Pleural Disease

Question 1

Normal amount of fluid in pleural space?

Answer 1

less than 10 cc

-only parietal pleural is innervated

Question 2

Causes of excess pleural fluid formation

Answer 2

• Leaky membranes (inflammation)
• Increased capillary hydrostatic pressure (CHF)
• decreased pleural pressure (atelectasis)
• Decreased capillary oncotic pressure (hypoalbuminemia)

Question 3

Possible symptoms of Pleural effusion

Answer 3

• None
• Pain
• Dyspnea
• Respiratory Failure

Question 4

Physical exam signs of pleural effusions

Answer 4

• dullness to percussion
• decreased breath sounds and tactile remits
• egophony

Question 5

Evaluation of Effusions

Answer 5

• H & P

- Thoracentesis (Diagnostic is 50cc)

Question 6

Criteria for exudates

Answer 6

• TP (pleura) / TP (serum) > 0.5
• LDH (pleura) / LDH (serum) > 0.6
• LDH (pleura) > 200 (or 2/3 upper normal)
• Cholesterol (pleura) > 45

Question 7

Diseases causing Transudative Effusions

Answer 7

• CHF
• Cirrhosis
• Nephrotic syndrome
• Atelectasis
• Hypothyroidism
• Pulmonary Embolism (15%)
• Peritoneal Dialysis

Question 8

Markers in Pleural effusions

-pH

Answer 8

low pH may be seen with infection (empyema), malignancy, and esophageal rupture

Question 9

Markers in Pleural effusions

-Glucose

Answer 9

low glucose in rheumatoid arthritis, TB, cancer, empyema

Question 10

Markers in Pleural effusions

-Total WBC

Answer 10

Not important unless frank pus

• many PMN’s suggest acute infection
• many lymphocytes suggest TB or or fungus
• more than 5% mesothelial cells speaks against TB

Question 11

Markers in Pleural effusions

-Total RBC

Answer 11

Hematocrit in pleura > half of peripheral circulation is a hemothorax

Question 12

Markers in Pleural effusions

-Amylase

Answer 12

-pancreatitis and/or esophageal rupture

Question 13

Patterns with TB

Answer 13

• exudative
• lymphocytic
• less than 5% mesothelial cells
• (+) for ADA
• PPD negative early

Question 14

Patterns with malignant effusions

Answer 14

• exudative
• lymphocytic
• RBCs
• maybe low pH
• low glucose

Question 15

Patterns with PE

Answer 15

• 85 % are exudative
• unilateral
• might have blood

Question 16

Patterns with Esophageal rupture

Answer 16

• Left sided
• low pH
• high amylase

Question 17

Patterns with Endometriosis

Answer 17

• Bloody

- Prophylactic treatment with hemoptysis

Question 18

Patterns with Hepatic effusions

Answer 18

-underlying cirrhosis
-transudates
-more right sided
rapid re-accumulation

Question 19

Patterns with Milky effusions

Answer 19

• Chylothorax (TG > 110)
• malignancy, trauma, mediastinal disease (ruptured thoracic duct)
• Pseudochylothorax (TG >100 and Chol > 200)
• Empyema

Question 20

What classifies a complicated exudate?

Answer 20

• very low pH and/ or glucose
• very high LDH
• it’s at risk to become an empyema

Question 21

What is a pleurodesis?

Answer 21

chemical or mechanical irritation of the visceral or parietal pleura to create adhesion and obliteration of the pleural space

• prevents re-accumulation of fluid
• chemically or mechanically

Question 22

How does a tension pneumothorax develop?

Answer 22

ball valve mechanism that leads to supra atmospheric pleural pressure
-causes decreased venous return and hypotension

Question 23

Symptoms for pneumothorax

Answer 23

• Often asymptomatic
• chest pain
• dyspnea
• cough
• shock (tension only)

Question 24

Physical exam for pneumothorax

Answer 24

• unilateral hyperinflation
• decreased breath sounds and tactile remits
• Hyper-resonance

Question 25

Classification of pneumothorax

Answer 25

• Spontaneous
• Traumatic/Iatrogenic
• Primary/Secondary