Pleural diseases

Question 1

What is the presentation of a patient suffering from pleural effusion?

Answer 1

• dyspnea
• gradual onset
• continuous & progressive
• alleviated by sitting & exacerbated by lying down
• productive cough with yellow sputum
• fever

Question 2

What are the findings of physical examination in pleural effusion?

Answer 2

• ill patient in moderate respiratory distress
• decreased chest expansion
• dullness on percussion
• tachycardia

Question 3

What will be present in lab examination of pleural effusion due to bacterial infection?

Answer 3

• leukocytosis

- increased neutrophil count

Question 4

What is seen on x-ray?

Answer 4

blunted costophrenic angle

Question 5

What should be done after diagnosis of pleural effusion?

Answer 5

• lateral view x-ray: if more than 10mm -> thoracentesis

Question 6

What is the most important criteria for confirming presence of exudate?

Answer 6

LIGHT’S CRITERIA

• pleural LDH/serum LDH >0.6
• pleural protein/serum protein > 0.5

Question 7

What are the causes of exudate?

Answer 7

• parapneumonic effusion or empyema
• malignancy
• asbestosis
• sarcoidosis
• autoimmune diseases (SLE, RA)
• pancreatitis

Question 8

How is empyema diagnosed?

Answer 8

• positive gram stain or culture of pleural fluid

- pleural fluid pH <7.2 or pleural glucose <60

Question 9

What are the causes of transudate?

Answer 9

• heart failure (high hydrostatic pressure)
• liver cirrhosis (high oncotic pressure)
• nephrotic syndrome

Question 10

how should pleural effusion be treated?

Answer 10

• exudate & transudate -> treat cause & drain if symptoms are worsening
• transudate due to CHF -> diuretics
• recurrent or uncontrolled (malignancy) -> pleurodesis
• empyema -> drainage by chest tube -> VATS or thoracotomy if chest tube is not enough

Question 11

if adenosine deaminase (ADA) is found in the pleural fluid what does it indicate?

Answer 11

TB

Question 12

what do positive triglycerides indicate if found in pleural fluid?

Answer 12

chylothorax

Question 13

What is asbestosis?

Answer 13

diffuse interstitial fibrosis of lung due to asbestos dust exposure -> restrictive lung disease

Question 14

What will a patient suffering from asbestosis complain of?

Answer 14

• progressive dyspnea
• dry cough
• risk of superimposed infection

Question 15

What physical signs are seen in asbestosis?

Answer 15

• clubbing
• contralateral tracheal deviation
• basilar crackles
• decreased chest expansion
• decreased tactile fremitus

Question 16

How should asbestosis be diagnosed?

Answer 16

• pulmonary function test: FEV1/FVC normal or >70

- high resolution CT chest: sub pleural linear opacities & basilar fibrosis

Question 17

How is asbestosis managed?

Answer 17

• stop exposure

- supportive measures

Question 18

What are the complications of asbestosis?

Answer 18

• pulmonary hypertension
• right heart failure
• bronchogenic carcinoma (more common)
• mesothelioma

Question 19

What are the types & presentation of pneumothorax?

Answer 19

• spontaneous: bleb rupture -> sudden chest pain & SOB
• tension: trauma -> sudden chest pain, SOB, hypotension, hypoxia, decreased chest expansion, decreased breath sound, hyper resonance, contralateral tracheal deviation, high JVP

Question 20

How is the diagnosis of pneumothorax confirmed?

Answer 20

CXR

Question 21

How is pneumothorax treated?

Answer 21

• tension: needle decompression (2nd intercostal space at midclavicular line) then chest tube
• spontaneous: 15% -> observe more than 15% aspiration