Pleural Diseases

Question 1

What is the pleura and pleural space? (include name of two layers)

Answer 1

The pleura is an elastic serous membrane with a smooth lubricating surface and is divided into two layers:

• Visceral pleura: covers the lung parenchyma and extends between the lobes.
• Parietal pleura: covers the inner surface of the thoracic cavity, diaphragm and mediastinum.

Question 2

What is the most common cause of pleural effusion?

Answer 2

Heart Failure (as part of pulmonary edema)

Question 3

What are Four types of fluid that can accumulate in the pleural space?

Answer 3

• Serous Fluid(Hydrothorax) - from vessels
• Chyle (chylothorax) - lymph and emulsified fats
• Blood(Hemothorax)
• Pus(Empyema)

Question 4

What are the two most important labs to check for Pleural Fluid Analysis?

Answer 4

• Protein

- LDH (Lactate dehydrogenase)

Question 5

What is Transudative effusions?

Answer 5

-Largely due to imbalances in hydrostatic and oncotic pressures in the chest:
(CHF, Atelectasis, Nephrotic syndrome, Cirrhosis)

Question 6

What is Exudative Effusions?

Answer 6

Disease in any organ can cause an exudative effusion, however, more commonly a result from pleural/lung inflammation or impaired lymphatic drainage.

Question 7

What is Light’s Criteria?

Answer 7

Fluid is exudate if one of the following Light’s Criteria is present:

• Effusion protein/serum ratio > 0.5
• Effusion LDH/Serum LDH > 0.6
• Effusion LDH > 2/3 upper limit of lab reference for serum LDH

Question 8

A patient presents with a new large pleural effusion. Lab analysis reveals the following:
-Grossly purulent fluid
-pH level less than 7.2
-WBC > 50,000 cells
-Glucose <60 mg/dL
-LDH > 1,000 IU/ml
What is the most likely diagnosis?

Answer 8

Empyema

Question 9

What is the most common cause of Empyema?

Answer 9

-Complication of pneumonia, where bacteria escape into the pleural space.

Question 10

What’s the usual treatment for Empyema?

Answer 10

-Antibiotic therapy along with thoracentesis

Question 11

What is Pleurodesis?

Answer 11

A medical procedure in which the pleural space is artificially obliterated by causing the visceral and parietal pleural to stick together.

Question 12

What are the Indications for Pleurodesis?

Answer 12

1. Recurrence of effusion or pneumothorax.
2. Lung re-expansion after thoracentesis.
   - Symptomatic improvement after thoracentesis.

Question 13

Why is it important not to remove air or liquid too rapidly from the pleural space with thoracentesis or chest drainage?

Answer 13

Reexpansion pulmonary edema may develop

Question 14

A tall, thin 17 year old healthy male presents with sudden onset of sharp chest pain and shortness of breath. The pain is located in the upper chest on the right side. What is the most likely diagnosis?

Answer 14

Spontaneous pneumothorax

Question 15

What’s treatment for Pneumothorax?

Answer 15

• Conservative management for small PTX

- Chest decompression via chest tube or pigtail catheter.

Question 16

What is Tension Pneumothorax?

Answer 16

• Progressive build-up of air within the pleural space.
• Usually due to a lung laceration via trauma or iatrogenic, which allows air to escape into the pleural space.
• Progressive build-up pushes the mediastium to the opposite hemithoax and obstructs venous return to the heart causing cardiac arrest.

Question 17

What is the lung sound most often associated with Foreign Body Aspiration?

Answer 17

-Stridor

Question 18

What’s the Foreign Body Management?

Answer 18

• Rigid/Flexible Bronchoscopy is almost always successful in FB removal (95% of the cases)
• Allows control of the airway, good visualization, manipulation of the object, and ready management of hemorrhage
• Surgery may be needed if FBs cannot be removed.