Pleural Disease

Question 1

define pneumothorax

Answer 1

an abnormal collection of air within the pleural space that causes deflation of the lung

Question 2

describe the types of pneumothorax

Answer 2

primary - no underlying lung pathology
secondary - underlying lung pathology
traumatic - occurs due to trauma penetrating injury
tension - large volume of air present within pleural space

Question 3

risk factors of pneumothorax

Answer 3

smoking 
PMH of pneumothorax
male sex - esp in fit, taller and thin young men
chronic lung disease
connective tissue disease

Question 4

clinical features of pneumothorax

Answer 4

sudden pleuritic chest pain
dyspnoea
risk factors

Question 5

signs of pneumothorax

Answer 5

tachycardia +tachypnoea
cyanosis
absent breath sounds on affected side 
hyper-resonsant percussion note on affected side 
reduced chest expansion

Question 6

signs of tension pneumothorax

Answer 6

tracheal deviation
tachycardia
hypotension

Question 7

investigations of pneumothorax

Answer 7

CXR
ABG
US (emergency/acute setting)
CT scan (if no evidence in CXR or suspicious)

Question 8

management of tension pneumothorax

Answer 8

use ABCDE algorithm 
high flow (15L/min) O2 via non-rebreather mask
immediate needle decompression using 16-gauge cannula at 2nd intercostal space, midclavicular line

Question 9

management of primary pneumothorax

Answer 9

if not SOB and <2cm:

• observe 4-6hrs, discharge and advise to avoid strenuous exercise and seek medical attention if symptoms return
• re-evaluate with CXR at 2wks

if SOB OR >2cm:

• provide supplemental O2
• aspirate with 16-18G cannula under local anaesthetic
• if fails, intercostal drain and admission required

Question 10

management of secondary pneumothorax

Answer 10

if not SOB and <1cm:
- admit for 24hrs observation and provide supplementary O2

if SOB OR 1-2cm:

• aspirate and adit + observe for 24hrs
• if not successful, chest drain required

if SOB OR >2cm:
- require intercostal drain

Question 11

when is surgical intervention considered in those with pneumothorax?

Answer 11

if episodes of pneumothorax have been recurrent or air leak persists >48hrs

Question 12

what surgical procedures are utilised in complicated pneumothorax cases?

Answer 12

open thoracotomy

pleurectomy

Question 13

define pleural effusion

Answer 13

an abnormal build up of fluid in the pleural cavity

Question 14

describe the two types of pleural effusion

Answer 14

exudative - inflammation causes leaking of protein into pleural cavity and a high protein count (>30g/L)

transudative - fluid moves across into pleural cavity, resulting in low protein count (<30g/L)

Question 15

causes of exudative pleural effusion

Answer 15

due to increased permeability of pleural surfaces/capillaries

e.g. lung cancer, TB, pneumonia, rheumatoid arthritis or trauma

Question 16

causes of transudative pleural effusion

Answer 16

due to imbalance in starling forces that govern interstitial fluid

e.g. congestive cardiac failure, cirrhosis, chronic kidney disease and coeliacs

Question 17

risk factors of pleural effusion

Answer 17

congestive heart failure 
pneumonia 
malignancy 
smoking 
PMH of chronic disease, lung infections or immunological disease

Question 18

clinical features of pleural effusion

Answer 18

dyspnoea (esp on exertion)
cough
pleuritic chest pain
bronchial breathing

Question 19

signs of pleural effusion

Answer 19

respiratory distress and tachypnoea 
reduced chest expansion
stony dull percussion 
reduced/absent breath sounds 
reduced/absent vocal resonance

Question 20

investigations of pleural effusion

Answer 20

1st line = CXR
US guided thoracentesis for pleural fluid

bloods:
- FBC, U+E, CRP, TFTs, LDH, serum amylase and tumour markers
- RF and autoimmune profile

Question 21

common appearances of pleural effusion in CXR

Answer 21

blunting of costophrenic angle

white-out of a hemifield

Question 22

contraindications of a pleural fluid sample

Answer 22

heart failure signs

• raised JVP
• pitting ankle oedema
• CXR signs

Question 23

analysis of pleural fluid if protein 25-35g/L

Answer 23

effusion exudate if:
fluid to serum protein ratio > 0.5
pleural fluid to serum LDH >0.6
pleural fluid LDH >2/3 of upper limit of serum LDH

Question 24

additional parameters of pleural fluid analysis

Answer 24

glucose - ⬇️ in RA, TB or malignancy
pH - <7.2 in empyema
amylase - ⬆️ in pancreatitis

Question 25

management of pleural effusion

Answer 25

treat underlying cause
manage ABCDE approach
US guided pleural aspiration

Question 26

consideration of intercostal drain use in pleural effusion

Answer 26

if pleural effusion large or empyema (pus in pleural space) present

Question 27

consideration of pleurodesis in pleural effusion

Answer 27

if pleural effusion recurrent or persistent - can be done chemically or surgically