Pleural Diseases

Question 1

Differentiate transudative and exudative pleural effusion

Answer 1

Transudative: Normal capillaries, occurs in absense of local pleural disease d/t inc. hydrostatic or dec. oncotic pressures

Exudative: abnormal capillary permeability resulting in high protein fluid

Question 2

What is the most common cause of transudative pleural effusion?

Answer 2

CHF

Question 3

What is the most common cause of exudative pleural effusions?

Answer 3

Parapneumonic

associated w/ bacterial PNA

Question 4

Pleural Effusion Analysis: What are the 4 parameters we look for?

Answer 4

Glucose
Protein
WBC
LDH

Question 5

If a patient had glucose levels > 60 mg/dL what kind of effusion is suspected?

Answer 5

Transudative

Question 6

If a patient had protein levels < 3.0 g/dL then what kind of effusion is suspected?

Answer 6

Transudative

Question 7

If a patient had LDH levels > 200 then what type of effusion is suspected?

Answer 7

Exudative

Question 8

What is the 2nd most common cause of exudative pleural effusions?

Answer 8

Malignancy

Question 9

What is the gold standard diagnostics test run for pleural effusions?

Answer 9

CXR

CT’s are helpful and can catch smaller effusions though

Question 10

Presentation of pleural effusions

Answer 10

Pt comes in for SOB, chest pain (pleuritic), cough usually

Dec. chest movements on effected side
Dec. breath sounds over area
Dull percussion
Pleural friction rub
Tracheal deviation away from pleural effusion if it is large enough

Question 11

Thoracentesis is the gold standard of care but not always necessary. What are the indications for thoracentesis?

Answer 11

1. When pleural effusion is large
2. Treatment of empyema
3. When the cause is unknown

Question 12

LDH stands for:

Answer 12

lactate dehydronase - released during tissue damage

Question 13

If a patient had a chylothorax what would the fluid look like? What does it contain? Exudative or transudative?

Answer 13

White/milky appearance and contains chylomicrons and high levels of triglycerides.

Exudative! (lymph)

Question 14

What is done for treatment if a patient has a malignant effusion?

Answer 14

Pleurodesis

–> it adheres the 2 pleura together irreversibly

Question 15

What is done for treatment if a patient has empyemas?

Answer 15

Drainage and long term abx

Question 16

What is the common cause of pleuritis?

Answer 16

Virus

Bacteria and rib fractures can also cause it

Question 17

What does the presentation of pleuritis look like?

Answer 17

Sharp, localized chest pain worsened by sneezing, deep breathing

Question 18

How do you treat pleuritis?

Answer 18

Tx underlying dz

NSAIDs and pain control

Question 19

Is the parietal or visceral pleura inflammed in pleuritis?

Answer 19

Parietal

Question 20

5 types of pneumothorax

Answer 20

1. Primary Spontaneous
2. Secondary spontaneous
3. Traumatic
4. Iatrogenic
5. Tension

Question 21

Distinguish primary and secondary spontaneous pneumothorax

Answer 21

Primary occurs in absense of underlying lung dz and secondary occurs in presense of underlying lung dz

Question 22

Who is at risk for primary spontaneous pneumothorax and what is the suggested cause of it?

Answer 22

Tall, thin, males 10-30 years old

Rupture of a subpleural apical bleb in response to high negative pressure

Question 23

Signs and symptoms of all types of pneumothoraxes

Answer 23

Chest pain
Dyspnea

These are the two main!

Question 24

PE findings of pneumothoraxes

Answer 24

Hyperresonance to percussion
Tachycardia
Hypotension
Mediastinal/tracheal shift suggest tension
Unilateral chest expansion

Question 25

What is the test of choice for pneumothroax?

Answer 25

CXR

Question 26

What are CXR findings for a patient with a penumothorax and should these x-rays be taken during inspiration or expiration?

Answer 26

Deep sulcus sign (deep lateral costophrenic angle)

Expiratory is best

Question 27

If a patient has a small pneumothorax then how would you treat?

Answer 27

It should resolve spontaneously
Supplemental O2
Occasionally monitor w/ serial CXR’s

Question 28

If a patient has a secondary pneumothorax, a large pneumothorax, or is on a ventilator how would you treat?

Answer 28

Chest tube placement (tube thoracostomy) to expand lung

Question 29

If a patient has a tension pneumothorax then how would you treat?

Answer 29

Immediate decompression followed by chest tube….no time to use anestesia, this is done at bedside