Pleural Disease

Question 1

Symptoms of pleural effusion

Answer 1

Worsening breathlessness
Pleuritic pain (progressive if malignant)
Dry cough

Question 2

Signs of Pleural effusion

Answer 2

Affected chest side:
Decreased expansion
Stony dullness
Decreased breath sounds
Decreased vocal resonance
Cervical lymph nodes
Increased JVP
Peripheral oedema

Question 3

Why is the net movement of fluid from the pleura into the lung?

Answer 3

Systemic arterial pressure is greater than the pulmonary arterial pressure (4>1.5)

Question 4

Transudates: protein content, usual presentation, common causes.

Answer 4

<30g/L
Bilateral
LVF
Liver cirrhosis
Hypoalbuminaemia
Peritoneal dialysis

Question 5

Exudates: protein content, usual presentation, common causes

Answer 5

> 30g/L
Unilateral
Malignancy
Parapneumic (inflammatory)

Question 6

When to investigate pleural effusion further?

Answer 6

Unilateral

Fails to respond to treatment

Question 7

Additional investigations for pleural effusion, what does each look for?

Answer 7

Pleural aspiration - content
Contrast CT - malignancy
CXR - pleural thickening

Question 8

How is a pleural aspiration performed?

Answer 8

Patient bends over
Guide needle with ultrasound
Use antiseptic and lignocaine
Drain 50ml

Question 9

Different tests performed on aspirated fluid?

Answer 9

Look and sniff
Blood gas analyser
Lab testing

Question 10

What does a foul smelling pleural fluid suggest?

Answer 10

Anaerobic empyema

Question 11

What does pus in the pleural fluid suggest?

Answer 11

Empyema

Question 12

What does food in the pleural fluid suggest?

Answer 12

Oesophageal rupture

Question 13

What does white/milky pleural fluid suggest?

Answer 13

Chylothorax - lymphoma

Question 14

Difference between blood in pleural fluid vs blood stained fluid?

Answer 14

Blood stained - malignancy

Blood - haemothorax

Question 15

What does a blood gas analyser result of pH <7.2 indicate?

Answer 15

Chest drain

Question 16

What criteria is used to identify whether a pleural fluid is exudate?

Answer 16

Light’s Criteria (exudate if one of):
 Effusion : serum protein ratio >0.5
 Effusion : serum LDH ratio >0.6
 Effusion LDH is 0.6 x ULN

Question 17

Raised amylase in pleural fluid suggests what?

Answer 17

Pancreatitis

Question 18

Cytology will test the pleural fluid for what?

Answer 18

Malignant cells
Lymphocytes (TB, Lymphoma)
Eosinophils

Question 19

Low glucose in pleural fluid suggests what?

Answer 19

Empyema
RA 
SLE
TB
Malignancy

Question 20

Which needle is used for biopsy?

Answer 20

Abrams needle (Blind)
Tru-cut (US guided)

Question 21

How many samples are taken, and where are they sent?

Answer 21

3 - to histology

1 - to microbiology (esp. if suspected TB)

Question 22

If no diagnosis for PE, what is recommended?

Answer 22

Thorascopy

Pleuradhesis

Question 23

What increases the risk of primary pneumothorax?

Answer 23

Tall, thin (marfans like)

Apical blebs

Question 24

What is the cause of non-iatrogenic pneumothorax?

Answer 24

Blunt/penetrating chest trauma

Question 25

Largest causes of secondary pneumothorax?

Answer 25

COPD (30-50%) TB, pneumonia, asthma CF

Question 26

Symptoms of pneumothorax?

Answer 26

None Pleuritic chest pain Extreme acute dypnoea

Question 27

Signs of non-tension pneumothorax?

Answer 27

Decreased expansion Hyper-resonance Absent breath sounds

Question 28

Signs of tension pneumothorax?

Answer 28

``` TRACHEAL DEVIATION Increased JVP/Haemodynamic compromise Decreased expansion Hyper-resonance Absent breath sounds ```

Question 29

Treatment for tension pneumothorax

Answer 29

Cannula 2nd ICS MCL | Drain

Question 30

Treatment of a small (minor) primary pneumothorax

Answer 30

Observe, repeat CXR | No change? Hole has sealed

Question 31

Treatment of a large (breathless) primary or secondary pneumothorax

Answer 31

Aspirate with 3 way tap (underwater seal)

Question 32

If you drain >3L, what does it suggest?

Answer 32

Persistent fluid leak into the pleural cavity

Question 33

What is the treatment if the lung fails to reinflate?

Answer 33

Surgical thoroscopy | Pleuradhesis

Question 34

When is pleuradhesis indicated?

Answer 34

2nd ipsilateral pneumothorax First contralateral pneumothorax Bilateral High risk profession

Question 35

Symptoms of mesothelioma?

Answer 35

Breathless Pleuritic pain (can also appear in the peritoneum)

Question 36

How late does mesothelioma occur post-exposure?

Answer 36

20-40y

Question 37

Expected radiological findings in mesothelioma?

Answer 37

Unilateral diffuse/local pleural thickening

Question 38

Three types of asbestos

Answer 38

Chrysotile (white asbestos) Crocidolite (blue asbestos) Amosite (brown or grey asbestos)