W4 - Effusion, Pneumothorax & Mesothelioma

Question 1

What is the most common primary malignancy of pleura?

Answer 1

Mesothelioma

Question 2

Are primary or secondary pleural tumours more common?

Answer 2

Primary

Question 3

Name 2 characteristics of mesothelioma

Answer 3

Rare
Aggressive

Question 4

Name 2 causes of mesothelioma

Answer 4

Occupational lung disease (so more common in men)

Inhaled asbestos dust/fibres

Question 5

Name 6 occupations which mesothelioma occurs in

Answer 5

Plumbers
Electricians
Shipbuilding
Power plants
Boilers
Engines

Question 6

Name 5 symptoms of mesothelioma

Answer 6

Chest pain
SOB
Weight loss
Clubbed, pleural effusion
Palpable neck nodes

Question 7

Name 2 types of diagnosis for mesothelioma

Answer 7

CXR to look for pleural effusion and mass
Biopsy to stage

Question 8

Name 3 types of biopsy used to stage mesothelioma

Answer 8

Blind pleural biopsy using Abram’s pleural needle

CT guided/US biopsy

Thorascopy - can also spray talcum (pleurodesis) to stop fluid reoccuring

Question 9

Describe 6 management options for mesothelioma

Answer 9

Palliative care
Treat effusion
Chemo
Recruit to trials via MDTs
Palliative surgery
Advise patient about compensation

Question 10

Describe the outlook for mesothelioma

Answer 10

Limited, survival poor

Question 11

Name 2 palliative surgeries for select patients with mesothelioma

Answer 11

Pleurodesis in young patients

Decortication (peeling off thickened pleura) to relieve SOB

Question 12

Define pneumothorax

Answer 12

Collection of air between visceral and parietal pleura

Question 13

Is pneumothorax restrictive or obstructive?

Answer 13

Restrictive

Question 14

Name 5 types of pneumothorax

Answer 14

Primary spontaneous
Secondary spontaneous
Traumatic
Iatrogenic
Tension

Question 15

Define primary spontaneous pneumothorax, it’s believed cause and effect

Answer 15

Out of the blue pneumothorax in normal lungs. Believed to be due to weak areas on lung surface called “blobs” which rupture spontaneously an leak air into pleural cavity, compressing underlying lung.

Question 16

Define secondary spontaneous pneumothorax and 6 related conditions

Answer 16

Out of the blue pneumothorax in someone with a pre-existing condition. Usually condition is:
Interstitial lung disease
COPD
Asthma
Cystic fibrosis
and rarely pleural endometriosis

Question 17

Name 6 presentations of pneumothorax

Answer 17

Sudden event
Chest pain
SOB
Tall thin young men
Sometimes underlying lung disease
History of biopsy/line insertion/mechanical ventilation

Question 18

Name 6 signs of pneumothorax

Answer 18

Tachypnoeic
Hypoxic
Reduced chest movement
Reduced/no breath sounds
Hyper-resonant percussion
Or exam may be normal!

Question 19

Name 3 investigations for pneumothorax

Answer 19

CXR
US
CT thorax

Question 20

Name 4 managements of pneumothorax

Answer 20

Watch and wait if they look well
Aspiration if over 2cm but well
Chest drain insertion
Surgery if recurrent/unresolving

Question 21

What’s the risk of recurrence of pneumothorax within the first year?

Answer 21

25-50%

Question 22

Following pneumothorax treatment, what 2 things should you advise a patient?

Answer 22

Avoid heavy lifting and flying for 1+ week

Question 23

Define pleural effusion

Answer 23

Excessive collection of fluid between parietal and visceral pleura

Question 24

Name the 2 types of pleural effusion

Answer 24

Transudate effusion - non-inflammatory

Exudate effusion - inflammatory

Question 25

How can we tell if effusion is transudate or exudate effusion?

Answer 25

Apply the Lights criteria

Question 26

Give the 3 Lights Criteria and whether they tell us which effusion we're faced with

Answer 26

1) Protein - plural fluid to serum fluid ratio >0.5 2) Serum Lactate Dehydrogenase (LDH) - pleural fluid / serum fluid ratio >0.6 3) Pleural fluid LDH > 23 ULN serum LDH If no criteria met, transudate effusion, otherwise exudate effusion

Question 27

In what 2 ways does transudate effusion present?

Answer 27

Bilateral Subcutaneous oedema

Question 28

What is the difference between transudate and exudate fluid?

Answer 28

Transudate - low protein content Exudate - 3g/dl or more protein content

Question 29

Name 2 common causes of transudate effusion

Answer 29

Left ventricular failure Liver cirrhosis

Question 30

How do we diagnose and treat transudate effusion?

Answer 30

Treat underlying cause May not need CT

Question 31

Name 4 common causes of exudate effusion?

Answer 31

Malignancy (pulmonary or not) Parapneumonic effusion Empyema TB

Question 32

How do we treat exudate effusion

Answer 32

Unless cause is identified, will need further investigation (e.g. imaging) and/or pleural biopsy

Question 33

When might we need a chest drain with pleural effusion

Answer 33

pH less than 7.2 with pneumonia/blood/pus

Question 34

Name 4 investigations for pleural effusion

Answer 34

US CXR CT thorax Pleural fluid analysis

Question 35

Name 6 types of pleural fluid analysis for effusion

Answer 35

Aspiration Inspect fluid pH (bedside ABG machine) Biochemistry Microbiology Cytology