlobar fissures

Question 2

What does the parietal pleura cover?

Answer 2

surface of chest wall
diaphragm
mediastinum

Question 3

How are the surfaces of the visceral and parietal pleura different?

Answer 3

visceral: the mesothelial cells are loosely arranged but have very tight junctions (bumpy) and they have very dense microvilli
parietal: the mesothelial cells are very tightly arranged but have leaky tight junctions with very sparse microvilli

Question 4

Describe are the components of the pleura?

Answer 4

mesothelial cells, BM, CT with blood vessels, lymphatics, and nerves

Question 5

Describe the normal pleural fluid.

Answer 5

Clear, odorless with mostly macrophages (some lymphocytes and few polys)
Its function is to lubricate the pleural surface

Question 6

What determines the amount of pleural fluid formed?

Answer 6

HP and OP balance
tissue pressure
lymphatic drainage

F = K (HPc-HPpl) - (OPc-OPpl)

Question 7

Describe how the normal movement of pleural fluid and (include how much in ml/hr)

Answer 7

HP in the parietal pleura > HP in visceral pleura
(HP systemic circulation > HP pulmonary circulation)

this HP gradient drives the movement of fluid from the parietal layer into the pleural space thru mesothelial junctions. The fluid is them absorbed by the visceral pleura
**the oncotic pressure of the parietal and the visceral pleura are = and therefore does not oppose the HP gradient

100 ml/hr fluid formed –> 300 ml/hr fluid absorbed

Question 8

Lymphatic drainage is present in (parietal or visceral pleura). * Why is this significant???

Answer 8

parietal
To transport cells and protein out of the parietal pleura to maintain low OP and maintain the balance so that fluid moves parietal –> space –> viceral ???? not sure she never really explained this, it is just my reasoning….

Question 9

What are the 2 types of pleural effusions?

Answer 9

exudates and transudates

high pro and low pro

Question 10

Increased HP will form (transudate or exudate)

Answer 10

trans

Question 11

decreased pleural pressure will form (transudate or exudate)

Answer 11

trans

Question 12

decreased oncotic pressure will form (transudate or exudate)

Answer 12

trans

Question 13

increased oncotic pressure will form (transudate or exudate)

Answer 13

exudate

Question 14

CHF will form (transudate or exudate). Why?

Answer 14

transudate bc the pulmonary artery HP > OP which causes the visceral pleura to shift from fluid absorption to fluid production

Question 15

What are addnl characteristics of pleural effusion due to CHF

Answer 15

bilateral + cardiomegaly

Question 16

How can malnutrition lead to a pleural effusion?

transudate or exudate

Answer 16

the decrease in plasma OP causes fluid to shift out of capillaries and into the pleural space from both the parietal and visceral sides
*transudate

Question 17

How can atelectasis cause pleural effusion?

transudate or exudate

Answer 17

the collapse makes the pleural pressure more negative –> causes the HP gradient to become > OP gradient –> fluid formation from both sides
*transudate

Question 18

How does inflammation cause pleural effusion?

transudate or exudate

Answer 18

inflammation increases vascular permeability –> leakage –> OP gradient decreases –> fluid moves into pleural space from both sides
*Exudate

Question 19

With a large pleural effusion:
RR (inc or dec)
Chest expansion (inc or dec)
fremitus (inc or dec)

Answer 19

RR increases
Chest expansion decreases
fremitus decreases

Question 20

What type of effusion will an increase in permeability lead to?

Answer 20

exudative

Question 21

Why are diminished or absent breath sounds a sign on pleural effusion?

Answer 21

the lung is farther ways from the chest wall

**i thought liquid transmitted sound waves better then air though..?

Question 22

What is the most common eitiology of pleural effusion?

Answer 22

CHF

Question 23

What is the most common noncardiac etiology of pleural effusion? 2nd most common?

Answer 23

1. neoplastic

2. infectous

Question 24

What types of neoplasms most commonly cause effusions? Why?

Answer 24

lung and breast

*close proximity to pleura

Question 25

What are the 2 forces that control the arrangement of free fluid in the pleural space?

Answer 25

1. gravity | 2. elastic recoil of lung (aka how much it relaxes during expiration)

Question 26

What is the first radiologic sign of pleural effusion? Later/when it gets bigger?

Answer 26

2. blunting of costophrenic angle | 2. meniscus sign

Question 27

What is the purpose of obtaining a lateral decubitus film?

Answer 27

once you suspect an effusion from an AP or PA CXR you can look at a lateral decubitus film to see if the fluid moves with gravity doue to the change in position = proves it is a fluid

Question 28

If you see evidence of an effusion + an infiltrate, you might suspect ...

Answer 28

parapneumonic effusion

Question 29

If you see evidence of an effusion + a mass or nodule, you might suspect ...

Answer 29

carconoma of the lung lymphoma mesothelioma metastatic carcinome

Question 30

If you see evidence of an effusion + a wedge shaped infarct, you might suspect ...

Answer 30

PE

Question 31

If you see evidence of an effusion + cardiomegaly, you might suspect ...

Answer 31

CHF

Question 32

If you see a pleural effusion without any other radiologic abnormalities what diseases might you suspect?

Answer 32

``` TB or viral pleurisy pancreatitis Lupus or RA PE Low albumin = Nephrotic syndrome or chirrosis ```

Question 33

What is the indication for performing a thoracentesis?

Answer 33

>10 mm on lateral decubitus XR

Question 34

What does a reddish tinged to bloody pleural fluid sample suggest?

Answer 34

if not traumatic tap.. - tumor - pulmonary infarction - trauma - post cardiac syndrome - asbestosis **due to RBCs in sample

Question 35

What does a turbid/cloudy pleural fluid sample suggest?

Answer 35

infection (including TB)

Question 36

What does a turbid/cloudy green pleural fluid sample suggest?

Answer 36

rheumatoid pleuritis

Question 37

What does a cloudy, milky white pleural fluid sample suggest?

Answer 37

Chylothorax | = disruption of thoracic duct from trauma or tumor

Question 38

What is an empyema?

Answer 38

puss is the pleural effusion

Question 39

What does a thick, bloody effusion sample suggest?

Answer 39

malignant mesothelioma

Question 40

What is a chylothorax

Answer 40

milky white pleural effusion = collection of lymphatic fluid *usually due to trauma to the thoracic duct

Question 41

What are lights criteria for distinguishing between transudate and exudate?

Answer 41

one ore more of the following: 1. Pleural/serum protein ratio: transudate: 0.5 2. 1. Pleural/serum LDH ratio: transudate: 0.6 1. Pleural LDH transudate: 200 U/L

Question 42

What are the most common causes of transudative pleural effusions?

Answer 42

CHF, Nephrotic syndroms, cirrhosis w/ ascites

Question 43

What are the most common causes of exudative pleural effusions?

Answer 43

parapneumonia effusion malignancy (bilateral) PE collagen vascular disease (lupus, RA, scleroderma) (bilateral) pancreatitis (usually left sided) TB postcardiac injury syndrome (=pericarditis, so inflammation just spills over?)

Question 44

WHat are common causes of BILATERAL Effusions

Answer 44

malignacy lupus, RA nephrotic syndrome, cirrhosis w/ascities esophageal rupture

Question 45

What does a lot of lymphocytes in an pleural effusion make you think?

Answer 45

exudate + chronic inflammation + TB, Malignancy, sarcoid, RA

Question 46

What does a lot of neutrophils in an pleural effusion make you think? What about >50K/microL of neutrophils?

Answer 46

exudate + acute inflammation + paraneumonic, pancreatitis, or pulmonary infarction paraneumonic

Question 47

What is the definitive diagnosis if you find ___ in the thoracentesis sample? - ADA - KOH - high triglycerides (>110) - high amylase and pH 6 - Hct PF/blood >/= 0.5

Answer 47

``` ADA = TB KOH = funcgus high triglycerides (>110) = chylothorax high amylase and pH 6 = esophageal rupture -Hct PF/blood >/= 0.5 = hemothorax ```

Question 48

What does >5% mesothial cells in thoracentesis sample mean?

Answer 48

it is NOT TB

Question 49

How do you identify wether or not the effusion sample is from a traumatic thoracentesis or is actually blood that has been there due to an underlying condition?

Answer 49

if the sample is allowed to sit and it clots within minutes, it is fresh blood = traumatic thoracentesis

Question 50

What does low glucose in pleural fluid sample suggest? (<60 mg/dl)

Answer 50

rheumatoid pleurisy (RA) due to dec transport of glc from blood to fluid epmyema or TB due to increased utilization/consumption of glc

Question 51

What is the mechanism of pleural fluid acidosis?

Answer 51

1. acid production by pleural fluid cells or bacteria 2. acid efflux from pleuritis or fibrosis (RA or malignancy) **think esophageal rupture, infection, RA

Question 52

What does a pleural fluid amylase/serum amylase >/= 1 suggest?

Answer 52

acute pancreatitis pancreatic pseudocyts **if amylase is salivary in origin = esophageal rupture

Question 53

How is an effusion due to a ruptured ectopic pregnancy unique?

Answer 53

pleural fluid amylase/serum amylase >/= 1 suggest

Question 54

T or F: a negative AFB rules out TB

Answer 54

false

Question 55

What is the pathophys of a pneumothorax?

Answer 55

pleural is breached --> air enters pleural space (Patm >Pps) --> lung collapses inward towards mediastinum

Question 56

What is the difference between primary and secondary pneumothorax?

Answer 56

``` primary = NO clinical lung disease present secondary = underlying clinical lung disease ```

Question 57

What is thge classic clinical presentation of a primary spontaneous phneumothorax?

Answer 57

young, previously healthy make with acute onset of pleuritic chest pain and dyspnea

Question 58

WHat are the possible mechanisms for a primary spontaneous pneumothorax?

Answer 58

1. visceral pleural bleb: a collection of air within the layers of the visceral pleura (thin and easily ruptured?) 2. bronchial obstruction with ball-valve mechanism (not sure how this works? i assume its a pressure thing)

Question 59

What are the causes of a secondary spontaneous pneumothorax?

Answer 59

OLD: COPD, asthma, CF ILD: sarcoid, lymphangioleiomyomatosis (LAM), pulmonary langerhans cell histiocytosis (PLCH) infections: pneumocystis carinii in AIDS ots, TB

Question 60

WHo gets a tension pneumothorax?

Answer 60

usually pts on MV (positive pressure ventilation) *can occur with trauma JUST NEED A ONE WAY VALVE, allowing air to enter the pleural space and preventing the air from escaping naturally

Question 61

What is a serious complication of a tension pneumothorax?

Answer 61

impaired venous return (compression of RA and SVC) | **clinically manifests as JVD

Question 62

What are the 3 findings on a CXR that suggest a tension pneumothorax?

Answer 62

lung collape contralateral mediastinal shift depression of diaphragm

Question 63

What are the clinical manifestations of a tension pneumothorax?

Answer 63

hypotension | hypoxemia

Question 64

What is the Tx for a tension pneumothorax?

Answer 64

1. emergent decompression with large bore needle | 2. chest tube