Pleural Diseases

Question 1

Abnml accumulation of fluid in pleural space

Answer 1

Pleural effusion

Question 2

Signs/Sxs (PEff)

Answer 2

Asx…
Dyspnea, cough
Dullness to percussion, Dec tactile fremitus, Dec BS

Question 3

Classification (PEff)

Answer 3

Transudates (Elevated pressures)

Exudates (Cancer, PNA)

Question 4

How to differentiate Transudate from Exudate

Answer 4

Light's Criteria:    Exudate
PF protein: serum protein > 0.5
PF LDH: serum LDH > 0.6 (or > 2/3)
SpGr > 1.020
Albumin lower, Cholesterol higher than blood
***Transudate - PF protein < 3gm
***Exudate - PF protein > 3gm

Question 5

Capillaries nml but inc fluid lost 2/2:
  inc hydrostatic press (CHF)
  dec oncotic press (dec albumin)
No local pleural damage
Clear fluid
Everything lower in PF x Albumin
Bilateral - always

Answer 5

Transudate

CHF, Cirrhosis, Nephrotic Syndrome, PE, Hypothyroidism

Question 6

Abnml capillaries (leaking fluid) 2/2:
  PNA
  Cancer ( dec lymphatic drainage)
Local pleural dz
Cloudy fluid
Everything higher in PF x Albumin
Bilateral or Unilateral

Answer 6

Exudate

Infxn (PNA, Empyema), Malignancy, Inflamm (RA, SLE), Pancreatitis, Trauma

Question 7

Exudate subtypes

Answer 7

Empyemas
Hemothorax
Chylothorax

Question 8

Direct infxn

Pus collection in pleural space

Answer 8

Empyema

Question 9

Gross blood in pleural space

From trauma

Answer 9

Hemothorax

Question 10

Thoracic duct disruption
Cholesterol complex accumulation (white)
Assoc c lymphoma or h/o thoracic surg

Answer 10

Chylothorax

Question 11

Dx (PEff)

Answer 11

CXR - trapped vs free, quantity
CT - to evaluate etiology
US-guided Thoracent (GOLD STND)
Fluid for prot./LDH - transudate vs exudate (other tests for subtype analysis)

Question 12

Tx (Transudate PEff)

Answer 12

90% 2/2 CHF
Underlying condition:
Diurese
ACEI/ARB
Thoracentesis for dyspnea

Question 13

Tx (Exudate PEff)

Assoc c PNA = Parapneumonic

Answer 13

Tx PNA
Classify effusion
Uncomplicated: free flowing; resolve c abx
Complicated: pleural peel/trap; CT/surgery
Empyema: abscess, multi-lobe; surgery

Question 14

Tx (Exudate PEff)

Assoc c malignancy

Answer 14

Treat cancer
Lung or breast ca MC; re-accumulate
Therapeutic thoracentesis (helps sxs)
Pleurodesis - scar c talc

Question 15

Air in pleural space

Answer 15

PTX

Question 16

Classification (PTX)

Answer 16

Spontaneous

Acquired

Question 17

PTX in absence of underlying dz

Tall, thin, male, smoker

Answer 17

Primary spontaneous PTX

Question 18

PTX as complication of underlying dz

COPD, asthma, CF

Answer 18

Secondary spontaneous PTX

Question 19

**MC type of PTX **

2/2 thoracentesis, central line, vent, CPR

Answer 19

Acquired - IATROGENIC

Question 20

PTX 2/2 penetrating or blunt trauma

Answer 20

Acquired - Traumatic

Question 21

PTX 2/2 mechanical ven

Answer 21

Acquired - Barotrauma

Question 22

Tracheal or mediastinal shift 2/2 PTX

commonly barotrauma or traumatic PTX

Answer 22

Tension PTX

Question 23

Signs/Sxs (PTX)

Answer 23

Ipsilateral CP
Dyspnea
Severity relates to size

Question 24

Dx (PTX)

Answer 24

CXR (expiratory)

CT (most sensitive)

Question 25

Tx (PTX)

Answer 25

Small (15%): CT, surgery, tx underlying cause