MKSAP 5: Pleural Disease Flashcards
What are typical signs and symptoms of a pleural effusion?
dyspnea, cough, and pleuritic chest pain
What other history specifics should be elicited in a patient with a pleural effusioin?
history of travel, prior or current occupation, medication use, prior surgery (CABG), malignancy, place of residency and prior asbestos exposure
What are the clinical examination hallmarks?
Diminished breath sounds, dullness to percussion and decreased tactile fremitus over the area of the pleural effusion
How much fluid needs to be present in a PA and a lat CXR to see an effusion?
PA: 200mL
Lat: 50mL
What imaging modality has a higher sensitivity for pleural fluid
Thoracic ultrasound
What are the indications for thoracentesis? In what situations can you wait?
Any new unexplained pleural effusion.
Observation is OK int he setting of known heart failure, small parapneumonic effusions or following CABG
Name the Light criteria
An effusion is considered an exudate if any of the following are met:
1) Pleural fluid total protein/serum total protein > 0.5
2) Pleural fluid LDH/serum LDH ? 0.6
3) Pleural fluid LDH > 2/3 upper limit of normal for serum LDH
What ratio do you use in the setting of ongoing diuresis?
Light criteria can occasionally misclassify transudative effusions as exudates in the setting of ongoing diuresis.
Determine serum albumin to pleural fluid albumin gradient, if greater than 1.2, the underlying process is likely transudative
Name common causes of transudates
Heart failure Hepatic hydrothorax Nephrotic syndrome Hypoalbuminemia Unexpandable lung Urinothorax Atelectasis Peritoneal dialysis
Name common causes of exudates
Parapneumonic effusions Malignancy Pulmonary embolism TB Autoimmune diseases Benign asbestos effusion Post CABG Pancreatitis Post-MI Yellow nail syndrome Drugs
Clinical significance of 5-10K erythrocytes on thoracentesis
Bloody appearance, hemothorax if pleural fluid hematocrit > 50% peripheral hematocrit; most commonly associated with cancer, pulmonary infarction, asbestosis related effusions or trauma
Clinical significance of the following levels of nucleated cells on thoracentesis:
>50K
>10K
<5K
> 50K: complicated parapneumonic effusions and empyema
10K: Bacterial PNA, acute pancreatitis, and lupus pleuritis
<5: chronic exudates (TB pleurisy and malignancy)
Clinical significance of >80% lymphocytes on thoracentesis
Suggests TB, lymphoma, chronic rheumatoid pleurisy, sarcoidosis and late post-CABG effusions, Pleural biopsy indicated if no diagnosis
Clinical significance of > 10% eosinophils on thoracentesis
Suggests air or blood in the pleural space if nonspecific. Can be seen in parapneumonic effusions, drug induced pleurisy, eosinohilic granulomatosis with polyangiitis, benign asbestos effusions, malignancy, pulmonary infarction, fungal disease and parasitic disease
What is the differential for pleural effusions with glucose level less than 60 mg/dL?
Rheumatoid pleurisy Complicated parapneumonic effusion or empyema Malignant effusion Tuberculous pleurisy Lupus pleuritis Esophageal rupture
What is the differential for pleural fluid acidosis (pH < 7.30)?
Complicated parapneumonic effusions, malignancy, tuberculous pleuritis, rheumatoid and lupus pleuritis and esophageal rupture
In suspected pleural infection, a pH less than 7.20 should be treated with pleural drainage
What is the use and significance of pleural fluid amylase?
Pleural fluid amylase is elevated if the pleural fluid to serum amylase ratio is greater than 1.0 and suggests pancreatic disease, esophageal rupture and malignant effusions
What diagnoses a chylothorax?
A pleural fluid triglyceride level greater than 110 mg/dL
What test should be ordered in a lymphocyte predominant pleural effuion to rule out tuberculous effusions?
adenosine deaminase
What is the test most likely to yield a positive mycobacterial culture?
Pleural biopsy (>70%)
What is the appropriate workup for a pleural effusion you suspect to be malignant?
Cytology should be perfomred on any effusion in which malignancy is suspected. If the first specimen is negative, you should repeat cytology. Increase yield of 27% on second specimen but yield drops on third attempt. Thoracoscopy is the next step in evaluation of an exudative pleural effusion that is indeterminate and malignancy suspected
Name the 3 types of parapneumonic effusions
Uncomplicated
Complicated
Empyema
Define parapneumonic effusions
Exudative pleural effusions that occur adjacent to a bacterial pneumonia and result from migration of excess interstitial lung fluid across the visceral pleura
What are the characteristics of an uncomplicated parapneumonic effusion?
Small (<10mm on lat decubitus) with inflammatory cells present but sterile culture. Typically resolve spontaneously with PNA
What are the characteristics of an complicated parapneumonic effusion?
Involves persistent invasion of bacteria resulting in an increase in inflammatory cells and decreased pH and glucose levels but cultures still sterile. Consider antibitoics then thoracostomy tube drainage , serial follow up, may require thorascopic debridement
What are the characteristics of an empyema?
Clear infection of the pleural space with presence of pus, positive Gram stain or culture in the pleural fluid. When pH less than 7.2 or glucose < 60, requires chest tube drainage
What are the recommendations for antibiotics for pleural space infection?
Empiric antimicrobial coverage should include anaerobic coverage
What are the 3 causes of pneumothorax?
Spontaneously, result of trauma or iatrogenically
How is spontaneous pneumothorax further classified?
Primary spontaneous PTX
Secondary spontaneous PTX
Define primary vs secondary spontaneous PTX
Primary - in person without underlying lung disease
Secondary - in person with underlying lung disease
Risk factors for PSP vs SSP
PSP: smoking, tall stature, family hx, Marfan syndrome and thoracic endometriosis
SSP: COPD
How are PTX measured and what is considered large?
measuring the distance between the lung margin and the inner chest wall at the level of the hilum. Greater than 2cm
Which type of PTX is at higher risk for persistent leak?
SSP or further expansion of PTX due to their underlying lung disease, thus best managed with small bore pleural drain
What is the management for PSP with following scenarios:
- <2cm, minimal symptoms
- > 2cm, breathlessness and CP
- Clinical instability regardless of size
- observation alone; may be managed as outpatient
- needle aspiration; if reaccumulates then small bore CT
- emergent needle decompression followed by chest tube
What is the management for SSP with following scenarios:
- <2cm, minimal symptoms
- > 2cm, breathlessness and chest pain
- clinical instability regardless of size
- admit to hospital for observation and supplemental oxygen
- insertion of small bore chest tube
- emergent needle decompression followed by chest tube insertion
What is the recommendation for intervention to prevent occurrence with SSP and PSP?
Intervention is recommended in all SSP and after the 2nd PSP
