Diseases of Pleura

Question 1

When do pleural effusions develop?q

Answer 1

Increased fluid entry
- Increase in microvascular pressure
   - Heart failure
- Increase in permeability
   - Inflammation
   - Malignancy
- Decrease in plasma oncotic pressure
Decreased fluid exit via lymphatics
- Infiltration by
   - Tumour
   - Injury
   - Inflammation

Question 2

What biochemistry is performed on pleural effusions to assist in diagnosis?

Answer 2

Protein
Glucose
LDH
pH

Question 3

How can you tell if a pleural effusion is transudative or exudative via its protein content?

Answer 3

Fluid protein/serum protein
If <0.5 > transudative
If >0.5 > exudative

Question 4

How can you tell if a pleural effusion is transudative or exudative via its LDH content?

Answer 4

Fluid LDH/serum LDH
If <0.6 > transudative
If >0.6 > exudative

Question 5

How can you tell if there is an empyema present by assessing the pleural effusion?

Answer 5

Glucose <5.5

Acidic

Question 6

What are the common causes of transudative pleural effusions?

Answer 6

Chronic liver disease
Heart failure
Renal failure

Question 7

What other investigations help evaluate a pleural effusion?

Answer 7

Imaging
- CXR
- US
- CT chest
Bronchoscopy - not routine unless suspecting TB/cancer
Thoracoscopy

Question 8

What are the signs on plain x-ray of a pleural effusion?

Answer 8

Can't see costophrenic angle
Meniscus sign
Uniform opacification
No air bronchogram
- Unless underlying consolidation/collapse > seen above meniscus

Question 9

What is the meniscus sign in the supine lateral chest x-ray?

Answer 9

Laminar sign

Question 10

What are the symptoms of pleural disease?

Answer 10

Pleuritic chest pain = pleurisy
SOB
Cough

Question 11

What are the signs of pleural disease?

Answer 11

Air in pleural space
- Decreased chest expansion
- Increased percussion note
-  Decreased breath sounds
Fluid/solid tissue in pleural space
- Decreased chest expansion
- Stony dull percussion note
- Decreased breath sounds

Question 12

What are the possible causes of bilateral pleural effusion?

Answer 12

Heart failure
Fluid overload
Low serum protein
- Nephrotic syndrome
- Liver disease
Inflammatory
Secondary malignancy

Question 13

What are the possible causes of unilateral pleural effusion?

Answer 13

Infection - including TB
Malignancy
- Primary
- Secondary
- Lymphoma
Inflammatory - including post PE
Heart failure - less common

Question 14

What is a primary pneumothorax?

Answer 14

Just pneumothorax, with no underlying lung disease

Question 15

What is a secondary pneumothorax?

Answer 15

Pneumothorax with underlying lung disease

Question 16

Why do pneumothoraces occur?

Answer 16

Spontaneous
Trauma
Underlying lung disease
- COPD
- Lung bullae

Question 17

What are the risk factors for a spontaneous pneumothorax?

Answer 17

Smoking
FHx
Marfan’s syndrome

Question 18

What is the initial management of air in the pleural space?

Answer 18

Observation
Drainage
- Aspiration
- ICC with underwater seal
Pain relief
O2

Question 19

What is the management of a possible empyema?

Answer 19

Sample fluid
- Protein
- Glucose
- pH
- Culture
- Cytology
Start Abx
Analgesia
Fluids
O2
Drain fluid

Question 20

What might cause pleural plaques?

Answer 20

Asbestos exposure

Previous empyema/blood in pleural space

Question 21

What are some asbestos-related lung diseases?

Answer 21

Pleural plaques
Pleural thickening/pleural effusions
Pulmonary fibrosis
Mesothelioma
Bronchogenic lung carcinoma

Question 22

What is the management for malignant pleural effusion?

Answer 22

Depends on symptoms and prognosis
Drainage with inter-costal catheter
- Very good for symptom relief
Treat underlying malignancy
Pleurodesis
Intrapleural catheter

Question 23

What is pleurodesis?

Answer 23

Obliterate pleural space to prevent pleural effusion or pneumothorax, or to treat persistent pneumothorax