Pleural Disease

Question 1

How does LV heart failure lead to pleural disease?

Answer 1

It leads to a back flow into the lungs that can lead to pulmonary edema and/or pleural effusions

Question 2

How does pulmonary HTN worsen pleural disease?

Answer 2

It results in back flow into the RV which will flow back into the IVC which worsens pleural effusion as it reduces the amount of fluid that is drained

Question 3

What are some of the mechanism by which pleural effusion can occur?

Answer 3

• Leaky Membranes - inflammation
• Increased Capillary Hydrostatic Pressures - CHF
• Decreased Pleural Hydrostatic Pressure - atelectasis
• Decreased Capillary Oncotic Pressures - hypoalbuminemia

Question 4

Pleural Effusion

Answer 4

Excessive fluid accumulation in the pleural space

Question 5

What are some physical exam signs of pleural effusion?

Answer 5

􏰁- Dullness to Percussion
􏰁- Decreased Breath Sounds and Tactile Fremitus 􏰁
- Egophony

Question 6

What are some CXR signs of pleural effusion?

Answer 6

􏰁“blunting of the angle” 􏰁 
“meniscus”
􏰁“white-out”
“lateral decubitus” shows “layering”
"loculations"

Question 7

What is the main tool for diagnosis of pleural effusions?

Answer 7

Thoracentesis

Question 8

What type of effusion do they following cause:

• LV failure
• Cirrhosis,
• Malnutrition
• Atelectasis

Answer 8

Transudative

Question 9

What type of effusion do the following cause:

• Infection
• Inflammation
• Cancer
• Direct entry of ascitic fluid blood, lymph, GI secretions

Answer 9

Exudative

Question 10

What are the criteria for transudative VS exudative effusion?

Answer 10

• LDH(pl) > 200 (or 2/3 upper normal)
  OR
  􏰁- Cholesterol(pl) > 45

Either of these will confirm the effusion as exudative

Question 11

What can cause LDL levels in the pleura to be falsely elevated and lead to a possible mis-diagnosis of an exudative effusion?

Answer 11

Diuresed HF can show falsely increased LDH due
to concentration as fluid back diffuses => this won’t
happen with cholesterol though

Question 12

What are the top 4 causes of transudative effusions?

Answer 12

􏰁 CHF
􏰁 Cirrhosis
􏰁 Nephrotic Syndrome
􏰁 Atelectasis

Question 13

What are the major causes of exudative effusions?

Answer 13

Cancer
Infections (Empyema)
Parapneumonic Effusions
Pulmonary Embolism

Question 14

What drug can cause exudative effusions?

Answer 14

Hydralazine

Question 15

What is the pH of pleural effusion normally around?

Answer 15

Higher than serum due to bicarbonate

Question 16

When will low pleural effusion pH be seen?

Answer 16

Infection and esophageal rupture

Question 17

Empyema

Answer 17

Infection in the pleural space

Question 18

Pleurodesis

Answer 18

Chemical or mechanical irritation of the visceral and parietal pleura to create adhesion and obliteration of the pleural space - to prevent re-accumulation of fluid in the space

Question 19

Tension Pneumothorax

Answer 19

Ball-Valve Mechanism - air enters the pleura during inspiration through a flap that closes during expiration, trapping ever more air/pressure in the pleural space that occurs after a pneumothorax occurs

Question 20

What is found on physical exam of a pneumothorax?

Answer 20

-􏰀 Unilateral Hyperinflation
􏰀- Decreased Breath Sounds and Tactile Fremitus
-􏰀 Hyper-resonance