Pleural Disease Flashcards
Amount of pleural fluid in the pleural space normally
0.3 ml/kg
Location of lymphatics that drain the pleural space
Parietal pleura
Pleural filtration based on location of lung
Filtration decreases from apex to base
Flow of pleural fluid
Costal to mediastinal region along diaphragm and mediastinal surfaces
Pleural pressure at FRC
-3 to -5 cmH2O
Effects of air, time, and lidocaine on pleural fluid pH
Air and time in syringe will increase pH
Lidocaine will decrease pH
pleural fluid pH that is predictive of poor outcomes and failed pleurodesis in malignancy
< 7.30
Light’s criteria
Pleural/serum ratios
Protein > 0.5
LDH > 0.6
LDH > 2/3 upper limit of serum LDH
Any 1 positive means exudate
Reason for falsely classifying a transudate as an exudate via light’s criteria
Diuretic use (25% of cases)
Pleural fluid cholesterol threshold for exudate classification
> 55 mg/dl
Pleural protein gradient for classification of transudate or exudate
Serum to pleural gradient
> 3.1 is transudate
< 3.1 is exudate
Serum to pleural albumin gradient predictive of transudate
> 1.2 gm/dl
Serum or pleural NT pro BNP suggestive of transudate
> 1300 pg/ml
6 causes of common transudative effusions
- Congestive heart failure
- Hepatic hydrothorax
- Nephrotic syndrome
- Urinothorax
- Peritoneal dialysis
- Trapped lung
9 common causes of exudative effusions
- Benign asbestos effusion
- Chylothorax
- GI Disease
- Neoplastic
- Parapneumonic effusion
- PE after CABG
- TB
- Systemic diseases
- Vascular effusions
Percentage of hepatic hydrothorax where there is no ascites found
20%
Criteria for spontaneous infection of hepatic hydrothorax
- Pleural fluid neutrophils > 250 and a positive culture
OR
- Pleural fluid neutrophils > 500 with negative culture
3 diagnostic criteria for Urinothorax
- Low pH
- Low glucose
- Pleural fluid creatinine > serum creatinine
OR
- Renal scintigraphy showing tracer going from urinary tract to pleural space
3 most common malignancies for pleural effusion
Lung, breast, and lymphoma
Lymphocyte count/neutrophil ratio for TB pleural effusion
> 0.75
AND
> 60% lymphocytes
OR
Adenosine deaminase positivity
Triglyceride threshold for chylothorax
> 110 (Check chylomicrons)
Exudative effusion associated with benign ovarian tumor
Meig’s syndrome
Bleeding risk and thoracentesis guidelines based off 2013 and 2014 studies
Safe to do with INR > 1.5 or platelets <50,000
Can also do safely on heparin, coumadin, plavix, or DOACs
Difference between lung entrapment and trapped lung
- Lung entrapment
- Inability of lung to re-expand
- Thick visceral pleura, endobronchial obstruction, etc.
- Inability of lung to re-expand
- Trapped lung
- Prior pleural inflammation and scarring
Threshold for which reexpansion pulmonary edema is unlikely to develop if pleural pressure stays above
-20 cm H20
3 classifications of parapneumonic effusion
- Uncomplicated
- Resolves with antibiotics alone
- Complicated
- Requires chest tube or surgery
- Empyema
- Presence of pus or bacteria (has to be drained)
How many cultures of pleural infections grow no organisms
40%
6 predictors of complicated effusion or empyema
- Albumin < 30
- Alcohol abuse
- CRP > 100
- IV drug use
- Platelets > 400K
- Sodium < 130
3 ACCP & BTS indications for complicated effusion drainage
- Pleural fluid pH < 7.20
- Pleural glucose < 60 (< 40 in BTS)
- Pleural fluid > 1000 (only in BTS)
RAPID clinical risk score for pleural effusions
- 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
Low, medium, and high risk RAPID scores in pleural effusions and associated mortality
- 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
Trial that showed 14 french chest tube was better than surgical chest tube for effusions
MIST1
Trial that showed TPA and DNase improved radiographic outcomes, lowered surgical referrals, and lowered mean hospital stay by 1 week
MIST2
radiographic cut off for small to large pneumothorax
Small = < 3 cm apex-cupola distance
Recommendations for management in small primary pneumothorax
- 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
Recommendation for CT imaging in first primary spontaneous pneumothorax
Do not order
Surgical treatment for patients with pneumothorax and apical bullae
Staple bullectomy
Prevention of pneumothorax recurrence in secondary pneumothorax
Medical or surgical thorascopy with or without staple bullectomy
Diagnosis suggested by catamenial pneumothorax, chest pain, or hemothorax
Thoracic endometriosis
(May not have pelvic disease)
Pleurodesis agent associated with ARDS
Doxycycline
What frequency to drain IPC for malignant effusion to achieve pleurodesis
daily
(ASAP trial showed better than EOD)
4 types of pleural reactions to asbestos
- Benign asbestos related pleural effusion
- Pleural plaques
- Diffuse pleural fibrosis
- Rounded atelectasis
4 histologic subtypes of mesothelioma
- Epithelioid
- Sarcomatoid (Spindle cells)
- Desmoplastic (Patternless pattern)
- Biphasic (epithelioid and sarcomatoid combined)
