Pleural Disease

Question 1

Amount of pleural fluid in the pleural space normally

Answer 1

0.3 ml/kg

Question 2

Location of lymphatics that drain the pleural space

Answer 2

Parietal pleura

Question 3

Pleural filtration based on location of lung

Answer 3

Filtration decreases from apex to base

Question 4

Flow of pleural fluid

Answer 4

Costal to mediastinal region along diaphragm and mediastinal surfaces

Question 5

Pleural pressure at FRC

Answer 5

-3 to -5 cmH2O

Question 6

Effects of air, time, and lidocaine on pleural fluid pH

Answer 6

Air and time in syringe will increase pH

Lidocaine will decrease pH

Question 7

pleural fluid pH that is predictive of poor outcomes and failed pleurodesis in malignancy

Answer 7

< 7.30

Question 8

Light’s criteria

Answer 8

Pleural/serum ratios

Protein > 0.5

LDH > 0.6

LDH > 2/3 upper limit of serum LDH

Any 1 positive means exudate

Question 9

Reason for falsely classifying a transudate as an exudate via light’s criteria

Answer 9

Diuretic use (25% of cases)

Question 10

Pleural fluid cholesterol threshold for exudate classification

Answer 10

> 55 mg/dl

Question 11

Pleural protein gradient for classification of transudate or exudate

Answer 11

Serum to pleural gradient

> 3.1 is transudate

< 3.1 is exudate

Question 12

Serum to pleural albumin gradient predictive of transudate

Answer 12

> 1.2 gm/dl

Question 13

Serum or pleural NT pro BNP suggestive of transudate

Answer 13

> 1300 pg/ml

Question 14

6 causes of common transudative effusions

Answer 14

1. Congestive heart failure
2. Hepatic hydrothorax
3. Nephrotic syndrome
4. Urinothorax
5. Peritoneal dialysis
6. Trapped lung

Question 15

9 common causes of exudative effusions

Answer 15

1. Benign asbestos effusion
2. Chylothorax
3. GI Disease
4. Neoplastic
5. Parapneumonic effusion
6. PE after CABG
7. TB
8. Systemic diseases
9. Vascular effusions

Question 16

Percentage of hepatic hydrothorax where there is no ascites found

Answer 16

20%

Question 17

Criteria for spontaneous infection of hepatic hydrothorax

Answer 17

• Pleural fluid neutrophils > 250 and a positive culture

OR

• Pleural fluid neutrophils > 500 with negative culture

Question 18

3 diagnostic criteria for Urinothorax

Answer 18

1. Low pH
2. Low glucose
3. Pleural fluid creatinine > serum creatinine

OR

• Renal scintigraphy showing tracer going from urinary tract to pleural space

Question 19

3 most common malignancies for pleural effusion

Answer 19

Lung, breast, and lymphoma

Question 20

Lymphocyte count/neutrophil ratio for TB pleural effusion

Answer 20

> 0.75

AND

> 60% lymphocytes

OR

Adenosine deaminase positivity

Question 21

Triglyceride threshold for chylothorax

Answer 21

> 110 (Check chylomicrons)

Question 22

Exudative effusion associated with benign ovarian tumor

Answer 22

Meig’s syndrome

Question 23

Bleeding risk and thoracentesis guidelines based off 2013 and 2014 studies

Answer 23

Safe to do with INR > 1.5 or platelets <50,000

Can also do safely on heparin, coumadin, plavix, or DOACs

Question 24

Difference between lung entrapment and trapped lung

Answer 24

• Lung entrapment
  
  • Inability of lung to re-expand
    
    • Thick visceral pleura, endobronchial obstruction, etc.
• Trapped lung
  
  • Prior pleural inflammation and scarring

Question 25

Threshold for which reexpansion pulmonary edema is unlikely to develop if pleural pressure stays above

Answer 25

-20 cm H20

Question 26

3 classifications of parapneumonic effusion

Answer 26

* Uncomplicated * Resolves with antibiotics alone * Complicated * Requires chest tube or surgery * Empyema * Presence of pus or bacteria (has to be drained)

Question 27

How many cultures of pleural infections grow no organisms

Answer 27

40%

Question 28

6 predictors of complicated effusion or empyema

Answer 28

1. Albumin \< 30 2. Alcohol abuse 3. CRP \> 100 4. IV drug use 5. Platelets \> 400K 6. Sodium \< 130

Question 29

3 ACCP & BTS indications for complicated effusion drainage

Answer 29

1. Pleural fluid pH \< 7.20 2. Pleural glucose \< 60 (\< 40 in BTS) 3. Pleural fluid \> 1000 (only in BTS)

Question 30

RAPID clinical risk score for pleural effusions

Answer 30

* Urea * \<5 = 0 * 5-8 = 1 * \> 8 = 2 * Age * \< 50 = 0 * 50-70 = 1 * \> 70 = 2 * Purulence * Present = 0 * Not present = 1 * Infection source * Community = 0 * Hospital = 1 * Dietary factors * Albumin \> 27 = 0 * Albumin \< 27 = 1

Question 31

Low, medium, and high risk RAPID scores in pleural effusions and associated mortality

Answer 31

* Low * Score 0-2 * 1-3% risk at 3 months * Medium * Score 3-4 * 9-12% risk at 3 months * High * Score 5-7 * 31-51% risk at 3 months

Question 32

Trial that showed 14 french chest tube was better than surgical chest tube for effusions

Answer 32

MIST1

Question 33

Trial that showed TPA and DNase improved radiographic outcomes, lowered surgical referrals, and lowered mean hospital stay by 1 week

Answer 33

MIST2

Question 34

radiographic cut off for small to large pneumothorax

Answer 34

Small = \< 3 cm apex-cupola distance

Question 35

Recommendations for management in small primary pneumothorax

Answer 35

* Observe in ED for 3-6 hours * Can DC home if repeat CXR shows no progression * Follow up in 12-48 hours with repeat CXR

Question 36

Recommendation for CT imaging in first primary spontaneous pneumothorax

Answer 36

Do not order

Question 37

Surgical treatment for patients with pneumothorax and apical bullae

Answer 37

Staple bullectomy

Question 38

Prevention of pneumothorax recurrence in secondary pneumothorax

Answer 38

Medical or surgical thorascopy with or without staple bullectomy

Question 39

Diagnosis suggested by catamenial pneumothorax, chest pain, or hemothorax

Answer 39

Thoracic endometriosis | (May not have pelvic disease)

Question 40

Pleurodesis agent associated with ARDS

Answer 40

Doxycycline

Question 41

What frequency to drain IPC for malignant effusion to achieve pleurodesis

Answer 41

daily | (ASAP trial showed better than EOD)

Question 42

4 types of pleural reactions to asbestos

Answer 42

1. Benign asbestos related pleural effusion 2. Pleural plaques 3. Diffuse pleural fibrosis 4. Rounded atelectasis

Question 43

4 histologic subtypes of mesothelioma

Answer 43

1. Epithelioid 2. Sarcomatoid (Spindle cells) 3. Desmoplastic (Patternless pattern) 4. Biphasic (epithelioid and sarcomatoid combined)