Pleural Diseases

Question 1

What is the pathophysiology of pleural fluid build-up

Answer 1

Remember that pleural fluid is fluid literally built up in the pleural space

Only one of the following need to occur

1. ) Increased production by cells in pleural space
2. ) Increased drainage of fluid into pleural space
3. ) Decreased drainage of fluid from pleural space

Question 2

How can pleural fluid be classified

Answer 2

Transudative vs. Exudative

1. ) Transudative: Either elevated oncotic pressure or decreased oncotic pressure (i.e. hypoalbuminemia)
   - That’s why all the same diseases of liver will also cause a transudative process: CHF, cirrhosis, nephrotic syndrome, peritoneal dialysis, PE

2.) Exudative: Actual damage to pleural membanes or vasculature

Question 3

For a suspected exudative process, what is the next step in the workup

Answer 3

Cell count, glucose, pH, amylase, triglycerides, microbiology and cytology

Question 4

What are the symptoms of pleural effusions

Answer 4

1. ) Dyspnea on exertion
2. ) Peripheral edema
3. ) Orthopnea, PND

Question 5

What are the signs associated with pleural effusion

Answer 5

1. ) Dullness to percussion
2. ) Decreased tactile fremitus
3. ) Decreased breath sounds over effusion

Question 6

What x-ray is the best for seeing pleural effusions

Answer 6

1.) Lateral decubitus films: Can also see if pleural effusion is loculated or mobile

Question 7

What is even better for seeing pleural effusion than x-ray

Answer 7

CT scan

Question 8

After performing paracentesis, what are the 4C’s that you should send it for

Answer 8

Chemistry, cytology, cell count, and culture

Question 9

The treatment for pleural effusions differs depending on whether it is transudative or exudative. What is the treatment for both

Answer 9

1. ) Transudative: Sodium restriction and diuretics
2. ) Exudative: Treat underlying cause

Parapneumonic: If complicated effusions or empyema from pneumonia, give a chest tube

Question 10

What is empyema?

Answer 10

Pleural fluid that is infected (pus); from longstanding exudative pleural effusion usually from pneumonia

Question 11

What is the true definition of pneumothorax

Answer 11

Air in the normally airless pleural space

Question 12

After which three procedures must you always get a CXR to ensure you did not cause a pneumothorax

Answer 12

1. ) Transthoracic needle aspiration
2. ) Thoracentesis
3. ) Central line placement

Question 13

What is spontaneous pneumothorax, and what could it be divided into

Answer 13

Spontaneous pneumothorax is what happens without any trauma

1. ) Primary pneumothorax: Without underlying lung disease - spontaneous blebs rupture, air escapes lung into pleural space, pleural space collapses lung - no severe pulmonary distress because of pulmonary reserve
2. ) Secondary pneumothorax: Underlying lung disease such as COPD, asthma, ILD, TB, no pulmonary reserve so severe respiratory distress

Question 14

What are the symptoms and physical signs of pneumothorax

Answer 14

Symptoms: Ipsilateral chest pain sudden in onset, dyspnea, cough

Signs: Decreased breath sounds over affected side, hyperresonance over chest, absent tactile fremitus, mediastinal shift

Question 15

What is the treatment for spontaneous pneumothorax

Answer 15

Small: Observation - takes 10 days to heal
Large: O2 and chest tube

Question 16

What is a tension pneumothorax, and the difference between this and spontaneous pneumothorax

Answer 16

Tension pneumothorax: Accumulation of air in pleural space such that tissues act as valves, allowing air to enter but not escape

The difference between this and spontaneous pneumothorax is that it collapses the ipsilateral lung and shifts the mediastinum away from the side of the pneumothorax

Question 17

What are the clinical features of tension pneumothorax

Answer 17

1. ) Hypotension - cardiac filling impaired de to compression of great vessels
2. ) Distended neck veins
3. ) Shift of trachea away from side of pneumothorax on CXR

Question 18

What is the treatment for tension pneumothorax

Answer 18

This time, do chest decompression with large bore needle, followed by chest tube placement