Pleural Malignancy

Question 1

What is a pleural effusion

Answer 1

Buildup of fluid in pleural cavity

Question 2

What pleura covers lung hilum

Answer 2

None, the two layers combine around the hilum

Question 3

What is the pulmonary ligament

Answer 3

Combination of pleural layers that attaches lungs inferiorly to the diaphragm

Question 4

When does pleural effusion not require sampling or drainage

Answer 4

If it’s caused by cardiac failure

Question 5

Transudate vs exudate

Answer 5

Transudate is fluid pushed through capillaries due to high pressure (low protein content < 30g/L).
Exudate is fluid a around capillary cells due to inflammation (high protein content > 30g/L)

Question 6

Straw coloured pleural fluid

Answer 6

Cardiac failure, hypoalbuminaemia

Question 7

Bloody pleural fluid

Answer 7

Trauma, malignancy, infection, infarction

Question 8

Turbid/milky pleural fluid

Answer 8

Empyema (pus), chylothorax (lymph)

Question 9

Foul smelling pleural fluid

Answer 9

Anaerobic empyema

Question 10

Food particles in pleural fluid

Answer 10

Oesophageal rupture

Question 11

Bilateral pleural fluid

Answer 11

LVF, pulmonary thromboembolism, drugs

Question 12

Common causes of transudates

Answer 12

Heart failure, liver cirrhosis, hypoalbuminaemia, atelectasis, peritoneal dialysis

Question 13

Common cause of exudates

Answer 13

Malignancy, infection including TB, pulmonary infarction, asbestos

Question 14

What does fluid pH < 7.3 suggest

Answer 14

Pleural inflammation due to malignancy

Question 15

What is fluid pH < 7.2

Answer 15

Requires drainage in setting of infection

Question 16

Lymphoctye vs neutrophil presence in pleural fluid

Answer 16

Neutrophils suggest an acute process whereas presence of lymphocytes suggests TB or malignancy

Question 17

Example of an acid-fast stain

Answer 17

Ziehl-Neelsen stain where the acid-fast bacteria stand out as bright red against a blue background

Question 18

Does increasing volume of aspirate in thoracentesis increase yield

Answer 18

No

Question 19

Third and subsequent sample effective in thoracentesis pleural aspirate

Answer 19

No, second sample increases yield slightly. Third and more are useless

Question 20

Why are biopsies often negative

Answer 20

Pleural disease is often discontinuous

Question 21

Systemic causes of ancillary effusions

Answer 21

Systemic tumour effects such as embolism or hypoalbuminaemia (type of hypoproteinaemia)

Question 22

What is mesothelioma

Answer 22

Malignant tumour of lining of lungs or sometimes abdominal cavity

Question 23

What increases likelihood of developing mesothelioma

Answer 23

Degree and length of exposure to asbestos. May also occur in persons who have been associated with people who have worked with asbestos

Question 24

Symptoms of mesothelioma

Answer 24

Breathlessness, chest pain, weight loss, fever, sweating and cough

Question 25

Cytological yield of mesothelioma

Answer 25

Poor, avoid repeated aspiration

Question 26

What can be seen on imaging of mesothelioma

Answer 26

Pleural nodularity, circumferential pleural thickening, local invasion and lung entrapment

Question 27

Treatment of mesothelioma

Answer 27

Pleurodesis, radiotheraphy, chemotherapy, surgery, palliative care

Question 28

Talc slurry vs talc poudrage for pleurodesis

Answer 28

Talc poudrage is preferred due to lower incidence of chest pain during the procedure. Poorer results also seen with talc slurry

Question 29

Common complications of talc pleurodesis

Answer 29

Minor pleuritic pain and fever

Question 30

When are long term catheters generally used

Answer 30

Patients with malignant effusions. Allows patients to control their effusion and symptoms

Question 31

Complications of long term pleural catheter

Answer 31

Incorrect placement, bleeding, infection

Question 32

How can survival be predicted in malignant pleural effusions

Answer 32

``` Using the LENT score - LDH - Lactate dehydrogenase ECOG score - Ability of patients to tolerate therapies serum Neutrophil to lymphocyte ratio Tumour type ```

Question 33

Treatment for LVF pleural effusion

Answer 33

Diuretics

Question 34

Treatment for infection related pleural effusion

Answer 34

Drain, antibiotics, surgery

Question 35

Treatment for malignancy related pleural effusion

Answer 35

Drain, pleurodesis, long term pleural catheter

Question 36

What is a pneumothorax

Answer 36

Abnormal collection of air between plural space

Question 37

Pneumothorax usually occurs in

Answer 37

Tall thin men, smokers, cannabis users, underlying lung disease

Question 38

Types of pneumothorax

Answer 38

Primary - Normal lungs, apical bullae rupture | Secondary - Underlying lung disease eg: COPD

Question 39

Which type of pneumothorax symptomatic

Answer 39

Secondary spontaneous pneumothorax is usually symptomatic even if small unlike primary spontaneous pneumothroax which are largely asymptomatic

Question 40

General signs of pneumothorax

Answer 40

Dyspnoea, hypoxia, acute onset pleuritic chest pain, tachycardia, hyper-resonant percussion sound, reduced expansion, quiet breath sounds on auscultation

Question 41

What is Hamman's sign

Answer 41

A mediastinal crunch or click sound, similiar to crackles, heard upon auscultation. It correlates with the heart beat and not respirations

Question 42

How can amount of pneumothorax be approximated

Answer 42

Measure rim of air at hilar level not apex Small < 2 cm rim of air Large > 2 cm rim of air 2 cm rim of air is approx 50 % pneumothorax

Question 43

Is chest x-ray sufficient to diagnose pneumothorax

Answer 43

Yes

Question 44

Management of pneumothorax

Answer 44

Oxygen even if no drain Aspiration if primary spontaneous pneumothorax, time consuming, avoids chest drain and may fail is ago > 50 or secondary spontaneous pneumothorax Surgery May need suction (air leak > 48 hours)

Question 45

Treatment of asymptomatic and small pneumothorax

Answer 45

No treatment if asymptomatic and small

Question 46

When can aspiration fail in pneumothorax

Answer 46

If age > 50 or secondary spontaneous pneumothorax

Question 47

When should surgery be considered for pneumothorax

Answer 47

``` Secondary ipsilateral ptx Primary contralateral ptx Bilateral spontaneous ptx Persistent air leaks Risk professions after first ptx (divers, pilots) ```

Question 48

Pneumothorax follow up

Answer 48

Chest x-ray until resolution Discuss flying and diving Risk of re-occurrence Smoking caessation

Question 49

What is tension pneumothorax

Answer 49

Progressive build-up of air in pleural space usually due to lung laceration which allows air to escape into the pleural space but not return

Question 50

Is tension pneumothorax an emergency

Answer 50

Yes

Question 51

Signs of tension pneumothorax

Answer 51

Trachea deviated to opposite signs, Hypotension, raised JVP, reduced air entry on affected side

Question 52

Treatment of tension pneumothorax

Answer 52

Needle compression, usually with large bore venflon

Question 53

Causes of tension pneumothorax

Answer 53

Ventilated patient, trauma, CPR, blocked/kinked/misplaced drain, pre-existing airway disease, patients undergoing hyperbaric treatment

Question 54

Where is venflon inserted for needle compression

Answer 54

Second intercoastal space, mid-clavicular line

Question 55

How can empyema be cleared

Answer 55

Paraneumonic effusions can be cleared by drainage however empyema can rapidly coagulate and organize to fibrous peels even with antibiotics. This needs surgery