Pleural disease

Question 1

What are the clinical signs of pleural effusion?

Answer 1

• asymmetric chest expansion
• asymmetric tactile fremitus
• dullness to percussion
• absent or diminished breath sounds

Question 2

What do left basal crackles indicate?

Answer 2

• Crackles that do not clear after a cough may indicate pulmonary edema or fluid in the alveoli due to heart failure, pulmonary fibrosis, or acute respiratory distress syndrome.
• Crackles that partially clear or change after coughing may indicate bronchiectasis.
• Crackles are often described as fine, medium, and coarse.

Question 3

What does a stony dull percussion note indicate?

Answer 3

Fluid present in the lung

Question 4

What is characteristic of pneumonia on a chest X-ray

Answer 4

White& fluffy indicating consolidation

Question 5

What is characteristic of a pleural effusion on a chest X-ray?

Answer 5

• Dense white shadowing
• White shadowing creeping up the chest walls
• Hemidiaphragm not visible ( in normal x-rays, two hemidiaphragms should be visible)

Question 6

What are the symptoms of pleural effusion

Answer 6

• chest pain.
• dry cough.
• fever.
• difficulty breathing when lying down.
• shortness of breath.
• difficulty taking deep breaths.
• persistent hiccups.
• difficulty with physical activity

Question 7

Define thoracocentesis

Answer 7

• Removal of fluid from the space between the lungs and the chest wall (the pleural cavity) for diagnostic or therapeutic purposes using a needle inserted between the ribs.
• diagnosic procedure; light’s criteria used subsequently to determine transudate/exudate

Question 8

How can we use the pleural fluid protein content to determine when a fluid is a transudate/exudate

Answer 8

<25g/L= transudate i.e low protein
>35g/L= exudate i.e high protein
-If 25-35g/L; use Light’s criteria

Question 9

Explain the difference between a transudate and exudate

Answer 9

Transudate:
-Caused by systemic causes that alter the pleural equilibrium or starling forces
-fluid pushed through the capillary due to high pressure within the capillary
-Normal vessel size
-low protein present
-Fluid does not contain protein cos protein cannot pass through the small spaces between the endothelial cells
Exudate:
-Caused by inflammation
-Local causes
-Our vessel is enlarged so the gap between the endothelial cells increases, therefore allowing protein as well as fluid to escape the gap

Question 10

What is Light’s criteria?

Answer 10

The fluid is an exudate if one/ more of the following is true:

1. ) Pleural protein/serum protein >0.5
2. ) Pleural LDH(lactate dehydrogenase) /serum LDH is>0.6
3. ) Pleural LDH >2/3 upper limit of lab normal LDH

Question 11

What are we looking for in an exudate following thoracocentesis

Answer 11

• Presence of protein
• Cholesterol
• Triglycerides
• Large particles

Question 12

What are the causes of transudates?

Answer 12

Systemic causes:

• CHF
• Liver failure.cirrhosis
• Kidney failure
• Mitral stenosis
• oesophageal rupture
• Left ventricular failure
• urinothorax
• constrictive pericarditis
• Hypoalbuminaemia
• Hypothyroidism
• nephrotic syndrome

Question 13

What are the causes of exudates?

Answer 13

Inflammatory/local causes:

• Malignancy
• Parapneumonic effusions
• TB
• Yellow nail syndrome
• PE
• Rheumatoid arthiritis
• Other autoimmune pleuritis
• Pneumonia
• Lupus

Question 14

What diagnostic tests do we use to determine cause of pleural disease

Answer 14

• Glucose
• LDH
• pH
• MCS( multiple chemical sensitivity)
• AFB (acid fast bacteria)
• Cytology (can highlight neutropenia)

Question 15

What is CRP an indication of

Answer 15

-inflammation/infection

Question 16

What is empyema?

Answer 16

-A collection of pus

Question 17

How can we treat empyema

Answer 17

-Use a chest drain e.g Saldinger chest drain

Question 18

What is a parapneumonic effusion?

Answer 18

A parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis. There are three types of parapneumonic effusions: uncomplicated effusions, complicated effusions, and empyema.

Question 19

What is a complicated parapneumonic effusion

Answer 19

A parapneumonic pleural effusion for which an invasive procedure, such as tube thoracostomy, is necessary for its resolution, or a parapneumonic effusion on which the bacterial cultures are positive

Question 20

What is an uncomplicated parapneumonic effusion

Answer 20

An uncomplicated parapneumonic effusion forms when lung interstitial fluid increases during pneumonia and moves across the adjacent visceral pleural membrane. The pleural fluid is characterized by “exudative” chemistries and an influx of neutrophils into the pleural space

Question 21

What is Meig’s syndrome

Answer 21

• Causes a transudate effusion
• The triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. Ovarian fibromas constitute the majority of the benign tumors seen in Meigs syndrome.

Question 22

What does high LDH indicate

Answer 22

-High levels of LDH(lactate dehydrogenase) indicate some form of tissue damage. High levels of more than one isoenzyme may indicate more than one cause of tissue damage. For example, a patient with pneumonia could also have a heart attack. Extremely high levels of LDH could indicate severe disease or multiple organ failure

Question 23

What is Pleurodesis?

Answer 23

-A procedure that uses medicine to adhere your lung to your chest wall. It seals up the space between the outer lining of your lung& chest wall (pleural cavity) to prevent fluid or air from continually building up around your lung.

Question 24

Define pnemothorax

Answer 24

-air present in the pleural space

shows up as black on an X-ray

Question 25

What causes a pneumothorax?

Answer 25

-trauma
e.g Tension pneumothorax( e.g motorbike accident)
Broken rib may present
May be caused by a tear/laceration
The tear may cause a flap of skin that acts as a one way valave; when they breathe in the one way valve closes and the air doesnt get out, so air only moves in one direction
-primary spontaneous(more common in smokers& young skinny men): likely due to the formation of small sacs of air (blebs) in lung tissue that rupture, causing air to leak into the pleural space. … Many things can cause a bleb to rupture, such as changes in air pressure or a very sudden deep breath.
-secondary spontaneous: occurs as a complication of underlying lung disease

Question 26

How can we treat a pneumothorax

Answer 26

• Aspiration: drain the air; put a needle in to do this
• Close hole: allows the lung to slowly inflate
• If unsuccessful you need to put a chest drain into the pleural space to let the air out
• Thoracostomy: a small incision of the chest wall, with maintenance of the opening for drainage. It is most commonly used for the treatment of a pneumothorax
• Pleurodesis
• Video-assisted thoracoscopic surgery
• Flutter valve

Question 27

Define cardiac tamponade

Answer 27

compression of the heart by an accumulation of fluid in the pericardial sac.

Question 28

Outline how tactile fremitus can help a respiratory diagnosis?

Answer 28

• An increase in tactile fremitus indicates denser or inflamed lung tissue, which can be caused by diseases such as pneumonia.
• A decrease suggests air or fluid in the pleural spaces or a decrease in lung tissue density, which can be caused by diseases such as chronic obstructive pulmonary disease or asthma.