Pleural disease

Question 1

What are the two types of pleura that line the chest cavity and lung tissue, respectively?

Answer 1

Answer:

Visceral pleura lines the lung tissue, while parietal pleura lines the chest wall.

Question 2

What is pleural effusion, and where does it occur?

Answer 2

Answer:

Pleural effusion is the leakage and accumulation of fluid in the pleural cavity, which is the space between the visceral pleura and the parietal pleura.

Question 3

Name the two main types of fluids that can cause pleural effusion, along with their characteristics.

Answer 3

Answer:
transudate and exudate.

• Transudate is watery and low in protein, while
• exudate contains increased protein, plasma, and cells (RBCs, WBCs).

Question 4

What are the two mechanisms that can lead to transudative pleural effusion, and what conditions can cause them?

Answer 4

Answer:

• Mechanism #1: High capillary hydrostatic pressure (CHP) caused by congestive heart failure (left-sided heart failure) and constrictive pericarditis.
• Mechanism #2: Low capillary osmotic pressure (COP) caused by cirrhosis and nephrotic syndrome.

Question 5

How does inflammation of capillaries contribute to exudative pleural effusion, and what conditions can lead to this type of effusion?

Answer 5

Answer:

Inflammation of capillaries increases their permeability, leading to leakage of various substances like protein, plasma, and blood cells into the pleural cavity.

Conditions that can cause exudative pleural effusion include pneumonia, malignancy, collagen vascular diseases (e.g., rheumatoid arthritis, systemic lupus erythematosus), and systemic inflammation due to sepsis or pancreatitis.

Question 6

Explain the difference between early and late pulmonary embolism in terms of their contribution to pleural effusion.

Answer 6

Answer:

• In early pulmonary embolism, a clot blocks a pulmonary vessel, causing increased pressure before the clot and subsequent transudative fluid leakage.
• In late pulmonary embolism, immune cells and endothelial cells release inflammatory molecules, increasing permeability and leading to exudative fluid leakage.

Question 7

Which type of fluid, transudate, or exudate, has increased protein, plasma, and cells like RBCs and WBCs?

Answer 7

Answer: Exudate has increased protein, plasma, and cells (RBCs, WBCs).

Question 8

What are the two possible causes of high capillary hydrostatic pressure (CHP) leading to transudative pleural effusion?

Answer 8

Answer:

• congestive heart failure (left-sided heart failure) and
• constrictive pericarditis.

Question 9

Which type of pleural effusion is caused by systemic inflammation resulting from sepsis or pancreatitis?

Answer 9

Answer: Systemic inflammation leads to exudative pleural effusion.

Question 10

Describe the mechanism of how cirrhosis and nephrotic syndrome contribute to transudative pleural effusion.

Answer 10

Answer:

Cirrhosis and nephrotic syndrome lead to a reduction in albumin levels in the capillaries, resulting in decreased capillary osmotic pressure (COP) and causing fluid to leak into the pleural cavity.

Question 11

What is the normal role of lymphatic vessels in the pleural cavity?

Answer 11

Answer: Lymphatic vessels are responsible for draining fluid from the pleural cavity and transporting it into the venous circulation.

Question 12

What are the two main causes of reduced fluid clearance by lymphatic vessels, leading to pleural effusion?

Answer 12

Answer:
lymphoma or malignancy causing obstruction or compression of the lymphatic vessels and damage or compression of the thoracic duct.

Question 13

What is Chylothorax, and how does it occur?

Answer 13

Answer:

• the accumulation of lymph fluid with high-fat content (triglycerides and cholesterol) in the pleural cavity.
• It occurs when lymphatic fluid isn’t drained properly due to lymphoma, malignancy, or damage to the thoracic duct.

Question 14

What is pneumothorax, and how does it affect the lungs?

Answer 14

Answer: a condition where air is trapped between the visceral and parietal pleura in the pleural cavity, causing the lungs to collapse.v

Question 15

Differentiate between primary and secondary pneumothorax in terms of their underlying causes.

Answer 15

Answer:

• Primary pneumothorax occurs without any underlying lung disease and is more common in susceptible patients such as tall, thin, young, male individuals with a smoking history or connective tissue disorders like Marfan’s syndrome or Ehler-Danlos syndrome.
• Secondary pneumothorax, on the other hand, is associated with underlying lung diseases or conditions.

Question 16

What factors make individuals susceptible to primary pneumothorax?

Answer 16

Answer:

Susceptible individuals for primary pneumothorax are those who are tall, thin, young, male, and have a history of smoking or connective tissue disorders like Marfan’s syndrome or Ehler-Danlos syndrome.

Question 17

Why does primary pneumothorax occur more frequently at the apex of the lungs?

Answer 17

Answer:

• shearing friction forces caused by the height and weakness of connective tissue in susceptible individuals, leading to the rupture of blebs.

Question 18

What are some common causes of secondary pneumothorax?

Answer 18

Answer:

Secondary pneumothorax is associated with underlying lung diseases or conditions such as chronic obstructive pulmonary disease (COPD), pneumonia, tuberculosis, or lung cancer.

Question 19

In which type of pneumothorax does the presence of an underlying lung disease play a role?

Answer 19

Answer:

The presence of an underlying lung disease is associated with secondary pneumothorax.

Question 20

How does pneumothorax affect lung function?

Answer 20

Answer:
Pneumothorax causes the lungs to collapse, leading to impaired lung function and potentially difficulty in breathing.

Question 21

What is secondary pneumothorax, and what are the two main categories of its causes?

Answer 21

Answer: Secondary pneumothorax is a condition with a pre-existing underlying lung disease or due to trauma. Its causes fall into two categories: underlying lung diseases and trauma.

Question 22

What are the common underlying lung diseases that can lead to secondary pneumothorax?

Answer 22

Answer:
hyperinflation disorders like COPD and asthma, necrotizing infections such as Pneumocystis jirovecii pneumonia (PJP) and tuberculosis, and malignancies growing into the visceral pleura.

Question 23

How does hyperinflation in conditions like COPD and asthma contribute to secondary pneumothorax?

Answer 23

Answer:

• Hyperinflation in conditions like COPD and asthma can lead to the formation of bullae.
• These bullae can rupture and release air into the pleural cavity, causing pneumothorax.

Question 24

What is the role of necrotizing infections in the development of secondary pneumothorax?

Answer 24

Answer:

Necrotizing infections, such as PJP and tuberculosis, can involve the lung parenchyma, leading to destruction of lung tissue and creating an opening for air from the lung parenchyma to enter the pleural cavity.

Question 25

What is the role of necrotizing infections in the development of secondary pneumothorax?

Answer 25

Answer:

Necrotizing infections, such as PJP and tuberculosis, can involve the lung parenchyma, leading to destruction of lung tissue and creating an opening for air from the lung parenchyma to enter the pleural cavity.

Question 26

How can malignancies contribute to secondary pneumothorax?

Answer 26

Answer: Malignancies growing into the visceral pleura can create an opening for air to enter the pleural cavity.

Question 27

What are the different types of trauma that can cause secondary pneumothorax?

Answer 27

Answer:

Trauma leading to secondary pneumothorax can be non-iatrogenic, such as penetrating forces or blunt trauma causing damage to the lung tissue, or iatrogenic, which includes procedures like mechanical ventilation or central line insertion that may inadvertently allow air to enter the pleural cavity.

Question 28

Describe the difference between open pneumothorax and tension pneumothorax.

Answer 28

Answer:

• Open pneumothorax occurs when there is an opening in the chest that allows air to enter the pleural space. Air has a two-way flow during each breath. In contrast,
• tension pneumothorax is more dangerous and life-threatening, where air accumulates in the pleural space and does not escape.
• The valve-like structure prevents air from leaving during expiration, leading to increasing pressure, compression, mid-line shift, and lung displacement.

Question 29

What is the characteristic feature of tension pneumothorax during expiration?

Answer 29

Answer:

• During expiration in tension pneumothorax, the damage to the pleura creates a valve-like structure that prevents air from escaping the pleural cavity.
• This leads to an accumulation of air in the pleural cavity and increasing pressure, causing compression and displacement of the lung.

Question 30

How can procedures like thoracentesis and central line placement contribute to pneumothorax?

Answer 30

Answer:

• During thoracentesis, if the needle is inserted too far, it can damage the lung and allow air to enter the pleural cavity, causing pneumothorax.
• Similarly, incorrect central line placement, such as inserting the central line into the apex of the lung instead of the internal jugular vein, can result in pneumothorax.

Question 31

Why is secondary pneumothorax potentially more severe than primary pneumothorax?

Answer 31

Answer:
Secondary pneumothorax is potentially more severe than primary pneumothorax because it is associated with pre-existing lung diseases or trauma, which can lead to more significant lung damage and complications.

Question 32

What is atelectasis, and how does it differ from pneumothorax?

Answer 32

Answer:

• Atelectasis is caused by alveolar/bronchiolar collapse, making the lung appear smaller.
• It differs from pneumothorax, where air is trapped between the visceral and parietal pleura, causing lung collapse.
• In atelectasis, lung collapse is due to alveolar/bronchiolar collapse, while in pneumothorax, it is due to air accumulation in the pleural cavity.

Question 33

What are the three main causes of atelectasis?

Answer 33

Answer: The three main causes of atelectasis are obstruction, compression, and contraction.

Question 34

How does airway obstruction lead to atelectasis, and what are some common causes of obstruction?

Answer 34

Answer:

• Airway obstruction prevents air from entering the lungs, leading to alveolar collapse.
• Common causes of obstruction include mucus plug, foreign bodies, and tumors.

Question 35

How does compression of the lung tissue result in atelectasis, and what are some conditions that can cause compression?

Answer 35

Answer:

• Accumulation of fluid and air in the pleural cavity presses on lung tissue, leading to alveolar collapse.
• Pleural effusion and pneumothorax are conditions that can cause compression.

Question 36

Explain how dense fibrosis of the lung tissue can lead to atelectasis, and mention a condition associated with this cause.

Answer 36

Answer:

• Dense fibrosis of the lung tissue, as seen in interstitial lung disease, prevents the lung from expanding easily during inspiration, leading to alveolar collapse.
• During expiration, the fibrous tissue causes intense recoil, reducing the air left in the alveoli and further contributing to their collapse.

Question 37

What role do surfactants play in preventing atelectasis, and how does their deficiency lead to lung collapse?

Answer 37

Answer:

• Surfactants are proteins in the lungs that help reduce surface tension, preventing alveolar collapse.
• In conditions where there is a surfactant deficiency (e.g., IRDS) or surfactants are cleared away due to inflammation (e.g., ARDS), the reduced surfactants lead to increased surface tension, collapsing the alveoli.

Question 38

Name the three causes of atelectasis related to external pressure on the lung tissue.

Answer 38

Answer:

compression due to pleural effusion, compression due to pneumothorax, and contraction caused by dense fibrosis of the lung tissue.

Question 39

Which type of atelectasis is caused by a mucus plug or foreign body blocking the airway?

Answer 39

Answer: Obstructive atelectasis is caused by a mucus plug or foreign body blocking the airway.

Question 40

How does the presence of dense fibrosis in the lung tissue contribute to atelectasis?

Answer 40

Answer:
Dense fibrosis in the lung tissue makes it difficult for the lung to expand during inspiration, leading to alveolar collapse and atelectasis.

Question 41

What is the role of surfactants in preventing alveolar collapse, and which lung conditions can result from surfactant deficiency?

Answer 41

Answer:

• Surfactants reduce surface tension, preventing alveolar collapse.
• Surfactant deficiency can lead to lung conditions like IRDS (Infant Respiratory Distress Syndrome) and ARDS (Acute Respiratory Distress Syndrome).

Question 42

What is a common symptom shared by both pleural effusion and pneumothorax?

Answer 42

Answer:

Pleuritic chest pain . Injury to the pleura, such as fluid irritating the pleura or injury causing air accumulation in the pleura, can produce pain in the chest during breathing.

Question 43

How does the presence of fluid or air in the lungs affect chest expansion on the affected side in both conditions?

Answer 43

Answer:

In both pleural effusion and pneumothorax, the presence of fluid or air in the lungs prevents the lungs from completely expanding, leading to a unilateral decrease in chest expansion on the affected side.

Question 44

What is tactile fremitus, and how is it affected in both pleural effusion and pneumothorax?

Answer 44

Answer:

• Tactile fremitus is the sensation of vibrations felt on the chest wall when a patient speaks.
• In both pleural effusion and pneumothorax, the accumulation of fluid or air alters the vibrations, resulting in a decrease in tactile fremitus on the affected side.

Question 45

What can cause hypoxemia in severe cases of pleural effusion, pneumothorax, and atelectasis?

Answer 45

Answer:

• In severe cases of pleural effusion, pneumothorax, and atelectasis, hypoxemia can occur due to impaired gas exchange.
• Collapsed alveoli in atelectasis or the presence of fluid or air in the pleural cavity can hinder oxygen movement to the pulmonary capillaries, leading to decreased oxygen saturation (SpO2).
• To compensate, the body responds with increased respiratory rate (tachypnea) and heart rate (tachycardia).

Question 46

How does pleuritic chest pain differ between pleural effusion and pneumothorax concerning body position?

Answer 46

Answer:

• In pleural effusion, pleuritic chest pain is worse when the patient lies flat due to the layering of the pleural effusion affecting more alveoli.
• In contrast, pneumothorax may not be significantly affected by body position in terms of pleuritic chest pain.

Question 47

What is the cause of ipsilateral referred pain in the shoulder and neck in pleural effusion?

Answer 47

Answer: Pleural effusion accumulates at the bases of the lungs, irritating the phrenic nerve of the diaphragm, leading to ipsilateral referred pain in the shoulder and neck.

Question 48

How does percussion sound differ in pleural effusion and pneumothorax?

Answer 48

Answer:
In pleural effusion, percussion produces a dull sound, whereas in pneumothorax, percussion produces a hyper-resonant sound.

Question 49

Describe the features of tension pneumothorax and how it differs from a regular pneumothorax.

Answer 49

Answer:
* Tension pneumothorax is a more severe form of pneumothorax.

• It includes all the features of a regular pneumothorax (hyper-resonant to percussion, absent breath sounds) but also presents with
• additional complications like tracheal deviation to the contralateral side, absent breath sounds due to increasing accumulation of fluids and air, superior vena cava compression leading to jugular vein distention, and heart compression resulting in obstructive shock with decreased preload, stroke volume, cardiac output, and blood pressure.

Question 50

What is the importance of obtaining a chest X-ray for all pleural diseases?

Answer 50

Answer:

• A chest X-ray (CXR) is essential in the diagnosis of all pleural diseases to visualize the lungs, pleura, and any abnormal findings like opacities, effusions, or other lung pathologies.

Question 51

What should the costophrenic angle look like on a normal CXR, and how does it change in cases of infection or pleural effusion?

Answer 51

Answer: On a normal CXR, the costophrenic angle should appear crisp. In cases of infection or pleural effusion, the costophrenic angle may be lost or blunted due to the opacity caused by fluid or infection in the pleural cavity.

Question 52

Describe the MENISCUS SIGN and its association with pleural effusion.

Answer 52

Answer:

• The MENISCUS SIGN is a crescent-shaped inclusion of air surrounded by consolidated lung tissue seen on CXR in cases of pleural effusion.
• It indicates the presence of fluid in the pleural cavity with a layer of air above it.

Question 53

How do lung markings appear on CXR, and how are they affected in pneumothorax?

Answer 53

Answer:

• Lung markings are normally seen on CXR starting from the apex to the hemidiaphragm.
• In pneumothorax, the visible visceral pleural edge appears as a very thin, sharp white line, and no lung markings are visible peripheral to this line.

Question 54

What do smaller and denser lungs on CXR indicate, and which condition is associated with this appearance?

Answer 54

Answer:

• Smaller and denser lungs on CXR indicate atelectasis, where lung collapse leads to a decrease in lung size and increased density on the X-ray.
• Severe atelectasis can cause the entire lung field to appear white-out. Ipsilateral tracheal deviation may be observed in severe atelectasis.

Question 55

How can CT help differentiate between the causes of pleural effusion (transudative vs. exudative)?

Answer 55

Answer:

CT can help differentiate between transudative and exudative pleural effusion.

• Massive pleural effusions seen in severe heart failure are likely to be bilateral and transudative.
• Unilateral effusions are more likely to be exudative, caused by inflammatory conditions.

Question 56

How does air appear on CT, and what can large pneumothorax seen on CT be indicative of?

Answer 56

Answer:

• On CT, air appears as black.
• Large pneumothorax seen on CT can be indicative of severe emphysema, and in extreme cases, air can even reach the subcutaneous tissue.

Question 57

What is the purpose of thoracentesis, and for what conditions is it contraindicated?

Answer 57

Answer:

• Thoracentesis is a procedure performed to remove fluid or air from the thoracic cavity for both diagnostic and therapeutic purposes.
• It is contraindicated in patients with congestive heart failure and bilateral pleural effusion.

Question 58

What are Light’s criteria used for in thoracentesis?

Answer 58

Answer:

• Light’s criteria are used to determine whether a pleural effusion is exudative or transudative.
• They involve comparing the levels of serum and pleural fluid lactate dehydrogenase (LDH) and protein.

Question 59

What are the three criteria used in Light’s criteria to classify pleural effusion as exudative?

Answer 59

Answer: The three criteria for an exudative pleural effusion are:

[Pleural LDH] : [Serum LDH] > 0.6
[Pleural LDH] > 2/3 of the upper limit of normal (ULN) of [Serum LDH]
[Pleural Protein] : [Serum Protein] > 0.5

Question 60

What does an exudative pleural effusion indicate, and what are some possible etiologies?

Answer 60

Answer:

• An exudative pleural effusion indicates increased permeability of capillaries to fluid, proteins, and cells, allowing them to accumulate in the pleural cavity.
• Etiologies can include infection, malignancy, and cardiovascular disease.

Question 61

What does the acronym “MEAT” represent, and what is its relevance in pleural effusion diagnosis?

Answer 61

Answer:

• The acronym “MEAT” represents Malignancy, Empyema, Arthritis (RA), and Tuberculosis.
• In pleural effusion diagnosis, MEAT is associated with low glucose levels (<60) in the pleural fluid.

Question 62

What are the characteristics of pleural effusion associated with malignancy?

Answer 62

Answer:

• Pleural effusion associated with malignancy may show a large mass in the CXR or CT.
• To confirm, thoracentesis can be done, and cytology may reveal cancer cells.
• Low glucose levels (<60) can also be observed in the pleural fluid.

Question 63

How can thoracentesis help diagnose parapneumonic effusion, and what are some associated characteristics?

Answer 63

Answer: Thoracentesis can help diagnose parapneumonic effusion when it reveals an increase in white blood cells (PMNs) and a sterile effusion with a low pH (<7.2).

Question 64

What characteristics are indicative of an empyema, and how is it differentiated from other conditions?

Answer 64

Answer:

• Empyema is characterized by an increase in white blood cells (PMNs), positive culture, low pH (<7.2), and low glucose levels (<60) in the pleural fluid.
• It is differentiated from parapneumonic effusion by its positive culture result.

Question 65

What are the characteristics of pleural effusion associated with tuberculosis (TB)?

Answer 65

Answer:

• Pleural effusion associated with TB may show an increase in lymphocytes, a positive acid-fast bacilli (AFB) or culture result, low pH (<7.2), and low glucose levels (<60) in the pleural fluid.
• CXR or CT may reveal cavitary lesions.

Question 66

What conditions fall under collagen vascular diseases, and what is the significance of low glucose levels in these cases?

Answer 66

Answer:

• Collagen vascular diseases include RA, SLE, Wagner’s, and Churgg-Strauss.
• Low glucose levels in the pleural fluid are commonly associated with RA.
• In such cases, further testing may involve serum ANA, rheumatoid factor, and ANCA levels (c-ANCA for Wagner’s, p-ANCA for Churgg-Strauss).

Question 67

What is the treatment approach for a small and asymptomatic primary pneumothorax?

Answer 67

Answer:

• For a small and asymptomatic primary pneumothorax, observation is the preferred approach.
• The patient is monitored without intervention unless symptoms worsen.

Question 68

How is a large and symptomatic primary pneumothorax treated?

Answer 68

Answer:

• A large and symptomatic primary pneumothorax can be managed with either needle aspiration or chest tube insertion.
• Supplemental oxygen is also administered to aid in the resorption of air.

Question 69

What treatment is recommended for secondary pneumothorax in patients with underlying lung disease or traumatic causes?

Answer 69

Answer:

Secondary pneumothorax in patients with underlying lung disease or traumatic causes is typically treated with a chest tube and supplemental oxygen.

Question 70

How is a tension pneumothorax treated, and what signs indicate the need for urgent intervention?

Answer 70

Answer:

• A tension pneumothorax is treated with immediate needle decompression, followed by chest tube insertion.
• Urgent intervention is necessary if the patient exhibits signs of tracheal deviation, absent breath sounds, jugular vein distention (JVD), hypotension, and tachycardia.

Question 71

What is the recommended treatment for recurrent pneumothorax?

Answer 71

Answer:

• Recurrent pneumothorax is often treated with pleurodesis, which involves inducing a fibrotic reaction to prevent the separation of the pleura.
• Pleurodesis can be achieved through chemical means, using substances like talc, doxycycline, or silver nitrate, or through surgical methods.

Question 72

What are the main differences between transudate and exudate in pleural effusion?

Answer 72

Answer:

• Transudate is characterized by the leakage of fluid from blood vessels into the pleural cavity due to an imbalance in hydrostatic and oncotic pressures.
• It is typically associated with conditions like congestive heart failure (CHF).
  On the other hand,
• exudate is caused by inflammation and increased permeability of capillaries, leading to the accumulation of protein-rich fluid and cells in the pleural cavity.
• It can be associated with various conditions, including infections, malignancies, and collagen vascular diseases.

Question 73

How is transudative pleural effusion, most commonly caused by CHF, treated?

Answer 73

Answer:

• For transudative pleural effusion caused by CHF, the primary focus is on treating the underlying heart failure.
• Supportive measures, such as sodium (Na+) restriction and diuretics, may also be used to manage the fluid accumulation.
• Thoracentesis can be considered if the effusion is refractory to diuretics and other measures.

Question 74

What is the approach to managing exudative pleural effusion?

Answer 74

Answer:

• treating the underlying cause.
• Depending on the specific condition, examples of underlying causes include pulmonary embolism (PE), cardiovascular issues, and malignancy.

Question 75

How is parapneumonic effusion treated, and what differentiates it from empyema?

Answer 75

Answer:

• Parapneumonic effusion, which is a sterile localized inflammation without infection of the pleural fluid, is treated by addressing the underlying pneumonia with antibiotics.
• On the other hand, empyema is characterized by infected pleural fluid.
• Empyema requires antibiotic treatment along with chest tube insertion to drain the infected fluid.
• In some cases, tissue plasminogen activator (TPA) may be used to break down fibrin structures contributing to the empyema.

Question 76

What treatment options are available for recurrent pleural effusion seen in collagen vascular diseases or malignancy?

Answer 76

Answer:

• Recurrent pleural effusion in collagen vascular diseases or malignancy is often managed with pleurodesis, which aims to obliterate the pleural space and prevent fluid accumulation.
• Pleurodesis can be achieved using chemical agents like talc, doxycycline, or silver nitrate.
• Alternatively, a mechanical approach involving surgical intervention to agitate the pleural surface and induce fibrosis can also be used.

Question 77

What is the main principle of managing pleural effusion?

Answer 77

Answer: to treat the underlying disorder causing the effusion. Identifying and addressing the root cause is essential for effective management.

Question 78

How are infections associated with pleural effusion managed based on pH levels?

Answer 78

Answer:

Infections causing pleural effusion can be managed differently depending on the pH of the effusion.

Simple effusions (pH > 7.2) can be treated with antibiotics alone, while complicated effusions (pH < 7.2) require both chest drainage and antibiotics.

Question 79

When is conservative management of pleural effusion appropriate?

Answer 79

Answer:

• Conservative management may be suitable for small effusions that are likely to resolve with treatment of the underlying cause.
• However, larger effusions often require more active intervention, such as aspiration or drainage.

Question 80

Describe the procedure of pleural aspiration.

Answer 80

Answer: Pleural aspiration involves inserting a needle into the pleural space and aspirating the fluid to temporarily relieve pressure. However, repeated aspirations may be necessary as effusions can recur.

Question 81

How is pleurodesis performed, and what is its purpose?

Answer 81

Answer: Pleurodesis is a medical procedure used to treat recurrent pleural effusions. It involves instilling a substance into the pleural space to cause adhesion between the two layers of pleura, preventing fluid accumulation, and reducing the risk of recurrence. Common substances used for pleurodesis include talc, doxycycline, bleomycin, and silver nitrate.

Question 82

Where is the recommended location for chest tube drainage in pleural effusion management?

Answer 82

Answer:

• the 5th intercostal space, midaxillary line, within the safe triangle.
• The safe triangle is bounded by the anterior border of the latissimus dorsi, the posterior border of the pectoralis major, and an axillary line superior to the nipple.

Question 83

What is the initial broad-spectrum antibiotic regimen used in managing pleural effusion, and what oral antibiotic is typically given later?

Answer 83

Answer:

• Initially, broad-spectrum intravenous (IV) antibiotics such as amoxicillin and metronidazole are used.
• Once cultures come back, oral antibiotics directed towards the cultured bacteria are administered, usually co-amoxiclav for approximately 6 weeks.

Question 84

Why is aminoglycoside not used in managing pleural effusion?

Answer 84

Answer: their poor pleural penetration, which limits their effectiveness in treating infections in the pleural space.

Question 85

What are intra-pleural tPA and DNase, and how do they work together in pleural effusion management?

Answer 85

Answer:

• Intra-pleural tPA (tissue plasminogen activator) is a medication that breaks down blood clots in the pleural space, improving drainage and reducing the volume of fluid. DNase (deoxyribonuclease) is an enzyme that breaks down DNA released by dead cells, reducing the viscosity of pleural fluid and enhancing drainage.
• When used together, tPA and DNase are effective in improving drainage of complicated pleural effusions and reducing the need for surgery.

Question 86

What are some possible side effects of intra-pleural tPA and DNase treatment for pleural effusion?

Answer 86

Answer:
fever, chest pain, and cough. In rare cases, these medications can cause bleeding or other serious complications, making close monitoring and adherence to appropriate administration protocols crucial.

Question 87

What are the signs that indicate no treatment is required for a pneumothorax?

Answer 87

Answer:

• No treatment is required for a pneumothorax if the patient is asymptomatic and there is a < 2cm rim of air on the chest x-ray.
• If the patient does not experience shortness of breath (SOB) and the pneumothorax meets the specified criteria, it will likely resolve spontaneously.
• Follow-up in 2-4 weeks is recommended.

Question 88

When should a chest drain be used for pneumothorax management?

Answer 88

Answer: A chest drain should be used in the following situations:

If aspiration fails twice AND
Unstable patients or
Bilateral pneumothoraces

Question 89

Where is the “triangle of safety” located for chest drain insertion in pneumothorax management?

Answer 89

Answer:

• located at the 5th intercostal space (or the inferior nipple line), the mid-axillary line (or the lateral edge of the latissimus dorsi), and the anterior axillary line (or the lateral edge of the pectoralis major).
• The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib.
• After chest drain insertion, a chest x-ray is obtained to confirm proper positioning.

Question 90

What is the recommended initial supportive therapy for all patients with pneumothorax?

Answer 90

Answer:

• All patients with pneumothorax should receive supplemental high flow oxygen through a non-rebreather mask or a high flow nasal cannula.
• This helps the pneumothorax to get resorbed.

Question 91

In what cases should aspiration be considered as a therapy for pneumothorax, and where should the aspiration needle be inserted?

Answer 91

Answer:

• Aspiration should be considered in acutely unwell patients with tension pneumothorax.
• The aspiration needle should be inserted between the 2nd and 3rd ribs below the midpoint of the clavicle.
• If aspiration fails, a chest drain should be inserted in the “triangle of safety.”