Pleural disease

Question 1

What is the pleura ?

Answer 1

Smooth, thin membrane around the lungs

Question 2

What is the outer layer ?

Answer 2

Parietal pleura

Question 3

What is the inner layer ?

Answer 3

Visceral pleura

Question 4

What cells are in the pleural fluid ?

Answer 4

Macrophages
Lymphocytes
Mesothelial cells

Question 5

What is the plural pressure ?

Answer 5

Subatmopheric
-3 to -5 cm of water
Apex-base

Question 6

What is a pleural effusion ?

Answer 6

Collection of fluid in the pleural space

Question 7

What are the signs of pleural effusion ?

Answer 7

Decreased expansion
Stony dullness on percussion
Decreased breath sounds
Decreased vocal resonance

Question 8

What is the imbalance in a pleural effusion ?

Answer 8

Imbalance between production and absoption

Question 9

What are the types of effusion ?

Answer 9

Transudate

Exudate

Question 10

What is a transudate effusion ?

Answer 10

Non-inflammatory

Question 11

What are some common causes of transudate effusion ?

Answer 11

Left ventricular failure

Liver cirrhosis

Question 12

What is an Exudate effusion ?

Answer 12

Inflammatory

Question 13

What are some common causes of exudate effusions ?

Answer 13

Malignancy
Parapneumonic effusions
Empyema
TB

Question 14

What is the protein content of exudate ?

Answer 14

3g/dl or more

Question 15

What is lights criteria ?

Answer 15

Protein: pleural fluid/ serum fluid ratio >0.5
LDH: pleural fluid/serum fluids ratio >0.6
Pleural fluid LDH >2/3rd ULN serum LDH

Question 16

What are the investigations of pleural effusions ?

Answer 16

US: more sensitive than CXR
mark site for aspiration
assess pleura, bedside

CXR: accessible
easy to interpret

CT thorax: complex effusions
vascular and mediastinal structures

Question 17

How is pleural fluid analysed ?

Answer 17

Aspiration

pH, biochemistry, microbiology and pleural biopsy

Question 18

What is the management of a pleural effusion ?

Answer 18

pH <7.2 with pneumonia, pus or blood may need a chest drain
Transudate: treat the underlying cause, may not need CT imaging
Exudate: further investigations and pleural biopsy

Question 19

What is a pneumothorax ?

Answer 19

Collection of air in the pleural space

Question 20

What are the types of pneumothorax ?

Answer 20

Primary spontaneous
Secondary spontaneous 
Traumatic
Latrogenic
Tension

Question 21

How is a pneumothorax presented ?

Answer 21

Sudden event
Chest pain or SOB
Tall thin young men
Underlying lung disease
History of biopsy/ line insertion/ mechanical ventilation

Question 22

What are the signs found on examination of a pneumothorax ?

Answer 22

Tachypnoeic- breathing fast
Hypoxic
Reduced chest wall movement and reduced or no breath sounds
Examination may be normal

Question 23

How is a pneumothorax diagnosed ?

Answer 23

CRX
US
CT thorax

Question 24

How is a pneumothorax managed ?

Answer 24

Aspiration: >2cm
Chest drain insertion
Surgery: recurring events, unresolving

Question 25

Where is a pleural drain put ?

Answer 25

2nd intercostal space midclavicular line

Question 26

What type of pleural tumours are rare ?

Answer 26

Benign

Question 27

What is a pleural malignancy ?

Answer 27

Mesothelioma

Question 28

What is mesothelioma ?

Answer 28

Rare, aggressive form of cancer in the pleura

Question 29

What can cause mesothelioma ?

Answer 29

Exposure to asbestos fibres

Question 30

What are the symptoms and signs of mesothelioma ?

Answer 30

Breathlessness
Chest pain
Weight loss 
Clubbing
Signs of pleural effusion

Question 31

How is mesothelioma diagnosed ?

Answer 31

CXR: pleural effusion, pleural based mass#
CT thorax and biopsy: needed to stage
Thickened pleura, pleural nodules or masses, pleural plaques, an effusion, soft tissue infiltration

Question 32

What is the management of mesothelioma ?

Answer 32

Limited, incurable
Treat effusion
Chemotherapy
Palliative surgery