Pleural disease

Question 1

Which conditions can cause a “pleural rub”?

Answer 1

Anything that causes inflammation of the pleura - PE or pneumonia

Question 2

Is there a pleural rub audible in pleural effusion?

Answer 2

No, the fluid in the pleural cavity keeps the two surfaces from touching so there is no rub to be heard.

Question 3

What is the pulmonary ligament?

Answer 3

Attachment of the root of the lung to the diaphragm

Consists of the two layers of pleura combining around the root of the lung

Question 4

What type of nerves supply the parietal pleura and what are their names?

Answer 4

Somatic sensory - senses pain

Supplied by the intercostal and phrenic nerves

Question 5

What type of nerves supply the visceral pleura and which nerve does this?

Answer 5

Autonomic - senses stretch

Vagus nerve

Question 6

How is effusion diagnosed?

Answer 6

History
CXR
Aspiration - transudate or exudate?

Question 7

What does an effusion with a bloody appearance indicate?

Answer 7

Trauma
Malignancy
Infection
Infarction

Question 8

What does an effusion with a straw-coloured appearance indicate?

Answer 8

Cardiac failure

Hypoalbuminaemia

Question 9

What does an effusion with a turbid/milky appearance indicate?

Answer 9

Chylothorax

Empyema

Question 10

What is the definition of a transudate effusion?

Answer 10

Effusion with a protein level <30g/L

Question 11

What is the definition of an exudate effusion?

Answer 11

Effusion with a protein level >30g/L

Question 12

What does a transudate effusion indicate?

Answer 12

"Organ failure"
Cardiac failure
Liver cirrhosis
Nephrotic syndrome
Hypothyroidism

Question 13

What does an exudate effusion indicate?

Answer 13

Malignancy
Infection
PE
Rheumatoid
TB
Benign asbestos related effusion
Pancreatitis

Question 14

Which workers are at risk of developing asbestosis?

Answer 14

Miners
Construction workers
Boiler workers 
Piping workers
Mechanics

Question 15

What is the characteristic pathology of asbestosis?

Answer 15

Benign pleural plaques

Question 16

What are benign pleural plaques at risk of developing into?

Answer 16

Mesothelioma - incurable cancer of the pleura

Question 17

How is asbestosis diagnosed?

Answer 17

Asbestos bodies can be detected in sputum and biopsy

Question 18

What other cancer are asbestosis patients at risk of developing?

Answer 18

Bronchial carcinoma

Question 19

What interstitial lung disease does asbestos exposure also cause?

Answer 19

Pulmonary fibrosis producing a restrictive pattern

Question 20

What changes occur in the pleura of patients with asbestosis?

Answer 20

Exudative pleural effusion
Diffuse pleural thickening
Benign pleural plaques

Question 21

How is pleurodesis performed?

Answer 21

Inflammation is induced between the two pleural surfaces, leading to all symptoms of pleurisy in the short term, but ultimately the inflammation allows the two surfaces to stick together, leaving no space for fluid to accumulate - this can be done by injecting talc

Question 22

What should the pH of aspirated effusion be?

Answer 22

pH 7.6

<7.2 needs to be drained

Question 23

How should effusion be treated?

Answer 23

Treat underlying cause

Thoracentesis (chest drainage)

Question 24

Why should large volumes of fluid not be drained all at once?

Answer 24

Risk of re-expansion pulmonary oedema - this can be life threatening

Question 25

What volume of fluid should be drained at what rate?

Answer 25

1L should be drained before drain is clamped for an hour to allow gradual re-expansion