Pleural Disease

Question 1

Normal amt of pleural fluid in an individual?

Answer 1

7-14 ml

Make about 0.15ml/kg/hr

Question 2

Treatment of re-expansion pulmonary edema?

Answer 2

Supportive

Question 3

When should you consider
terminating fluid removal
during thoracentesis?

Answer 3

When a patient complains
of chest discomfort or
when 1.5L has been
removed

Question 4

Which organism is
associated with a
complicated
parapneumonic pleural
effusion that has an
elevated pH?

Answer 4

Proteus. In general, all
other complicated
parapneumonic effusions
will have a low pH.

Question 5

Tell me the different meanings of pleural albumin gradients (albumin gradient = serum albumin - PF albumin).

Answer 5

Gradient > 1.2 g/dL = transudate

Gradient <1.2 g/dL = exudate

Question 6

Tuberculous pleuritis, post CABG, RA, yellow nail syndrome, and chylothorax all cause what cell prodominence on effusions?

Answer 6

Lymphocytic effusions

Question 7

Trauma (PTX, hemothorax, surgery), malignancy, asbestos effusions, parasitic, fungal, and drug induced effusions have what cell predominance?

Answer 7

Eosinophilic

Question 8

Which pleural effusion
most commonly presents
with dyspnea out of
proportion to pleural
effusion size?

Answer 8

Pleural effusion secondary

to CHF

Question 9

A patient with CHF being
diuresed has an exudative
pleural effusion. What is
the best way to evaluate
whether this is a false
exudate in the setting of
diuresis?

Answer 9

Check PF albumin (or

protein) gradient

Question 10

What % of CHF effusions are unilateral?

Answer 10

30%

Question 11

What % of hepatic hydrothorax effusions are unilateral?

Answer 11

80%

Question 12

What do you see on cell count to diagnose spontaneous bacterial pleuritis (aka the other SBP)?

Answer 12

Same criteria as the other SBP!

Neutrophil count > 250 cells/mm3 with positive culture
OR
>500 cells/mm3 with negative culture

Question 13

Treatment of spontaneous bacterial pleuritis?

Answer 13

Antibiotics alone - chest tube is seldom required

Question 14

Case:

45 y/o gets started on peritoneal dialysis due to SLE. 16 days after starting PD she develops worsening dyspnea and CXR reveals large right sided effusion. What is the best initial treatment?

Answer 14

Stop PD for 2-6 weeks, 50% are able to resume PD without recurrence

Consider VATS to correct diaphragmatic defects

Question 15

A patient with nephrotic
syndrome presents with an
exudative pleural effusion.
What diagnosis should you
suspect?

Answer 15

Pulmonary embolus

Question 16

When to consider surgery for trapped lung?

Answer 16

When dyspnea is clearly due to trapped lung, otherwise thoracic interventions rarely help.

Question 17

Case:

Patient develops dyspnea 3 days post-op from ex lap due to trauma. Right pleural effusion noted. Thoracentesis fluid reveals pleural creatinine:serum Cr >1. Diagnosis?

Answer 17

Urinothorax

Question 18

Case:

Patient develops dyspnea 3 days post-op from ex lap due to trauma. Right pleural effusion noted. Thoracentesis fluid reveals protein <1 and positive beta-2 transferrin. Diagnosis?

Answer 18

Duropleural fistula/subarachnoid pleural fistula

Question 19

Tell me the stage of parapneumonic effusion (simple vs complicated) given the following fluid characteristics:

Appears clear or slightly turbid

Answer 19

Simple

Question 20

Tell me the stage of parapneumonic effusion (simple vs complicated) given the following fluid characteristics:

pH < 7.20

Answer 20

Complicated

Question 21

Tell me the stage of parapneumonic effusion (simple vs complicated) given the following fluid characteristics:

Glucose < 60 mg/dL

Answer 21

Complicated

Question 22

Tell me the stage of parapneumonic effusion (simple vs complicated) given the following fluid characteristics:

LDH <1000

Answer 22

Simple

Question 23

Tell me the stage of parapneumonic effusion (simple vs complicated) given the following fluid characteristics:

Gram stain may be positive

Answer 23

Complicated

Question 24

Most common pathogens that cause empyema?

Answer 24

Strep (50%)
Anaerobes (20%)
Staph (10%)

Question 25

This study found that intrapleural tPA + DNase is superior to either agents alone in the treatment of empyema in terms of improved fluid drainage, reduced frequency of surgical referral, and reduced duration of hospital stay

Answer 25

MIST-2

Question 26

What are the indications for chest-tube drainage of a parapneumonic effusion?

Answer 26

Frankly purulent or turbid/cloudy PF, pH < 7.2, positive Gram stain or culture

Question 27

When to consider IPC in malignant effusions?

Answer 27

Effusions that are 1. Symptomatic 2. Prognosis >1 month 3. No trapped lung

Question 28

This study was for malignant effusions where there was IPC vs chest tube pleurodesis in management in pleural effusions, showing no difference in dyspnea at 6 weeks but shorter length of initial hopsitalization and less dyspnea at 6 months in IPC group

Answer 28

Therapeutic Intervention in Malignant Effusion (TIME)

Question 29

What % of patient with acute PE have pleural effusions from increased pulmonary capillary permeability?

Answer 29

20-50%

Question 30

Given the following effusion characteristics, tell me if this is more post-CABG related or more post-cardiac injury syndrome (PCIS) related: Fever, pleuritic chest pain, pericardial rub

Answer 30

PCIS

Question 31

Given the following effusion characteristics, tell me if this is more post-CABG related or more post-cardiac injury syndrome (PCIS) related: Occurs due to myocardial or pericardial injury

Answer 31

PCIS

Question 32

Given the following effusion characteristics, tell me if this is more post-CABG related or more post-cardiac injury syndrome (PCIS) related: Mostly small unilateral left-sided pleural effusions, but 10% can be larger

Answer 32

Post-CABG

Question 33

Given the following effusion characteristics, tell me if this is more post-CABG related or more post-cardiac injury syndrome (PCIS) related: Appearance can be bloody early but clear-yellow late

Answer 33

Post CABG PCIS has bloody or serosanguenous throughout

Question 34

True/False: bloody pleural effusion in the setting of a PE is a contraindication to anticoagulation/lytics.

Answer 34

FALSE

Question 35

True/False: pleural fluid from patients with TB pleuritis typically contains >5% mesothelial cells

Answer 35

FALSE If >5% mesothelial cells, would argue against TB pleuritis

Question 36

Typical fluid analysis of pleural fluid from TB pleuritis?

Answer 36

Exudative Low glucose Lymphocytic Mesothelial cells <5%

Question 37

What % of pleural fluid cultures are positive in TB pleuritis?

Answer 37

40%

Question 38

What pleural fluid test has a sensitivity and specificity of 90% in diagnosing TB pleuritis?

Answer 38

ADA

Question 39

What other condition can create a high pleural fluid ADA?

Answer 39

RA

Question 40

What procedure can get 90-100% diagnostic yield to diagnose TB pleuritis?

Answer 40

Thoracoscopy

Question 41

Based on the following characteristics, tell me if this is more consistent with RA or SLE pleuritis: Older male with subQ nodules, arthritis preceeding

Answer 41

RA

Question 42

Based on the following characteristics, tell me if this is more consistent with RA or SLE pleuritis: Pleural fluid has glucose <40, pH<7.2, high LDH (>700)

Answer 42

RA

Question 43

Based on the following characteristics, tell me if this is more consistent with RA or SLE pleuritis: 50% have bilateral effusions

Answer 43

SLE

Question 44

Based on the following characteristics, tell me if this is more consistent with RA or SLE pleuritis: Treatment is NSAIDs and steroids

Answer 44

SLE

Question 45

What hct is consistent with hemothorax?

Answer 45

at least 50%

Question 46

Based on the following characteristics, tell me if this more consistent with chylothorax or cholesterol effusion/pseudochylothorax: Milky or opalescent

Answer 46

both Ha! got ya

Question 47

Based on the following characteristics, tell me if this more consistent with chylothorax or cholesterol effusion/pseudochylothorax: Chylomicron +

Answer 47

Chylothorax

Question 48

Based on the following characteristics, tell me if this more consistent with chylothorax or cholesterol effusion/pseudochylothorax: Triglyceride > 100

Answer 48

Chylothorax

Question 49

Based on the following characteristics, tell me if this more consistent with chylothorax or cholesterol effusion/pseudochylothorax: Most common cause are TB effusion and RA pleural effusion

Answer 49

Cholesterol effusion

Question 50

Based on the following characteristics, tell me if this more consistent with chylothorax or cholesterol effusion/pseudochylothorax: Treatment is dietary measures, possible high-protein, low-fat diet supplemented with medium-chain triglycerides

Answer 50

Chylothorax

Question 51

Give me 4 causes of elevated amylase in effusions

Answer 51

Acute pancreatitis Chronic pancreatitis Esophageal rupture Malignancy

Question 52

Effusions secondary to pancreatitis are usually left or right sided?

Answer 52

Left

Question 53

This is the triad of lymphedema, yellow and thickened nails, and pleural effusion.

Answer 53

Yellow nail syndrome

Question 54

This is the development of pleural effusions with the use of hCG for fertility purposes

Answer 54

Ovarian hyperstimulation syndrome

Question 55

Average time from asbestos exposure to the development of benign asbestos pleural effusion (BAPE)?

Answer 55

15-20 years

Question 56

Typical pleural fluid charactersistics on BAPE?

Answer 56

Unilateral Exudative 1/3 eosinophilic >50% bloody

Question 57

True/False: BAPE has prognostic implications for the development of plaques or malignancy.

Answer 57

FALSE

Question 58

Average time from asbestos exposure to the development of pleural plaques?

Answer 58

>20 years

Question 59

This is the comet-tail sign pointing toward the hilum, associated with asbestos history, can trap underlying lung, and stable of 2-3 year time span

Answer 59

Rounded atelectasis

Question 60

What are the signs of a pneumothorax on ultrasound?

Answer 60

Absence of lung sliding on 2-D mode and presence of stratosphere or barcode sign on M-mode

Question 61

When should recurrence prevention be offered for spontaneous pneumothorax?

Answer 61

At the time of the second occurrence of a PSP or the first occurrence of a SSP

Question 62

As they say at the end of French movies

Answer 62

Fin