Pleural disease

Question 1

Causes of pleural effusion

Answer 1

Infection
Malignancy
Inflammation
Hydrothorax (transudate)
Chylothorax (lymph)
Haemothorax (blood)
Acute pancreatitis

Question 2

Pleural effusions can be classified as

Answer 2

Large vs small
Unilateral vs bilateral
Exudate vs transudate

Question 3

Unilateral effusion usually due to

Answer 3

Malignancy

Question 4

Bilateral effusion usually due to

Answer 4

Cardiac/renal/hepatic impairment

Question 5

Differential between exudate and transudate

Answer 5

Protein level

Question 6

Exudate protein level

Answer 6

> 30g/L

Question 7

Transudate protein level

Answer 7

<30g/L

Question 8

Exudate

Answer 8

Fluid that leaks around the cells of the capillaries due to inflammation resulting in leaky vessels - reason for high protein

Question 9

Transudate

Answer 9

Fluid pushed through the capillary due to high pressure within the capillary

Question 10

Symptoms of pleural effusion

Answer 10

Shortness of breath
Cough
Pleuritic chest pain

Question 11

Signs of pleural effusion

Answer 11

Reduced chest expansion on affected side
Tracheal deviation
Stony dullness on percussion
Diminished/absent breath sounds
Loss of vocal resonance

Question 12

Investigations of pleural effusion

Answer 12

Chest x-ray
Ultrasound
Thoracentesis and pleural fluid analysis

Question 13

Thoracentesis

Answer 13

Insertion of needle into pleural space to remove fluid from pleural effusion

Question 14

Investigations to determine cause of effusion

Answer 14

Bloods
CT
MRI
Thoracoscopy, bronchoscopy, pleural biopsy

Question 15

Pleural effusion x-ray findings

Answer 15

Loss of costophrenic angles
White-out if effusion is large
Other abnormalities point to cause

Question 16

Overall management of effusion encompasses

Answer 16

Management of underlying disease and management of effusion

Question 17

Management of effusion depends on

Answer 17

Size, cause and type

Question 18

Management of effusion

Answer 18

Observation
Aspiration
Chest drain
Pleuroperitoneal shunts 
Pleurodesis (stick lung to chest wall)
Pleurectomy (removal of part of pleura)

Question 19

Differentials of pneumothorax

Answer 19

Pleaural effusion
Musculoskeletal cause
Pulmonary embolism

Question 20

Causes/risk factors of primary spontaneous pneumothorax

Answer 20

Smoking
Tall thin male
Family history (marfans habitus)

Question 21

Causes/risk factors of secondary pneumothorax

Answer 21

Associated with underlying lung disease - COPD, asthma

Question 22

Causes/ risk factors of tension pneumothorax

Answer 22

Usually traumatic

One way valve with air coming in but none going out

Question 23

Pneumothorax

Answer 23

A collapsed lung caused by air leaking into the intrapulmonary space

Question 24

Symptoms of pneumothorax

Answer 24

Chest pain - sudden onset
Shortness of breath
Asymptomatic

Question 25

Signs of pneumothorax

Answer 25

``` Sweating Tachycardia Reduced chest expansion Hyperresonance Reduced/absent breath sounds ```

Question 26

Presentation of tension pneumothorax

Answer 26

HR > 135 Tracheal deviation Raised JVP

Question 27

Pneumothorax investigations

Answer 27

Chest x-ray Ultrasound CT

Question 28

Pneumothorax x-ray findings

Answer 28

Visible visceral pleural edge very thing sharp white line No lung markings peripheral to line Peripheral space is radiolucent compared to adjacent lung Mediastinum shifted away from affected side (tension) Subcutaneous emphysema and pneumomediastinum may be present

Question 29

Management of primary spontaneous pneumothorax

Answer 29

<2cm - nothing | >2cm - chest drain

Question 30

Management of secondary pneumothorax

Answer 30

<1cm - admit and observe for 24 hours 1-2cm - aspiration, chest drain if fails Over 50 yo, >2cm - chest drain

Question 31

Management of tension pneumothorax

Answer 31

Large bore cannula into second intercostal space in midclavicular line Chest drain

Question 32

Management of recurring pneumothorax

Answer 32

Pleurodesis | Pleurectomy

Question 33

Pleural plaques

Answer 33

Localised fibrous deposits that thicken the lung lining

Question 34

Malignant mesothelioma

Answer 34

Cancer of mesothelium that lines the lungs, chest wall and abdomen

Question 35

Symptoms of malignant mesothelioma

Answer 35

``` Chest pain Breathlessness Fever Weakness Cough Weight loss ```

Question 36

Management of malignant mesothelioma

Answer 36

Chemotherapy | Pleurodesis and long term drain

Question 37

Asbestos related diseases

Answer 37

Malignant mesothelioma Benign asbestos effusion Pleaural plaques

Question 38

Management of pleural plaque

Answer 38

No treatment