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Lecture 9: Pleural and Mediastinal Diseases Flashcards

1
Q

What are the 3 leading causes of pleural effusion in the US?

A
  1. Heart failure
  2. Pneumonia
  3. Cancer
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2
Q

What is the most common finding auscultated over a pleural effusion; and what is auscultated toward the top of an effusion?

A
  • Decreased to absent breath sounds over an effusion
  • Bronchial breath sounds toward the top of an effusion
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3
Q

Which imaging study is usually the first study used to identify and quantify the amount of fluid seen with a pleural effusion?

A

CXR

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4
Q

How much pleural fluid is needed to blunt the costophrenic angle on plain CXR?

A

~250 mL

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5
Q

Which sign is created as greater amounts of fluid with a pleural effusion opacify the lower thorax?

A

“Meniscus sign”

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6
Q

After the presence of a pleural effusion is documented what study is used to evaluate whether an effusion is free-flowing or loculated (non-free flowing) and whether a sufficient quantity is present to perform thoracentesis?

A

Decubitus films

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7
Q

How much distance measured from the pleural fluid line to the chest wall on a decubitus radiograph is indicative of adequate pleural fluid to perform thoracentesis?

A

1-cm distance

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8
Q

Which imaging modality is highly sensitive for pulmonary embolism and may be indicated if the pretest probability of pulmonary embolism is moderate to high?

A

Spiral chest CT

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9
Q

Which imaging modality can be used to detect loculations, guide thoracentesis of a pleural effusion, and detect pleural abnormalities not apparent on CXR?

A

Ultrasound

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10
Q

Bilateral transudative pleural effusions are commonly associated with what underlying diseases?

A

Heart or liver failure

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11
Q

Bilatral exudative pleural effusions suggest what underlying disease(s)?

A

Malignancy, but may aso occur in pt’s w/ pleuritis due to SLE and other collagen vascular disorders

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12
Q

Caution is advised when performing thoacentesis in which pt’s?

A

Those w/ severe coagulopathy, thrombocytopenia, hemodynamic compromise, or on mechanical ventilation

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13
Q

What is the major complication of thoracentesis?

A

Pneumothorax

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14
Q

Gross pus in the pleural space is diagnostic of what?

A

Empyema

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15
Q

If TB is suspected on clinical presentation w/ pleural effusion which 3 diagnostic studies can be used as adjuncts to diagnosis?

A
  • Lymphocytic predominance on leukocyte count
  • Adenosine deaminase activity
  • PCR
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16
Q

An increased lymphocytic effusion (>50%) is most often due to what 2 etiologies?

A
  • Malignancy
  • TB
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17
Q

Transudates are associated with a pleural fluid pH in what range (normal = 7.6 to 7.66)?

A

7.45 to 7.55

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18
Q

Pleural fluid amylase should be measured only when what 3 causes are being considered?

A
  • Pancreatic disease
  • Esophageal rupture
  • Malignancy
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19
Q

What are 5 underlying causes of a low pleural glucose?

A
  • Parapneumonic effusion
  • Malignant effusion
  • Tuberculosis
  • Hemothorax
  • Rheumatoid Arthritis
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20
Q

Increased eosinophils (>10%) within the pleural space most often due to what?

A

Air in the pleural space

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21
Q

2 major causes of transudative pleural effusion and what are 3 other less common causes?

A
  • Major = LVF or CHF
  • Other = misplaced central line; massive cirrhosis; nephrosis
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22
Q

Which ratio of pleural protein/serum protein suggests the presence of an exudative vs. transudative pleural effusion?

A
  • Exudative = pleural protein/serum protein >0.5
  • Transudative = <0.5
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23
Q

Which ratio of pleural fluid LDH to serum LDH is suggestive of exudative vs. transudative pleural effusion?

A
  • Exudative = pleural LDH/serum LDH >0.6
  • Transudative = pleural LDH/serum LDH <0.6
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24
Q

Which findings of pleural fluid LDH compared to the upper limit of normal for serum is suggestive of exudative vs. transudative effusion?

A
  • Exudative = >2/3 upper limit of normal for serum
  • Transudative = <2/3 upper limit of normal for serum
25
Which type of effusion is associated with a low leukocyte count vs. high leukocyte count?
- **Transudative** effusions typically have a **low** leukocyte count (\<1000/uL) - Pleural leukocyte count \>10,000 uL is most likely due to **parapneumonic effusion; pancreatitis****; splenic infarction**; and**subphrenic, hepatic**, and**splenic abscesses**
26
A pleural leukocyte count \>50,000/uL is always associated with what?
Complicated **parapneumonic effusions** and **empyema**
27
When malignancy is suspected but intitial thoracentesis is non-diagnostic, what is the next step?
Cytologic evaluation of a **second**, **large-voume** pleural fluid sample
28
In regards to the sensitivity of pleural fluid cytology, which type of tumor is associated with high positivity and which has low positivity?
- **High positivity** = Adenocarcinoma - **Low positivity** = Hodgkin lymphoma
29
What is the tx for acute pleural effusions?
- Tx the underlying cause - Abx for pneumonia - Observation
30
Therapeutic thoracentesis should be limited to the removal of how much fluid at a time?
**NO more than 1.5 L**; minimizes likelihood of reexpansion pulmonary ededma
31
What are 2 options for the mangement of chronc pleural effusions?
- **PleurX catheter** --\> indwelling catheter in pleural space allowing for at-home drainage - **Pleurodesis** --\> obliteration of the pleural space w/ a chemical agent (i.e., talc, tetracycline, etc.) using a **thorascope** or in **IR**
32
50% of patients with pneumothorax in the setting of recurrent (but not primary) *Pneumocystis* pneumonia will develop what?
**Pneumothorax** on the **contralateral** side
33
Tension pneumothorax should be suspected in the presence of what signs/sx's?
- Marked **tachycardia** - **HYPOtension** - Mediastinal or tracheal **shift**
34
Demonstration of what on a chest radiograph is diagnostic of a pneumothorax?
**Visceral pleural line**
35
Which characteristic sign may be seen on chest radiograph in supine pt's presenting with pneumothorax?
"**Deep sulcus**" sign
36
What is treatment for reliable pt with a small (\<15% of a hemithorax), stable, spontaneous primary pneumothorax?
**Observation** alone may be appropriate
37
Which therapy may increase the rate of reabsorption of air associated with a pneumothorax?
Supplemental O2
38
Placement of what in a pt with pneumothorax can provide protection against development of tensio pneumothorax and may permit observation from home?
**Small-bore chest tube** attached to **one-way Heimlich valve**
39
Observation of pt with pneumothorax should invovle serial CXR's how often?
Every 24 hours
40
Pts with secondary pneumothorax, large pneumothorax, tension pneumothorax, severe sx's, or those with pneumothorax on mechanical ventilation should undergo what tx?
Chest tube placement (tube thoracostomy)
41
What are indications for a thorascopy or open thoracotomy in pneumothorax pt's?
- **Recurrences** of spontaneous pneumothorax - **Any** occurrence of **bilateral pneumothorax** - **Failure of tube thoracostomy for first episode** (failure of lung to reexpand or persistent air leak)
42
What are the differences in percussion in a pneumothorax vs. pleural effusion?
- **Hyper-resonance** in **pneumothorax** - **Dull** in **pleural effusion**
43
What are the positional changes of breath sounds like in a pneumothorax vs. pleural effusion?
- **No change** in **pneumothorax** - May **improve** in **pleural effusion**
44
What 3 major structures are found in the anterior mediastinal compartment?
- **Thymus gland** - Anterior mediastinal LN's - **Internal mammary** arteries and veins
45
Which region of the mediastinum contains the descending thoracic aorta, esophagus, thoracic duct, and the azygos and hemiazygos veins?
Posterior mediastinum
46
What are the most common lesions of the anterior mediastinum (4 or them - remembered as the "4-T's")?
- **T**hymomas - "**T**errible" (T cell) Lymphomas - can be B cells as well as Hodgkin - **T**eratomatous neoplasms - **T**hyroid masses
47
What are the 3 most common masses of the middle mediastinum (remembered VAC)?
- **Vascular masses** - **A**denopathy from **metastases** or **granulomatous** disease - **Cysts** - **Pleuropericardial** and **bronchogenic**
48
What are the most common lesions found in the posterior mediastinum?
- **Neurogenic tumors** - **Meningoceles** and **meningomyeloceles** - **Gastroenteric cysts** and **esophageal diverticula**
49
What is the most valuable imaging technique for evaluating mediastinal masses and is often the only imaging technique that should be done in most instances?
CT
50
Which diagnostic studies are indicated in many pt's with posterior mediastinal lesions, because hernias, diverticula, and achalasia are readily diagnosed in this manner?
**Barium** studies
51
Which scan can efficiently establish the diagnosis of intrathoracic goiter (anterior mediastinum)?
**iodine-131 scan**
52
Which invasive techniques allow for definitive diagnosis of masses in the anterior or middle mediastinal compartments?
**MediastinOSCOPY** or **anterior mediastinOTOMY**
53
Via what technique can a diagnosis and removal of a mediastinal mass be accomplished?
**Video-assisted thoracoscopy**
54
How is the diagnosis of acute mediastinitis following median sternotomy for cardiac surgery made?
Mediastinal needle aspiration
55
Most cases of chronic mediastinitis are due to what?
**Histoplasmosis** or **TB**
56
What are the 3 main causes of pneumomediastinum?
1) Alveolar rupture w/ dissection of air into the mediastinum 2) Perforation or rupture of the esophagus, trachea, or main bronchi 3) Dissection of air from the neck or the abdomen into the mediastinum
57
What are signs/sx's and PE findings indicative of pneumomediastinum?
- **Severe** substernal chest pain **with** or **w/o radiation** into the **neck and arms** - PE reveals **subcutaneous emphysema** in the **suprasternal notch** and **Hamman's sign**, which is crunching or clicking nose synchronouse w/ the heartbeat
58
Which imaging modality is used for confirming the diagnosis of pneumomediastinum?
CXR

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