Pleural Disease

Question 1

Pleural effusion

Answer 1

An abnormal accumulation of fluid in pleural space.

1) Transudate: secondary to increased pulmonary capillary wedge pressure or decreased oncotic pressure
2) Exudate: secondary to increased pleural vasculature permeability

Question 2

History and physical for pleural effusion

Answer 2

Presents with dyspnea, pleuritic chest pain, and/or cough. Exam reveals dullness to percussion and decreased breath sounds over the effusion. A pleural friction rub may be present

Question 3

Dx of pleural effusion

Answer 3

1) CXR shows costophrenic angle blunting. A lateral decubitus view can be used to assess loculation
2) Thoracentesis is indicated for new effusions greater than 1cm in decubitus view, except with bilateral effusions and other clinical evidence of CHF
3) The effusion is an exudate if it meets any of Light’s criteria

Question 4

Causes of transudative effusions

Answer 4

1) CHF
2) Cirrhosis
3) Nephrotic Syndrome

Question 5

Causes of exudative effusions

Answer 5

1) Pneumonia (parapneumonic effusion)
2) TB
3) Malignancy
4) PE
5) Collagen vascular disease (RA, SLE)
6) Pancreatitis
7) Trauma

Question 6

Light’s criteria

Answer 6

An effusion is an exudate if ANY of the criteria are met

1) Pleural protein: serum protein more than 0.5
2) Pleural LDH: serum LDH more than 0.6
3) Pleural fluid LDH more than two thirds the upper limit of normal serum LDH

Question 7

Tx of pleural effusion

Answer 7

1) Treatment is directed toward the underlying condition causing the effusion
2) Complicated parapneumonic effusions and empyemas require chest tube drainage in addition to antibiotic therapy

Question 8

Pneumothorax

Answer 8

Defined as a collection of air in the pleural space that can lead to pulmonary collapse. Etiologies include penetrating trauma, infection, and positive pressure mechanical ventilation

Shock and death result unless the condition is immediately recognized and treated.

1) Primary spontaneous PTX - secondary to rupture of subpleural apical blebs (usually found in tall, thin young males)
2) Secondary PTX - secondary to COPD, trauma, infections (TB, pneumocystis jiroveci), and iatrogenic factors (thoracentesis, subclavian line placement, positive pressure ventilation, bronchoscopy)
3) Tension PTX - a pulmonary or chest wall defect acts as a 1-way valve causing air trapping in the pleural space

Question 9

History and physical for PTX

Answer 9

Presentation is P-THORAX

Pleuritic pain
Tracheal deviation
Hyperresonance
Onset sudden
Reduced breath sounds (and dyspnea)
Absent fremitus (asymmetric chest wall)
XR shows collapse

1) Presents with acute onset of unilateral pleuritic chest pain and dyspnea
2) Exam reveals tachypnea, diminished or absent breath sounds, hyperresonance, low tactile fremitus, and JVD secondary to compression of SVC
3) Tension pneumo also presents with tracheal deviation and hemodynamic instability

Question 10

Dx of PTX

Answer 10

1) Diagnosis of T-PTX should be made clinically and should be followed by immediate treatment
2) CXR shows the presence of a visceral pleural line and/or lung retraction from chest wall (both seen in end-expiratory films)

Question 11

Tx of PTX

Answer 11

1) Tension PTX requires immediate needle decompression (second intercostal space at the midclavicular line) followed by the chest tube placement
2) Small pneumothoraces may resorb spontaneously. Supplemental O2 is helpful
3) Large, symptomatic PTXs require chest tube