Pleural Disease

Question 1

The normal pleural space is filled with approximately 7–14 mL of low-protein pleural fluid in a normal adult man and approximately 0.15 mL/kg of fluid is produced hourly by the parietal pleura.

Answer 1

The symptom most associated with significant drops in pleural pressure is chest discomfort.

Question 2

When should you consider terminating fluid removal during thoracentesis?

Answer 2

When a patient complains of chest discomfort or when 1.5L has been removed

Question 3

Which organism is associated with a complicated parapneumonic pleural effusion that has an elevated pH?

Answer 3

Proteus. In general, all other complicated parapneumonic effusions will have a low pH.

Question 4

PF albumin (or protein) gradient is useful in diagnosing false exudates in a congestive heart failure (CHF) patient who has undergone diuresis:
Albumin gradient = serum albumin - PF albumin.

Answer 4

Albumin gradient > 1.2g/dL is consistent with a transudate.
Albumin gradient ≤ 1.2g/dL is consistent with an exudate. o Protein gradient > 3.1 g/dL is consistent with a transudate.

Question 5

Pleural pH and it’s pitfalls

Answer 5

Air in the syringe increases pH.
Time increases pH.
Lidocaine decreases pH.

Question 6

The most common causes of lymphocytic effusions:

Answer 6

Tuberculous pleuritis,
post-CABG
rheumatoid arthritis (RA) pleural effusion
yellow nail syndrome,
chylothorax (typically > 80% of total nucleated cells)
Malignant effusions (typically 50–70% of nucleated cells)

Question 7

Eosinophilic effusions >10% of nucleated cells. most common causes:

Answer 7

Eosinophils in an effusion are nonspecific and usually reflect blood (hemothorax) or air (pneumothorax).

Question 8

Which pleural effusion most commonly presents with dyspnea out of proportion to pleural effusion size?

Answer 8

Pleural effusion secondary to CHF

Question 9

A patient with CHF being diuresed has an exudative pleural effusion. What is the best way to evaluate whether this is a false exudate in the setting of diuresis?

Answer 9

Check PF albumin (or protein) gradient
>1.2 transudate

Question 10

What is the treatment of choice for spontaneous bacterial pleuritis?

Answer 10

Antibiotics (e.g., cefotaxime), similar to treatment of spontaneous bacterial peritonitis

Question 11

A patient with nephrotic syndrome presents with an exudative pleural effusion. What diagnosis should you suspect?

Answer 11

Pulmonary embolus

Question 12

A CT scan after thoracentesis showing incomplete lung re- expansion with a thickened visceral pleura suggests either a trapped or an entrapped lung. Chest-tube placement in this scenario is unlikely to lead to lung re-expansion.

Answer 12

Malignant pleural effusions are the second leading cause of exudative effusions next to parapneumonic effusions.

Question 13

Low pH and transudative pleural effusion cause?

Answer 13

Urinothorax is the only cause of a low pH transudative pleural effusion.
Pleural creatinine: Serum creatinine ratio > 1

Question 14

MIST-1 study:

Answer 14

MIST-1 study = intrapleural tPA vs. placebo in treatment of empyema with no benefits noted.

Question 15

MIST-2 study:

Answer 15

MIST-2 study = intrapleural tPA + DNase superior to either agent alone in treatment of empyema in terms of improved fluid drainage, reduced frequency of surgical referral, and reduced duration of hospital stay.

Question 16

What are the indications for chest-tube drainage of a parapneumonic effusion?

Answer 16

Frankly purulent or turbid/cloudy PF, pH < 7.2, positive Gram stain or culture

Question 17

A new unilateral left-sided pleural effusion in the absence of active infectious symptoms should be considered a malignant pleural effusion until proven otherwise.

Question 18

Therapeutic Intervention in
Malignant Effusion (TIME)-

Answer 18

2 Study = IPC vs. chest-
tube pleurodesis in
Talc is the most effective management of malignant
agent for chest-tube pleural effusion → no
pleurodesis.
difference in dyspnea at 6
weeks but shorter length of initial hospitalization and less dyspnea at 6 months in IPC group.

Question 19

Dressler syndrome:

Answer 19

Dressler syndrome is a secondary form of pericarditis that occurs after myocardial or pericardial injury and consists of the triad of fever, pleuritis, and pericarditis.

Question 20

Pleural fluid from patients with TB rarely contains >5% mesothelial cells and would strongly argue against tuberculous pleuritis if present.

Answer 20

PF cultures positive in < 40% of patients with tuberculous pleuritis.

Question 21

Two main diseases other than tuberculous pleuritis that are associated with a high PF ADA are?

Answer 21

empyema and rheumatoid pleuritis.

Question 22

The most striking characteristics of rheumatoid pleural effusion are its low glucose and low pH, helping distinguish it from lupus pleuritis.

Answer 22

Lupus pleuritis has normal or high glucose and pH normal

Question 23

Effusions secondary to pancreatitis are typically left-sided.

Question 24

BAPE is typically the first manifestation of asbestos- related disease that occurs after exposure.

Answer 24

BAPE has no clear prognostic implications for the development of pleural plaques or malignancy.

Question 25

Pleural plaques serve as a marker of asbestos exposure

Question 26

When should recurrence prevention be offered for spontaneous pneumothorax?

Answer 26

At the time of the second occurrence of a PSP or the first occurrence of a SSP