disease of the pleura

Question 1

anatomy of pleura

Answer 1

• Made of mesothelial cells, connective tissue
and fibroelastic tissue
• Visceral and parietal pleura normally in
close contact
• Only small amount of fluid (< 1ml)
• Frictionless, energy free movement between
lung and chest wall

Question 2

parietl and visceral filtration

Answer 2

parietal pleura filtrates

visceral pleura absorbs fluid

Question 3

history

Answer 3

• Dyspnoea
• Cough
• Chest pain/ heaviness
• Features of associated disease e.g. weight
loss, leg swelling etc
• ? Smoking/ TB/ asbestos/ cardiac/ drugs

Question 4

examination

Answer 4

-Breathlessness
-Increased respiratory rate
-?clubbing
-decreased expansion
-tracheal deviation
-stony dullness on percussion
-reduced breath sounds and vocal fremitus
-features of associated disease e.g. JVP/ weight
loss/ lymphadenopathy

Question 5

imagin

Answer 5

-CXR -dense white shadow with concave upper

edge/ blunting costophrenic angle
- U/S (fluid or thickening?)
-?Contrast enhanced CT (assess underlying lung and
mediastinum)

Question 6

thoracocentesis

Answer 6

• Pleural fluid appearance: straw coloured/ blood stained/ pus/ chylous/
blood
• Fluid for - Protein
- glucose
- pH
- LDH
Culture AAFB
Routine
Cytology
Biopsy - culture and histology

Question 7

pleural effusion

Answer 7

Transudate ~ protein <30g/L
Exudate ~ protein >30g/L
Empyema
Malignancy

Question 8

exudate

Answer 8

Protein > 30g/L only 90% accurate
Other measures to refine separation
(LIGHT’S CRITERIA)
Pleural fluid LDH > 2/3 upper limit normal
serum LDH
Pleural fluid LDH : serum > 0.6
Pleural fluid Protein : serum protein> 0.5

Question 9

transudate

Answer 9

• Heart failure
• Cirrhosis
• Nephrotic syndrome
• Acute glomerulonephritis
Uncommon
Myxoedema/ peritoneal dialysis/ pulmonary
emboli

Question 10

causes of exudate?

Answer 10

• Infection (pneumonia/ TB /subphrenic abscess)
• Malignancy (lung local spread or metastatic)
• Collagen vascular disease, rheumatoid/SLE
• Trauma, haemothorax/ chylothorax
• Pancreatitis

Question 11

uncommon exudate causes?

Answer 11

• Other organisms (e.g. actinomycosis)
• Oesophageal rupture
• Asbestos
• Dressler’s syndrome

Question 12

pelrual effusion reatmetn

Answer 12

Question 13

pleural infection

Answer 13

Question 14

infections

Answer 14

• Streptococcal
• Staphylococcus aureus
• E Coli
• Pseudomonas
• Heamophilus
• Klebsiella

Question 15

treatment of empyema

Answer 15

• All receive antibiotics
• ICD insertion
• Good nutrition
• Treat associated factors
• If no improvement Surgical input:-
– VATS/ thoracotomy + decortication, open
drainage (rib resection)

Question 16

oneumothroax classification

Answer 16

• Primary ( apparently normal lungs)
– Often in tall, thin men esp. if smokers
– male : female 3:1
– young < 30 bullae/blebs rupture
• Secondary (presence of underlying lung
disease)
– COPD, Cystic Fibrosis, Asthma , ILD

Question 17

examinations

Answer 17

• Will depend on size and whether 1
0
/2
0
• Increased Respiratory rate
• Increased heart rate
• Decreased chest expansion
• ?deviated trachea
• PN hyper resonant
• Decreased breath sounds
• ? Sub cutaneous emphysema

Question 18

investigations

Answer 18

• Oxygen Saturations / ABG
• CXR
• Consider CT thorax
• Diagnosis of any underlying lung disease

Question 19

size of pneumo

Answer 19

• Width of rim of air surrounding the lung
• Small : rim of air <2cm ( equivalent to 50%
pneumothorax in volume)
• Large : rim of air ≥ 2cm

Question 20

treatment

Answer 20

• ABC
• BTS Guidelines: Important considerations
– Primary or secondary
– Size of pneumothorax (as defined by rim of air)
– Symptoms

• Observe
• High flow Oxygen
• Aspiration
• ICD insertion
• Suction
• VATS (pleural abrasion/ pleurectomy/ stapling)
• Pleurodesis
• Smoking cessation
• Diving/ flying advice

Question 21

tension pneumothorax

Answer 21

• Tension : pneumothorax acts as one way valve
• Iatrogenic : drainage seldom required
• Traumatic: often require ICD
• Catamenial : at menstruation, often recurrent