Pleural disease

Question 1

What is a pleural effusion?

Answer 1

Collection of fluid in the pleural cavity

Question 2

Fluid can be of what two types?

How do these differ?

Answer 2

1. Transudative - lower protein count (<3g/dL)
2. Exudative - high protein count (>3g/dL)

Question 3

Cause of exudative effusion

Answer 3

Inflammation

Results in protein leaking out of the tissues in to the pleural space

Question 4

List 4 Exudative causes of pleural effusion

Answer 4

1. Lung cancer
2. Pneumonia
3. Rheumatoid arthritis
4. Tuberculosis

Question 5

Cause of transudative effusion

Answer 5

Related to fluid moving across into the pleural space

Question 6

List 4 Transudative causes of pleural effusion

Answer 6

1. Congestive cardiac failure
2. Hypoalbuminaemia
3. Hypothroidism
4. Meig’s syndrome

Question 7

What criteria allows differentiation of a transudate vs exudate

In what instance is it used?

Answer 7

Light’s criteria

Should be used on if the protein level is between 25-35 g/L

Question 8

Explain lights criteria

Answer 8

An exudate is likely if at least one of the following are met:

1. pleural fluid protein divided by serum protein >0.5
2. pleural fluid LDH divided by serum LDH >0.6
3. pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

Question 9

What is Meig’s syndrome?

Answer 9

Right sided pleural effusion with ovarian malignancy

Question 10

How does a pleural effusion present?

Answer 10

1. SOB
2. Dullness to percussion over the effusion
3. Reduced breath sounds
4. Tracheal deviation away from the effusion if large

Question 11

Investigations for a pleural effusion?

Highlight the first line

Answer 11

1. Chest X-ray
2. USS: for aspiration
3. Contrast CT: to identify cause

Question 12

List 4 X-ray findings which may be seen in a pleural effusion

Answer 12

1. Blunting of the costophrenic angle
2. Fluid in the lung fissures
3. Meniscus
4. Tracheal and mediastinal deviation

Question 13

What size needle and syringe should be used in aspiration of a pleural effusion?

Answer 13

21G needle and 50ml syringe

Question 14

What should be tested in a Pleural aspiration

Answer 14

1. pH
2. protein
3. lactate dehydrogenase (LDH)
4. cytology and microbiology

Question 15

What should be tested in a Pleural aspiration

Answer 15

1. pH
2. protein
3. lactate dehydrogenase (LDH)
4. cytology and microbiology

Question 16

List 2 ddx for low glucose on pleural aspiration

Answer 16

RA or TB

Question 17

List 2 ddx for raised amylase on pleural aspiration

Answer 17

1. Pancreatitis
2. Oesophageal perforation

Question 18

List 3 ddx for heavy blood staining on pleural aspiration

Answer 18

1. Mesothelioma
2. PE
3. TB

Question 19

Treatment of a pleural effusion?

Answer 19

1. Conservative management for small effusions
2. Pleural aspiration for larger effusions (temporary relief)
3. Chest drain (to drain effusion and prevent reoccurrence)

Question 20

What is Empyema

Answer 20

An infected pleural effusion

Question 21

List 4 findings on pleural aspiration which indicate Empyema?

Answer 21

1. Pus
2. Acidic pH (pH < 7.2)
3. low glucose
4. high LDH

Question 22

How is Empyema treated?

Answer 22

Chest drain to remove the pus and antibiotics

Question 23

What is a pneumothorax?

Answer 23

When air gets into the pleural space, separating the lung from the chest wall

Typical patient in exams is a tall, thin young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sports

Question 24

List 4 causes of a penumothorax

Answer 24

1. Spontaneous
2. Trauma
3. Iatrogenic ie. lung biopsy, mechanical ventilation or central line insertion
4. Lung pathologies ie. asthma or COPD

Question 25

What is the investigation of choice for a simple pneumothorax?

Answer 25

Erect chest x-ray

Question 26

What would be seen on x-ray in a simple pneumothorax?

Answer 26

Area between lung tissue and the chest wall where there are no lung markings

Line demarcating the edge of the lung

Question 27

According the the BTS guidelines, how can the size of a pneumothorax be measured on x-ray?

Answer 27

Involves measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum

Question 28

What investigation may be used if a pneumothorax is too small to be seen on x-ray?

Answer 28

CT thorax

Can also be used to accurately assess the size of the pneumothorax

Question 29

How is the management of a pneumothorax be divided?

Answer 29

1. No shortness of breath and less than a 2cm rim of air on the chest x-ray
2. Shortness of breath and/or more than a 2cm rim of air on the chest x-ray

Question 30

Treatment if there is no SOB and < 2cm rim of air on the chest x-ray?

Answer 30

1. No treatment required, will spontaneously resolve
2. Follow up in 2-4 weeks is recommended

Question 31

Treatment if there is SOB and/or > 2cm rim of air on the chest x-ray?

Answer 31

1. Aspiration followed by reassessment
2. If aspiration fails twice, a chest drain is required

Question 32

In what instances may a chest drain be required as first line management?

Answer 32

1. Unstable patients
2. Bilateral or secondary pneumothoraces

Question 33

Chest drains are inserted in the “triangle of safety”

List the boarders of this

Answer 33

1. 5th intercostal space
2. Midaxillary line
3. Anterior axillary line

Question 34

Where is the needle inserted in relation to the rib?

Answer 34

Just above the rib to avoid the NV bundle

Question 35

List 2 key complications of a chest drain

Answer 35

1. Air leaks at drain site (indicated by persistent fluid bubbling, esp on coughing)
2. Surgical emphysema when air collects in the subcutaneous tissue