Pleural Diseases

Question 1

What are the possible types of pleural effusions and what are their differences??

Answer 1

Transudate - often bilateral, due to imbalance hydrostatic forces, protein content <25g/L

Exudate - unilateral, due to permeable capillaries, protein content >35g/L

Question 2

how is a pleural effusion characterised if its protein content is between 25-35g/L?

Answer 2

Light’s criteria used to compare LDH and protein content in pleural fluid and plasma

Question 3

what are the commonest causes of transudate pleural effusions?

Answer 3

left ventricular heart failure
hypoalbuminaemia
peritoneal dialysis
liver cirrhosis

Question 4

what are some less common causes of transudate pleural effusions?

Answer 4

hypothyroidism
mitral stenosis
yellow nail syndrome

Question 5

what are the commonest causes of exudate pleural effusions?

Answer 5

malignancy

post-pneumonia

Question 6

what are some less common causes of exudate pleural effusions?

Answer 6

pancreatitis
pulmonary embolism/infarction
rheumatoid arthritis
autoimmune disease

Question 7

what are some signs of pleural effusion?

Answer 7

reduced chest expansion
dull sounds on percussion
reduced breath sounds
reduced vocal resonance

nail clubbing
raised JVP
pulmonary oedema
cervical lymphadenopathy

Question 8

what are some symptoms of pleural effusion?

Answer 8

dry cough
increasing SOB
maybe pleuritic chest pain
dull ache
malaise/fever/weight loss

Question 9

what are the main investigations for pleural effusion?

Answer 9

1. CXR
2. CT with enhanced contrast
3. Pleural aspiration
4. Pleural biopsy
5. Thoracoscopy

Question 10

what is the main management of pleural effusion?

Answer 10

1. treating underlying condition
2. palliative - drain fluid regularly
3. pleurodesis (chemical or surgical)

Question 11

what needle is used to perform a pleural aspiration?

Answer 11

green 21G needle

Question 12

how much fluid is collected for pleural aspiration, where is it sent to and for what?

Answer 12

50mg

• biochemistry (glucose, amylase, protein, LDH)
• cytology (lymphocytes, malignant cells, eosinophils)
• microbiology (culture, staining)

Question 13

how many pleural biopsies should be taken and where should they be sent to?

Answer 13

4 minimum

• 3 sent to histology (in formaldehyde)
• 1 sent to microbiology (in saline)

Question 14

what is the difference between chemical and surgical pleurodesion?

Answer 14

chemical - bedside, local anesthetic, talc slurry

surgical - during thoracoscopy, talc insufflation

Question 15

what considerations should be made prior to going ahead with chemical pleurodesis?

Answer 15

see whether the lung reinflates after drainage of effusion

Question 16

what are some complications which could occur as a result of pleural aspiration?

Answer 16

pneumothorax
haemothorax
air embolism
empyema
vagal reflex

Question 17

what should be done immediately after a pleural aspiration?

Answer 17

look and smell to assess what the cause could be (anaerobic empyema, esophageal rupture, lymphoma, TB or cancer)

Question 18

what are the different types of pneumothorax?

Answer 18

spontaneous primary and secondary
traumatic iatrogenic and non-iatrogenic
tension pneumothorax

Question 19

what are the causes of spontaneous pneumothoraces?

Answer 19

primary - no apparent disease, young people, <45yo

secondary - underlying lung disease (COPD, asthma, TB, pneumonia)

Question 20

what causes tension pneumothorax?

Answer 20

small tear in pleura, air escapes and gets trapped in pleural space every time the patient breathes out

Question 21

what causes traumatic pneumothoraces?

Answer 21

iatrogenic - needle perforates pleura (aspiration,biopsy)

non-iatrogenic - stabwound, gunshot wound

Question 22

what are the signs of pneumothorax?

Answer 22

sometimes none
otherwise reduced or no breath sounds
hyperresonance
reduced expansion
tracheal displacement (to area in non-tension, away from area in tension)

Question 23

what are the symptoms of pneumothorax?

Answer 23

can be none
pleuritic chest pain
acute or increasing SOB
extreme SOB (tension pneumothorax)

Question 24

what is the management of pneumothorax?

Answer 24

primary pneumothorax no symptoms - observe overnight, CXR and discharge
primary pneumothorax with symptoms - aspirate
secondary pneumothorax with symptoms - chest drain
tension pneumothorax - chest drain

Question 25

where should an aspiration needle be inserted for a primary pneumothorax with symptoms?

Answer 25

2nd intercostal space, midclavicular line

Question 26

where should a chest drain be inserted for a tension pneumothorax?

Answer 26

2nd intercostal space, midclavicular line

Question 27

where should a chest drain be inserted for a secondary pneumothorax with symptoms?

Answer 27

4th intercostal space, midclavicular line

Question 28

what should be done if a secondary pneumothorax has not improved with a chest drain or suction?

Answer 28

thoracoscopy for a better view and/or pleurodesis

Question 29

who is referred for pleurodesis as soon as they have a pneumothorax?

Answer 29

divers and pilots/airplane staff

Question 30

how likely is it for a second pneumothorax to occur after the first one?

Answer 30

> 50% chance recurrence in 4 years

Question 31

when should patients be referred for pleurodesis?

Answer 31

if occupation requires it (divers, pilots)
first contralateral pneumothorax
second ipsilateral pneumothorax
spontaneous bilateral pneumothorax

Question 32

which type of asbestos is most likely to cause mesothelioma?

Answer 32

crocidolite

Question 33

what is the prognosis for mesothelioma?

Answer 33

very poor, 18 months

Question 34

what is the main investigation for mesothelioma?

Answer 34

chest xray

Question 35

what are the possible symptoms of mesothelioma?

Answer 35

SOB

chest pain

Question 36

when does mesothelioma occur?

Answer 36

after contact with asbestos

can happen up to 30 years after exposure

Question 37

who is most likely to get mesothelioma?

Answer 37

boiler men, engineers, electricians, construction workers, roof tilers etc