Diseases of the Pleura

Question 1

What is the definition of an exudative pleural effusion and what is the pathophysiology behind their formation?

Answer 1

Effusion containing a high concentration of protein >30g/l. Results from high capillary permeability and impaired fluid reabsorption

Question 2

What is the definition of an transudate pleural effusion and what is the pathophysiology behind their formation?

Answer 2

Effusion containing a low concentration of protein <30g/l. Results from low oncotic pressure or high hydrostatic pressure

Question 3

What do exudative and transudative pleural effusions result from in general for each?

Answer 3

Transudate - ALL THE FAILURES

Exudate - Infection, inflammation and autoimmune

Question 4

What are examples of causes for exudative pleural effusions?

Answer 4

Malignancy
Simple parapneumonic
PE

Question 5

What are examples of autoimmune causes for exudative pleural effusions?

Answer 5

SLE
Scleroderma
Sarcoidosis

Question 6

What is the most common cause of pleural effusion for <40 and >60?

Answer 6

<40 - Simple parapneumonic. Occurs in 40% of bacterial pneumonia

> 60 - malignancy

Question 7

What are example of causes of transudate pleural effusion?

Answer 7

Left ventricular failure
Liver failure
Nephrotic syndrome
Meig syndrome

Question 8

What is the triad associated with Meig syndrome?

Answer 8

Ovarian tumour
Ascites
Pleural effusion

Question 9

What are signs and symptoms of pleural effusions?

Answer 9

SOB
Pleuritic chest pain

Signs - reduced breath sounds, tactile vocal fremitus, stony dull percussion and tracheal deviation

Question 10

What imaging would you do for ? Pleural effusion?

Answer 10

PA CXR

Question 11

What would you consider as underlying cause if a pleural effusion was bilateral or a complete white out?

Answer 11

Bilateral consider transudate

White out consider malignancy

Question 12

What procedure would you do and what relevant investigation of sample collected would you consider to aid identification of underlying cause of Pleural effusion?

Answer 12

Thoracocentesis

Test for - cytology, microbiology, LDH, biochemistry and pH

Question 13

Why measure pH of pleural fluid drained?

Answer 13

<7.2 you should consider emphyema

Question 14

What is the management of a pleural effusion?

Answer 14

Chest drain

Question 15

How much fluid can you drain from a pleural effusion in one go and why is this?

Answer 15

1.5 litres due to risk of rapid expansion pulmonary oedema

Question 16

How would you treat rapid expansion pulmonary oedema?

Answer 16

IV protein solution

Question 17

How might you manage a patient who gets recurrent pleural effusions and how does this work?

Answer 17

Pleurodesis

With substance such as talc attaches the visceral and the parietal pleura together

Question 18

Where do the visceral and parietal pleura attach?

Answer 18

Visceral - ribs 6,8,10

Parietal - ribs 8,10,12

Question 19

What are the boarders of the safe triangle used for chest drain insertion?

Answer 19

Lateral boarder of the pec major
Mid axiallary line
Horizontal line from the nipples

Question 20

Which ICS are chest drains normally inserted (3 options)?

Answer 20

4, 5, 6 intercostal spaces

Question 21

What is the name of the criteria used to distinguish a transudate and exudate pleural effusion?

Answer 21

Lights criteria

Question 22

What is the definition of a pneumothorax?

Answer 22

Air in the pleural space

Question 23

What is the definition of a tension pneumothorax and how do they usually occur?

Answer 23

Formation of a one way valve into the pleural space resulting in mediastinal shift and compression of structures in the thorax. Usually result following a traumatic injury

Question 24

What is the definition of a primary spontaneous pneumothorax?

Answer 24

No underlying lung disease or mechanism of injury

Question 25

What is the definition of secondary spontaneous pneumothorax?

Answer 25

Underlying lung disease that results in the formation of a pneumothorax

Question 26

What underlying conditions can result in a secondary spontaneous pneumothorax?

Answer 26

COPD
Pneumonia
TB

Question 27

What is a catamenial pneumothorax?

Answer 27

Formation of a pneumothorax in conjunction with menstruation and is thought to be due to endometriosis of the pleural cavity

Question 28

What is the presentation of a pneumothorax?

Answer 28

Hyperresonance 
SOB 
Reduced chest expansion 
Reduced breath sounds 
Sudden onset pleuritic chest pain

Question 29

What would be seen if tension pneumothorax was present?

Answer 29

tracheal deviation away from the lesion, jugular venous distension, hypotension and tachycardia

Question 30

What is management of a primary spontaneous pneumothorax?

Answer 30

<2 cm - discharge and review in 2 weeks

> 2cm or SOB - aspirate 16-18cm cannula

Question 31

What is management of a secondary spontaneous pneumothorax?

Answer 31

<1 cm - O2 and observe for 24 hours
1-2cm - aspirate 16-18cm cannula
>2cm or SOB - chest drain

Question 32

What is the management of a bilateral or haemodynamically unstable spontaneous pneumothorax?

Answer 32

Chest drain

Question 33

What is the management of a tension pneumothorax?

Answer 33

Wide bore cannula into 2 ICS mid clavicular line with subsequent chest drain insertion

Question 34

What is the Ix of choice for a pneumothorax and what would you expect to see?

Answer 34

Lung markings not extending to the edge of the lung field

If large - mediastinal shift

Question 35

What characteristics predisposes to increased risk of a primary spontaneous pneumothorax?

Answer 35

Tall, thin, male, smoker