pleural disease

Question 1

what is pleural pressure

Answer 1

subatmospheric
-3 to -5cm of water
gradient from apex to base

Question 2

what is the protein content of pleural fluid

Answer 2

1.5 -2g/dl

Question 3

what are some examples of pleural problems

Answer 3

collection of fluid - pleural effusion
collection of air - pneumothorax
pleural malignancy - mesothelioma

Question 4

what is pleural effusion

Answer 4

collection of fluid in the pleural space
imbalance between production and absorption
absorption: pleural lymphatics in the parietal pleura

Question 5

what are the types of effusion

Answer 5

transudate: non inflammatory
exudate: inflammatory
protein content of exudate: 3g/dl or more

Question 6

what is the lights criteria

Answer 6

protein: pleural fluid/ serum fluid ratio>0.5
LDH: pleural fluid/serum fluid ratio > 0.6
pleural fluid LDH > 2/3 rd ULN serum LDG

Question 7

what are the causes of transudates

Answer 7

left ventricular failure 
left cirrhosis 
hypoalbuminaemia 
peritoneal dialysis 
constructive pericarditis

Question 8

what are causes of exudates

Answer 8

malignancy 
parapneumonic effusion, empyema 
tuberculosis 
pancreatis
pulmonary embolism 
haemothorax
fungal infection

Question 9

how do you analyse pleural fluid

Answer 9

aspiration: simple and safe, trained operator
inspect the fluid
pH (bedside ABG machine), biochemistry, microbiology, cytology

Question 10

how do you manage pleural effusion

Answer 10

pH less than 7.2 with pneumonia, pus or blood may need to chest drain
transudate : treat the underlying cause, may not need CT imaging
exudate: unless cause identified will need further investigation for eg further imaging and or pleural biopsy

Question 11

what are the examples of pneumothorax

Answer 11

primary spontaneous 
secondary spontaneous 
traumatic 
latrogenic 
tension

Question 12

what are the presentations of pneumothorax

Answer 12

sudden event 
chest pain or breathlessness 
tall thin young men 
underlying lung disease 
history of biopsy/line insertion/mechanical ventilation

Question 13

what may be found on examination of people w a pneumothorax

Answer 13

breathing fast: tachypneic
hypoxic
reduced chest wall movement and reduced or no breath sounds
not uncommonly examination may be normal

Question 14

how do u diagnose a pneumothorax

Answer 14

CXR
us experienced operator usuallt A and E And ITU
CT thorax

Question 15

how do u manage a pneumothorax

Answer 15

observe: small and patient well
aspiration: over 2cm in size, patient well
chest drain insertion
surgery: recurrent events, unresolving

Question 16

where do you do pleural aspiration/ drain

Answer 16

safe triangle

2nd intercostal space midclavicular lime

Question 17

what are pleural tumours

Answer 17

benign:rare
malignant pleural effusions are common and associated with a poor outcome
primary malignancy: mesothelioma is the most frequent

Question 18

what is mesothelioma

Answer 18

rare and aggressive
occupational
inhaled asbestos fibres reach the pleura and cause inflammation provokes tumour formation

Question 19

what are the symptoms of mesothelioma

Answer 19

breathlessness
chest pain
weight loss
clubbed, signs of pleural effusion

Question 20

how do you diagnose a pleural tumours

Answer 20

CXR: Pleural effusion, pleural based mass
CT thorax and biopsy: needed to stage (gauge extent eg any distant spread etc)
thickened pleura, pleural nodules or masses, pleural plaques, an effusion, soft tissue infiltration

Question 21

how do you manage pleural tumours

Answer 21

treatment options limited, palliative, survival poor 
treating the effusion
chemotherapy
recruitment to trails via MDTs 
palliative surgery in select patients