Disease of the pleura

Question 1

What is pleura effusion

Answer 1

when a greater than normal amount of fluid collects within the pleural space

Question 2

what are the 2 types of pleural effusion

Answer 2

exudate

transudate

Question 3

what are the common causes of exudate causes of pleural effusion?

Answer 3

increased capillary permeability

inflammation
infective (pneumonia, TB, lung cancer)
neoplastic

Question 4

what are the common causes of transudate causes of pleural effusion?

Answer 4

increased capillary hydrostatic pressure, or decreased oncotic pressure

heart failure
liver failure
hypalbuminaemia
Meig syndrome (pleural effusion, ascites, ovarian cancer)
pulmonary embolism

Question 5

exudates typically has protein content of what value?

Answer 5

> 35g/L

Question 6

Transudates typically has protein content of what value?

Answer 6

<25g/L

Question 7

For borderline effusions (between 25 and

35g/L, apply the Light criteria), what criteria is used to determine if it’s exudate pleural effusion?

Answer 7

Light criteria

Question 8

According to the Light criteria the pleural effusion is exudates if? (only needs to meet one criteria)

Answer 8

1. Effusion protein/serum protein ratio >0.5
2. Effusion LDH/serum LDH ratio >0.6
3. Effusion LDH more than 0.6 × the upper
   limit of normal

Question 9

what are the clinical features of pleural effusion>

Answer 9

dysponea

pleuritic chest pain

Question 10

what is the pathognomonic sign of pleural effusion on percussion?

Answer 10

Stony dullness

Question 11

Other than stony dullness, what are the other signs of pleural dullness?

Answer 11

tracheal deviation

reduced chest expansion

Question 12

What investigations are done in pleural effusion?

Answer 12

PA CXR

if the pleural effusion is suspected to by exudate–> pleural aspiration via US. 21G needle in a 50ml syringe

pleural fluid test: LDH, Gram stain, cytology, culture

chest drain if there is pleural infection

pleurodesis if necessary

Question 13

what is pleurodesis?

Answer 13

Pleurodesis (adhering parietal and visceral

pleura with substances such as talc

Question 14

A pleural fluid pH <7.2 should prompt

suspicion of what?

Answer 14

empyema or a para-pneumonic
effusion (non-infected pleural effusion with
a background of pneumonia). Note that
these require both antibiotics and chest tube
drainage to treat.

Question 15

what are the borders of the triangle of safety in chest drain

Answer 15

Mid-axillary line
Imaginary horizontal line at the nipple
Lateral border of the pectoris major

The drain is usually sited at the fourth, fifth or
sixth intercostal space

Question 16

What is a pneumothorax

Answer 16

a process by which there is an abnormal amount of air accumulates in the pleural space

Question 17

what are the risk factors of pneumothorax

Answer 17

smokers

trauma (chest trauma)

Question 18

what is an open pneumothorax?

Answer 18

communicating with the exterior

Question 19

what is an closed pneumothorax?

Answer 19

chest wall is intact, with accumulation of

air in the pleural space

Question 20

what is a tension pneumothorax

Answer 20

air enters the pleural cavity via a one-way valve and compresses surrounding structures

Question 21

what is a Primary spontaneous pneumothorax (PSP)

Answer 21

occurs in healthy individuals, with no underlying
lung disease; classically associated with young, tall,
thin men and smokers

Question 22

what is a Secondary spontaneous pneumothorax (SSP)

Answer 22

usually occurs in individuals with underlying lung

disease, such as COPD, infection, TB, etc

Question 23

Non-tension spontaneous pneumothoraces can be

classified into what 2 types?

Answer 23

Primary spontaneous pneumothorax (PSP)

Secondary spontaneous pneumothorax (SSP)

Question 24

what is a catamenial pneumothorax?

Answer 24

a pneumothorax that occurs at the time
of menstruation (linked to endometriosis
involving the pleura).

Question 25

what are the clinical features of pneumothorax?

Answer 25

sudden-onset dyspnoea or
pleuritic chest pain

decreased chest expansion, reduced breath sounds and hyper-resonance on percussion

Question 26

how to treat pneumothorax?

Answer 26

Treatment of a tension pneumothorax involves insertion of a large-bore cannula into the second intercostal space at the mid-clavicular line, with subsequent chest drain insertion after the emergent case has been dealt with.

Question 27

what is Subcutaneous emphysema?

Answer 27

where there is trapped air in
the subcutaneous tissue. This can usually be
felt as crepitus on the face, chest and neck.
It (usually) occurs as a result of air travelling
from the respiratory system or GI tract, and
may be caused by pneumothoraces, gunshot
wounds or infections (e.g. gas gangrene/
Clostridium perfringens)

Question 28

management of pneumothorax

Answer 28

PA CXR

Distinguish between a primary and
secondary spontaneous pneumothorax
• As a rule of thumb, SSPs involve underlying lung
disease and are less well tolerated than PSPs

Refer to the treatment flow chart