Diseases of pleura

Question 1

What is pleura made of?

Answer 1

mesothelial cells and sub-pleural connective tissue

Question 2

How much fluid is there in pleural space?

Answer 2

2-3 ml

Question 3

How is the pleural fluid formed?

Answer 3

It is formed from systemic circulation, as the hydrostatic pressure there is 4 kPa whereas in pulmonary arteries it is 1.5kPa. Thus the overall net flow is from the systemic circulation to pleural scape and to lungs

Question 4

Which organs does pleural membrane cover?

Answer 4

Spleen, kidneys, liver

Question 5

What is pleural effusion?

Answer 5

Abnormal accumulation of fluid in pleural space

Question 6

What are the symptoms of pleural effusion?

Answer 6

can be asymptomatic, breathlessness, dry cough, pleuritic chest pain, dull ache, fevers, night sweats

Question 7

What are the signs of pleural effusion?

Answer 7

Decreased expansion, stony dullness on percussion, reduced breath sounds, absent vocal resonance, other signs such as clubbing, raised JPV, peripheral oedema, cervical lymphadenopathy, trachea away from effusion

Question 8

What are the two types of pleural effusion?

Answer 8

Transudate and exudate

Question 9

What is transudate?

Answer 9

Pleural fluid with fluid protein smaller than 30 g/l, imbalance of hydrostatic forces, usually bilateral

Question 10

What are the common causes of transudate?

Answer 10

left ventricular failure, liver cirrhosis, hypoalbuminaemia, peritoneal dialysis, less common causes are hypothyroidism, nephrotic syndrome, mitral stenosis, pulmonary embolism, rare are constructive pericarditis, ovarian hyper stimulation syndrome, Meigs syndrome

Question 11

What is exudate ?

Answer 11

Pleural fluid with protein content higher than 30 g/L, usually unilateral, due to increased permeability of the pleural blood vessels

Question 12

What are the causes of exudate?

Answer 12

Lung, breast, cancer, mesothelioma, parapneumonic, less common pulmonary embolism, rheumatoid arthritis, autoimmune diseases, benign asbestos effusion, pancreatitis, post myocardial infarction, craniotomy syndrome, rare are yellow nail syndrome, due to some drugs

Question 13

What are the essential investigations?

Answer 13

transudate usually does not require investigation, chest X ray, congrats enhanced CT, aspiration and analysis of the fluid, pleural biopsy, thoracoscopy

Question 14

What can be determined from aspirated fluid?

Answer 14

Foul smelling -anaerobic empyema, pus -empyema, milky chylothorax, food particles -oesophagus rupture, blood - haemothorax, blood stained -malignancy

Question 15

What tests can be performed on the pirated fluid?

Answer 15

test for protein, LDH, amylase, glucose, TB, cytology, microbiology

Question 16

What are the lights criteria?

Answer 16

Used for proteins levels between 25 -35, it is exudate if one or more are true, pleural/serum protein >0.5, pleural / serum LDH >0.6
pleural LDH >0.66 of upper limit of serum LDH

Question 17

What is the treatment for pleural effusion?

Answer 17

transudate treat the cause, exudate treat by chemotherapy if possible,corticosteroids, palliative aspiration 1.5 L maximum at any one time, pleurodesis chemical or surgical, inflammation should seal the two membranes together

Question 18

What is pneumothorax?

Answer 18

Collapsed lung with air in the pleural cavity, in can be primary or secondary

Question 19

What are the different types of pneumothorax?

Answer 19

spontaneous primary, spontaneous secondary, traumatic non-iatrogenic, traumatic iatrogenic

Question 20

What is primary spontaneous pneumothorax?

Answer 20

No clinically apparent disease, more likely in tall and young people

Question 21

What is spontaneous secondary pneumothorax?

Answer 21

Occurs in patients with pulmonary pathology such as asthma, COPD< pneumonia, TB, CF, sarcoidosis, fibrosing alveoli

Question 22

What is traumatic non-iatrogenic pneumothorax?

Answer 22

penetrating chest injury stab, gun shot, blunt chest injuries, broken ribs etc

Question 23

What is traumatic iatrogenic pneumothorax?

Answer 23

Caused by pleural aspiration, subclavian vein cannulation, lung, liver and renal biopsy, acupuncture

Question 24

What is tension pneumothorax?

Answer 24

The pressure in the pleural cavity is very big, mediastinal shift, obstructing venous return , circulatory instability, very dangerous, needs to be treated immediately

Question 25

What are the symptoms of pneumothorax ?

Answer 25

Can be assymptomatic if small, chest pain, dyspnoea

Question 26

What are the signs on non-tension pneumothorax?

Answer 26

Trachea deviated to the affected site, hyper-resonant, absent breath sounds, decreased expansion

Question 27

What are the signs of tension pneumothorax?

Answer 27

Trachea away from the affected site, increased JVP, absent breast sounds, hyper-resonant, decreased expansion

Question 28

What investigations should be carried out?

Answer 28

chest X ray

Question 29

What is the treatment for tension pneumothorax?

Answer 29

Cannula to 2nd intercostal space mid-clavicular line, then insert chest drain

Question 30

What is the treatment of small primary pneumothorax?

Answer 30

if not breathless observe overnight, if no change send home

Question 31

How to treat breathlessness primary pneumothorax?

Answer 31

aspiratore 50 ml each time, 3 way tap, only up to 3 L, successful X ray after 24 h, if not chest drain

Question 32

How to treat breathless secondary pneumothorax?

Answer 32

Chest drain in 4th intercostal space mid axillary line

Question 33

When it is required to perform pleurodesis ?

Answer 33

second ipsilateral , first contralateral, bilateral spontaneous, first in high risk professions