Pulmonary And Pleural Lung Disease.

Question 1

What is the pulmonary oedema? What pattern of disease does it cause?

Answer 1

Accumulation of fluid in the lung interstitium and alveolar spaces. Causes a restrictive pattern of disease.

Question 2

What are some of the causes of pulmonary oedema?

Answer 2

Haemodynamic from increased hydrostatic pressure.
Cellular injury e.g. Alveolar lining cells or alveolar endothelium.
Can be localised e.g. Pneumonia.
Or general e.g. ARDS.

Question 3

What are the two types of ARDS?

Answer 3

Alveolar damage syndrome (DADS)
Or
Shock lung.

Question 4

What can cause shock lung?

Answer 4

Sepsis, diffuse infection, severe trauma and O2 damage.

Question 5

What is the pathogenesis of ARDS?

Answer 5

Injury e.g. From a bacterial endotoxin leading to:
Infiltration of inflammatory cells
Cytokines
Oxygen free radicals and injury to cell membranes.

Question 6

What pathological findings do we have in ARDS?

Answer 6

Fibrous exudate lining the alveolar walls.

Cellular regeneration and inflammation.

Question 7

What are the possible outcomes of ARDS?

Answer 7

Death, resolution or fibrosis e.g. Chronic restrictive lung disease.

Question 8

What two arterial supplies does the pulmonary circulation get?

Answer 8

Bronchial and pulmonary arteries.

Question 9

What two types of hypertension are there?

Answer 9

Primary and secondary.

Question 10

What type of pulmonary hypertension is more common?

Answer 10

Secondary

Question 11

What can cause pulmonary hypertension?

What are the mechanisms behind them?

Answer 11

Hypoxia (vascular constriction).
Congenital heart disease (increased flow).
Blockage (PE) or loss of vascular bed (emphysema)
Back pressure from LVH.
Morphology change of vessels e.g. Intima thickening by fibrosis and medial hypertrophy of arteries.
RVH.
Cardiac left to right shunt.
Drugs e.g. Appetite suppressants.

Question 12

What are some cardiac causes of pulmonary hypertension?

Answer 12

LVF, mistral regurg or stenosis and cardiomyopathy e.g. From alcohol or a virus.

Question 13

What are the signs of pulmonary hypertension?

Answer 13

Central cyanosis if hypoxic, dependent oedema, raised JVP with V waves (due to tricuspid regurg) right ventricular heave at left para sternal edge, tricuspid regurg murmur and enlarged pulsatile liver.

Question 14

What investigations do we do for pulmonary hypertension?

Answer 14

ECG, CXR, sats and ABGs, pulmonary function tests, echo, D dimers, VQ scan if PE suspected, CT pulmonary angiogram, cardiac MRI and auto-antibodies if vasculitis supspected.

Question 15

How do we diagnose primary pulmonary hypertension?

Answer 15

Diagnosis by exclusion of other causes. Progressive shortness of breath and signs of right sided heart failure.

Question 16

What is the pharmacological treatment of primary pulmonary hypertension?

Answer 16

Prophylactic anticoagulation - warfarin.
PO vasodilators e.g. Calcium channel blockers - oral nifedipine, diltiazem.
Endothelin antagonists - oral bosentan
PDE5 inhibitor - oral sildenafil.
Prostanoids - IV epoprostenol or inhiloprost.
Guanylate cyclase stimulator - oral riociguat.

Question 17

What is cor pulmonale?

Answer 17

Pulmonary hypertension complicating lung disease causing right ventricular hypertrophy.

Question 18

What is the pathogenesis of cor pulmonale?

Answer 18

Hypoxaemic pulmonary vasoconstriction causing increased ventricular afterload. This causes right ventricular hypertrophy which leads to dilation and failure.

Question 19

How do we treat cor pulmonale?

Answer 19

Optimise small degree of reversibility with high dose B2 agonists and anticholinergics.
Remove hypoxic stimulus with home 02.
Thiazides or loop diuretic to remove oedema.

Question 20

What type of cells make the pleura and what do they do to fluid?
How does disease affect this?

Answer 20

Mesothelial cells that are designed to absorb fluid.

Hallmark of pleural disease is effusion.

Question 21

How much pleural fluid of we normally have and what type of fluid is it?

Answer 21

Serous fluid, usually around 4mls.

Question 22

What happens to the pleura at the root of the lung?

Answer 22

The two layers combine, meaning the root of the lung has no pleural coverage. The layers combine to form the pulmonary ligament which runs inferiorly and attaches the root of the lung to the diaphragm.

Question 23

What can the parietal pleura sense and what is its innervation?

Answer 23

Senses pain. Is supplied by the intercostal and the phrenic nerves.

Question 24

What does the visceral pleura sense and what is its nerve supply?

Answer 24

Sensitive to stretch. It contains vasomotor fibres and sensory endings of the cranial nerve X for respiratory reflexes.

Question 25

What is a pleural effusion and what does it look like on X-ray?

Answer 25

It is common in numerous diseases and is an abnormal collection of fluid in the pleural space. Looks almost completely white on X-ray and we can see the line of the lung edge.

Question 26

What effusions should we be particularly worried about?

Answer 26

Unilateral effusions in a smoker or patient with significant asbestos exposure.

Question 27

What two categories of effusion do we have and what is the difference?

Answer 27

Transudates - protein under 30g/L | Exudates - protein over 30g/L

Question 28

What condition gives a pleural effusion that we dont have to drain or aspirate?

Answer 28

Heart failure.

Question 29

What tests do we do to find the cause of pleural effusions?

Answer 29

History and examination. PA CXR and lateral. Pleural aspirate if it's not convincingly caused by heart failure. CT Repeat cytology Pleural biopsy and bronchoscopy if concern of malignancy.

Question 30

If the pleural fluid is bloody what does this mean?

Answer 30

Trauma, malignancy, infection and infarction.

Question 31

If the pleural fluid is straw coloured what does this mean?

Answer 31

Cardiac failure and hypoalbuminaemia.

Question 32

If the pleural fluid is turbid/milky what does this mean?

Answer 32

Empyema or chylothorax.

Question 33

If the pleural fluid is foul smelling what does this mean?

Answer 33

Anaerobic empyema.

Question 34

If the pleural fluid is viscous what does this mean?

Answer 34

Mesothelioma.

Question 35

If the pleural fluid contains food particles what does this mean?

Answer 35

Oesophageal rupture.

Question 36

What criteria do we use to determine if pleural fluid is exudative?

Answer 36

Lights criteria.

Question 37

What are the lights criteria for exudative pleural fluid?

Answer 37

A serum protein ration of over 0.5 Serum LDH level of over 6. A pleural fluid LDH of over two thirds of the upper ,I it if normal serum LDH. If the fluid has any of the above it is exudative.

Question 38

If there are neutrophils present in pleural fluid, what diagnosis does this point is too?

Answer 38

Parapneumonic or PE.

Question 39

If there are mononuclear cells present in pleural fluid, what diagnosis does this point is too?

Answer 39

Chronic effusions.

Question 40

If there are mesothelial cells present in pleural fluid, what diagnosis does this point is too?

Answer 40

Inflammatory process diseases like TB.

Question 41

If there are lymphocytes present in pleural fluid, what diagnosis does this point is too?

Answer 41

Most commonly TB | Can also be sarcoidosis, lymphoma or rheumatoid.

Question 42

What are the common causes of pleural transudate?

Answer 42

Heart failure, liver cirrhosis, nephrotic syndrome and atelactasis.

Question 43

What are the not so common causes of pleural transudate?

Answer 43

Hypothyroidism, constrictive pericarditis, meigs syndrome and urinothorax.

Question 44

What is meigs syndrome?

Answer 44

Ovarian or pelvic malignancy.

Question 45

What does parapneumonic mean?

Answer 45

In the pleural space.

Question 46

What are common pleural exudate causes?

Answer 46

Parapneumonic, PE, malignant effusions, rheumatoid or mesothelioma.

Question 47

What are not so common causes of pleural exudate?

Answer 47

TB, oesophageal rupture, pancreatitis, SLE, post cardiac injury, radiotherapy, uraemia, chylothorax etc.

Question 48

What microbiology tests do we do for pleural effusions?

Answer 48

Gram stain and microscopy. Culture. PCR, SFB stain and liquid culture.

Question 49

What is the normal pH of pleural fluid?

Answer 49

7.6

Question 50

What does it mean in the pH of the pleural fluid is under 7.3?

Answer 50

Suggest pleural inflammation

Question 51

What does it mean in the pH of the pleural fluid is under 7.2? What causes this?

Answer 51

Requires drainage. | Usually caused by parapneumonic or empyema.

Question 52

When do we get a low glucose level in pleural fluid?

Answer 52

Infection, TB, rheumatoid, malignancy, lupus or oesophageal rupture.

Question 53

How do we treat effusions?

Answer 53

Treat underlying cause. Throacentesis (chest drainage) Pleurodesis for malignant effusions. Talc or surgery.

Question 54

What should we never do to a bubbling chest drain?

Answer 54

Clamp it.

Question 55

What type of chest drain uses a guidewire?

Answer 55

Seldinger.

Question 56

What are the indications for chest drain insertion?

Answer 56

Tension pneumothorax after initial needle decompression. Symptomatic pneumothorax. Complicated parapneumonic effusion and empyema. Malignant pleural effusion Traumatic haemopheumothorax.

Question 57

What are the complications of chest drains?

Answer 57

Pain, inadequate placement, surgical emphysema, infection, haemorrhage, organ damage, re expansion pulmonary oedema. Vasovagal reactions and rarely sudden death.

Question 58

Is asbestosis a pleural disease?

Answer 58

No.

Question 59

What different types of asbestos related disease do we get in the pleura?

Answer 59

``` Benign pleural plaques Benign pleural effusions Diffuse pleural thickening Rounded actelectasis Mesothelioma. ```

Question 60

What is rounded actelectasis?

Answer 60

Folded lung.

Question 61

What latency period can asbestos have?

Answer 61

Up to 40 years.

Question 62

What are benign pleural plaques? What do they look like on X-ray? How common are they? What is the treatment?

Answer 62

Discrete areas of pleural thickening that can calcify. They are usually symmetrical and look like bright white lines on X-ray. They are common. They aren't premalignant so don't need follow up.

Question 63

What are benign asbestos pleural effusions? | What is the treatment?

Answer 63

Early manifestation of pleural disease that are small and unilateral and usually resolve spontaneously. They give blood stained exudate and so we must exclude mesothelioma. We treat the symptoms.

Question 64

What happens during diffuse pleural thickening? What are the symptoms? What do investigation show?

Answer 64

Extensive fibrosis of visceral pleura with adhesion to the parietal pleura. SOB and chest pain are common. Shows restrictive spirometry and can show as costophrenic angle blunting on X-ray and can see the lines of the pleura easily.

Question 65

What is a mesothelioma?

Answer 65

Malignant tumour of the pleura or peritoneum. Not associated with smoking and is not dose related. It often invades the chest wall and has a poor prognosis.

Question 66

What are the symptoms of mesothelioma?

Answer 66

Chest pain, shortness of breath and sweating.

Question 67

What investigations do we do for mesothelioma?

Answer 67

Aspirate pleural fluid, CXR and CT. If there is a moderate to large effusion, pleural mass or thickening, lung entrapment or local invasion then do a biopsy under CT, USS or direct vision.

Question 68

What is the treatment for mesothelioma?

Answer 68

Radiotherapy, palliative care, surgery if very fit and chemo.

Question 69

What special consideration do we need to think of for mesothelioma?

Answer 69

Patients are due compensation and the PF must be informed of their deaths.

Question 70

What kind of patients is pneumothorax more common in?

Answer 70

Tall thin men, smokers, cannabis users and those with underlying lung disease.

Question 71

What is a primary pneumothorax?

Answer 71

Happens to normal lungs or as a result of apical bullae rupture.

Question 72

What is a secondary pneumothorax?

Answer 72

One caused by an underlying lung disease e.g. COPD.

Question 73

What are the symptoms of pneumothorax?

Answer 73

Shortness of breath, hypoxia and acute onset pleuritic chest pain.

Question 74

What are the signs of a pneumothorax?

Answer 74

Tachycardia, hyper resonant percussion note, reduced expansion, quiet breath sounds on auscultation and ham and sign (click on auscultation left side).

Question 75

What are the investigations for a pneumothorax?

Answer 75

Chest X-ray usually sufficient. | ABG.

Question 76

What percentage of pneumothorax is one with a 2cm rim?

Answer 76

50% pneumothorax by volume.

Question 77

What is the management of a pneumothorax?

Answer 77

Oxygen if no drain, no treatment if symptomatic and small. Aspiration may avoid chest drain but may be time consuming and may fail. May need chest drain Suction drain Surgical intervention.

Question 78

What are the indications for surgical intervention of pneumothorax?

Answer 78

Second ipsilateral or first contra lateral. Bilateral spontaneous. Persistent air leak over 5 days of drainage. Spontaneous haemothorax. Risky professions after first collapse e.g. Pilots and divers.

Question 79

What is the follow up after pneumothorax?

Answer 79

CXR, discussion about flying and diving. Risk of recurrence and smoking cessation.

Question 80

What is a major complication of a tension pneumothorax?

Answer 80

Can lead to cardiac arrest.

Question 81

What are the signs of a tension pneumothorax?

Answer 81

Trachea deviated to the opposite side, hypotension, raised JVP and reduced air entry on the affected side.

Question 82

Where is needle decompression for a tension pneumothorax done?

Answer 82

Second intercostal space anteriorly in the mid clavicular line.