Pleural Disease

Question 1

Pleural effusion

Answer 1

Collection of fluid in the pleura

Question 2

Tracheal deviation

Answer 2

Can be pushed by pleural effusion

Question 3

Colour of normal pleural fluid

Answer 3

Straw

Question 4

Cloudy pleural fluid

Answer 4

Exudate, infection

Question 5

Blood in pleural fluid

Answer 5

Malignancy, TB, trauma, infarct

Question 6

Pus in pleural cavity

Answer 6

Empyema

Question 7

What is pleural fluid

Answer 7

Protein, LDH, glucose etc

Question 8

How to look at the microbiology of pleural fluid

Answer 8

Gram stain, AAFB and culture

Question 9

Transudate

Answer 9

Less than 2.5 G/dl of protein. Normal LDH. Is filtered, a collection signals organ failure/low albumin so you need to fix the organ not the fluid

Question 10

Exudate

Answer 10

More than 3.5g/dl of protein and high LDH. A collection is a sign of an underlying probably respiratory problem or malignancy

Question 11

Abrams pleural biopsy

Answer 11

Bedside with local anaesthetic, blind with low success rate for diagnosis

Question 12

Image guided biopsy

Answer 12

Better success rate, with local anaesthetic for diagnosis

Question 13

Medical thorascopy

Answer 13

Uses a camera, local sedation, higher success rate, used for pleurodesis not diagnosis

Question 14

Vats pleural biopsy

Answer 14

Highest success rate, done under general anaesthetic with direct visualisation by camera, scars tissue after so it heals up

Question 15

When to drain an effusion

Answer 15

Breathless, raised RR, hypoxia, tachycardia, CXR shows deviated trachea, parapneumonic, pH < 7.2, pus or trauma

Question 16

What happens if you remove too much fluid out

Answer 16

The lung can fill with fluid, so take <1500mls

Question 17

How to close the pleural space if recurrent

Answer 17

Spray talcum powder in it or have a permanent drain

Question 18

Chest tube placement

Answer 18

5th intercostal space anterior to midaxillary line

Question 19

Parapneumonic effusions

Answer 19

Up to 1/3 of all effusions, 10% are complicated eg pus, with poor outcome

Question 20

Locules

Answer 20

Pockets of fluid

Question 21

Treatment of parapneumonic effusions

Answer 21

Drain if ph <7.2, give IV abx, possibly surgery if poor control of sepsis

Question 22

Traumatic pneumothorax

Answer 22

Can be iatrogenic or not, eg stabs or fractured ribs

Question 23

Spontaneous pneumothorax

Answer 23

Can be primary (70-80%) especially in men 15-30 and smokers, with 25% recurrence

Or secondary, in older men especially and conditions like COPD, asthma, cancer, with a higher recurrence rate. Consider pleurodeisis

Question 24

Management of pneumothorax

Answer 24

Do nothing, sometimes aspirate, give oxygen and chest drain

Question 25

Tension pneumothorax treatment

Answer 25

Give oxygen, aspirate in 2nd anterior intercostal space in midclavicular line.

Question 26

Discharging a pneumothorax

Answer 26

Advice about recurrence, smoking cessation, no flying

Question 27

3 types of asbestos

Answer 27

Chrysotile(white)- most common Amosite (brown) Crocidolite (blue)- most dangerous

Question 28

Latent period for asbestos related pleural disease

Answer 28

20-40 years

Question 29

Pleural plaques

Answer 29

Marker of asbestos exposure, benign

Question 30

Benign asbestos effusion

Answer 30

Exclusion diagnosis. Exudate, chronic but can resolve spontaneously, can cause thickening

Question 31

Malignant mesothelioma

Answer 31

Cancer, causes chest pain, breathlessness, fever, weakness, cough, weight loss. Do CXR and CT, aspirate which will have blood and look at cells, need tissue to confirm (biopsy). Median survival less than a year, use chemo and pleurodesis and long term drain for palliation