Pleural Disease

Question 1

What is the pleural cavity?

Answer 1

Potential space created by pleural surfaces
Serous membrane folds back on itself
Contains pleural fluid

Question 2

What is the outer pleura attached to the chest wall called?

Answer 2

Parietal pleura

Question 3

What is the inner pleura covering the lungs called?

Answer 3

Visceral pleura

Question 4

What is a pneumothorax?

Answer 4

Air in the pleural cavity

Question 5

What is a pleural effusion?

Answer 5

Fluid in the pleural cavity

Question 6

What is empyema?

Answer 6

Infected fluid in the pleural cavity

Question 7

What are pleural plaques?

Answer 7

Discrete fibrous areas

Question 8

What causes pleural thickening?

Answer 8

Scarring and calcification

Question 9

What are the types of pneumothorax?

Answer 9

Spontaneous (primary vs secondary)
Traumatic
Tension
Iatrogenic

Question 10

What is the difference between the two types of spontaneous pneumothorax?

Answer 10

Primary there is no lung disease

Secondary there is lung disease

Question 11

What are some risk factors for pneumothorax?

Answer 11

Pre existing lung disease
Height
Smoking/cannabis
Diving
Trauma/chest procedure
Other conditions e.g. marfans

Question 12

What is the management for primary pneumothorax?

Answer 12

If symptomatic and rim of air >2cm on CXR give O2 and aspirate
If unsuccessful, respirate and consider intercostal drain

Question 13

What is the management for secondary pneumothorax?

Answer 13

Same as for primary but with a lower threshold for intercostal drain

Question 14

What should be done if there is a bronchopleural fistula?

Answer 14

If persistent air leak for >5days then refer to thoracic surgeons

Question 15

What is the discharge advice for pneumothorax patients?

Answer 15

No flying or diving until resolved

Question 16

How should a suspected pleural effusion be approached?

Answer 16

Good history and examination
CXR, ECG, Bloods: FBC, U&E, LFT, CRP, bone profile, LDH, clotting, ECHO if suspect heart failure, staging Ct with contrast if suspect an exudative cause

Question 17

How should pleural effusion be diagnosed?

Answer 17

Ultrasound guided pleural aspiration
(biochem- protein, pH, LDH, cytology, microbiology including AAFB)

Could do thoracoscopy or CT pleural biopsy

Question 18

Why should you never insert a chest drain in pleural effusion unless the diagnosis/cause is well established?

Answer 18

May hinder the opportunity to obtain pleural biopsies

Question 19

When would the only indication for urgent chest drain insertion for a new effusion be?

Answer 19

An underlying empyema

(pH of pleural fluid <7.2 or visible pus on aspirate

Question 20

What would the pleural protein level be for transudate effusions?

Answer 20

pleural protein <30g/L

Question 21

What are some common causes of transudate effusions?

Answer 21

Heart failure, cirrhosis, hypoalbuminaemia (nephrotic syndrome or peritoneal dialysis)

Question 22

What are some less common causes of transudate effusions?

Answer 22

Hypothyroidism, mitral stenosis, pulmonary embolism

Question 23

What are some rare causes of transudate effusions?

Answer 23

Constrictive pericarditis, superior vena cava obstructio, meigs syndrome

Question 24

What would the pleural protein level be in an exudate effusion?

Answer 24

> 30g/L

Question 25

What are some common causes of exudate effusions?

Answer 25

Malignancy

Infections - parapneumoic, TB, HIV (kaposis)

Question 26

What are some less common causes of exudate effuisions?

Answer 26

Inflammatory (RA, pancreatitis etc)
Lymphatic disorders
Connective tissue disease

Question 27

What are some rare causes of exudate effusions?

Answer 27

Yellow nail syndrome, fungal infections, drugs

Question 28

When should Lights criteria be used?

Answer 28

If pleural fluid protein level is between 25-30g/L

Question 29

What are Lights criteria

Answer 29

Exudate if one or more of
Pleural fluid/serum protein >0.5
Pleural fluid/serum LDH >0.6
Pleural fluid LDH >2/3 upper limit of normal