Pleural Diseases

Question 1

 Visceral Pleura – Single layer of mesothelial cells with
microvilli projections and a ___ connective tissue layer

 Parietal Pleural – Single layer of mesothelial cells with
microvilli projections and a ___ loose connective tissue
layer with lymphatic stomata

Answer 1

 Visceral Pleura – Single layer of mesothelial cells with
microvilli projections and a thick connective tissue layer  Parietal Pleural – Single layer of mesothelial cells with
microvilli projections and a thin loose connective tissue
layer with lymphatic stomata

Question 2

pleural function

Answer 2

allows extensive movement of the lung relative to thec hest wall.

the visceral pleural mya provide mechanical support to the lung since it has thick CT.

• pleural space and parietal pleural lymphatics can drain edema.
• mesothelial cells have a number of immune and metabolic functions.

Question 3

explain the microcirculation of the pleural space.

Answer 3

in the pleural space, it is slightly negative pressure. this allows for lymphatic fluid and lubricating fluid to come in and circulate. it gets circulated by lymphatic stoma.

Question 4

what is pleural effusion

Answer 4

when the increased fluid entry rate is too high for the rate of fluid exit in the pleural space.

• causes retrodriaphragmatic opacity, costophrenic blunting, and can see fluid levels on XR

Question 5

transudate vs exudate

Answer 5

transudate; leaking due to increased pressures into the pleural space.

exudate; leaking due to broken capillaries and membranes in the pleural space. often results in a hetergenous cell make up.

Question 6

Lights criteria for transudate vs exudate distinguishment

Answer 6

basically for an exudate, there are higher PF/serume protein and LDF ratios.more protein is leaking into the pleural space.lots of cell breakdown leaking through damaged capillatry.

Question 7

causes of pleural fluid transudates and exudates.

Answer 7

Question 8

tests to run on pleural fluid analysis that you got from the pleural effusion

Answer 8

• glucose, ldh, protein serum, PF, pH, triglycerides, cholesterol
• cell count and differential
• culture, cytology
• tumor markesr

Question 9

Common transudates

Answer 9

heart failure accounts for 90% of transudate cases.

Question 10

Heart failure
• Account for > ___% of all transudates

• Diagnosis is usually made on ___ grounds

• NT-____can be measured in the pleural fluid to assist with the
diagnosis but is expensive

• Effusion usually resolves after treatment of heart dysfunction and volume overload

Answer 10

Heart failure
• Account for > 90% of all transudates • Diagnosis is usually made on clinical grounds

• NT-proBNP can be measured in the pleural fluid to assist with the diagnosis but is expensive

• Effusion usually resolves after treatment of heart dysfunction and
volume overload

Question 11

underlying cause of hepatic hydrothorax

Answer 11

liver dysfunction –> increased hepatic portal hypertension –> ascites –> belly full of water –> water drawn up into chest. Fluid migrates across the diaphragm and causes effusion.

Question 12

Hepatic hydrothorax
• Incidence ~ 6% of patients with cirrhosis

• Diagnosis usually made on clinical grounds
• __ > L > bilateral
• Fluid analysis will have a similar profile as __ fluid
• Effusion usually resolve with drainage of __ and treatment of liver dysfunction (__, transplant)

Answer 12

Hepatic hydrothorax
• Incidence ~ 6% of patients with cirrhosis

• Diagnosis usually made on clinical grounds
• R > L > bilateral
• Fluid analysis will have a similar profile as ascetic fluid
• Effusion usually resolve with drainage of ascites and treatment of liver dysfunction (TIPS, transplant)

Question 13

Nephrotic syndrome
• Incidence ~ 20% of patients with nephrotic syndrome

• Caused by both ___ pressure and ___ pressure gradients
• Fluid analysis usually with very ___ protein

• As with most other transudates, the treatment is to treat the
underlying disorder

Answer 13

Nephrotic syndrome
• Incidence ~ 20% of patients with nephrotic syndrome

• Caused by both oncotic pressure and hydrostatic pressure gradients
• Fluid analysis usually with very low protein

• As with most other transudates, the treatment is to treat the
underlying disorder

Question 14

common exudate causes

Answer 14

anything that can cause the lung tissue integrity to be compromised

• pulmonary embolism
• connective tissue disease
• chylothorax
• pleural infection
• pleural malignancy

Question 16

A pulmonary embolism causes widespread ___ wave depression ECG. It causes ____ of the lung parenchyma.

Answer 16

t wave depression, it causes inflammation of the lung parnchyma.

• No specific treatment is indicated as the
effusion resolves with resolution of
inflammation and clot resorption

Question 17

outline the characteristic pleural fluid profile in someone with connective tissue disease (RA)

Answer 17

Question 18

2 characteristic findings on the pleural fluid analysis indicative of RA causing the PE exudate

Answer 18

• cholesterol crystals and comet tail macrophages.

• Most resolve spontaneous • Don’t clearly respond to immune suppression • May persist and cause pleural thickening requiring surgical
decortication

Question 19

T/F: the pleural fluid analysis profile for SLE has the same profile as RA

Answer 19

false

Question 20

chylothorax

Answer 20

pleural fluid containing chylomicron rich lymph form the digestive system. type of exudate that is caused by thoracic duct malfunction. causes lymph to lead out of pleural space.

Question 21

treatment of chylothorax

Answer 21

treated with diet management, drainage, repair/ligation of the thoracic duct or treatment of an underlying disease.

Question 22

simple parapneumonic effusion, complicated parapneumonic effeusion, and empyema

Answer 22

Simple parapneumonic effusion – Free flowing sterile effusion with normal glucose and pH

Complicated parapneumonic effusion – Loculated effusion or infected or low glucose (< 40 mg/dL) and pH <7.20

Empyema – Pus in the pleural space

Question 23

out of the three types f pleural infections, which two requie a chest tube?

Answer 23

• complicated para pneumonic effusion
• empyema

Question 25

incidence of empyema

Answer 25

6/100k. incidence is increasing for unknown reasons.

Question 26

• Majority of empyema cases are
associated with ___
acquired __
___

Answer 26

• Majority of cases are
associated with community
acquired bacterial
pneumonia

Question 27

diagnosis of empyema

Answer 27

physical exam or chest imaging necessary to identiy effusion. chest imaging is the mainstay of diagnosis and can offer clues to the nature of the effusion.

Question 28

characteristic MRI findings of empyema

Answer 28

there is thickened pleural and gas producing bacteria.

Question 29

3 stages of empyema (EFO)

Answer 29

1. exudative phase:leaking of sterile pleural fluid. can cause lung collapse if too much fluid. causes the initial pleural effusion on XRAY..
2. fibrosis: migration and proliferation of bacteria resulting in pus formation.
3. organization phase: fibroblast growth over pleural surfaces causing loculations

Question 30

what pleural fluid analysis findings would you find in someone with a pleural effusion caused by infection?

Answer 30

• exudate with high protein and high LDH
• may have low glucose and low pH when complicated
• wbcs
• positive culture.

Question 31

relationship between dentition and empyema

Answer 31

patients with bad teeth are more likely to develop complicated pleural effusion infections.

Question 32

outline common bacteria that causes infection and pleural effusion. what’s the most comon?

Answer 32

strep pneumo

styph aureus

haemofilus influ

mrsa

strep pyo

enterococcus

ecoli

e coli

kelbisella

Question 33

Treatment for empyema

Answer 33

chest tube

TPA and DNASE

Antibiotics for underlying infection

• surgical decortation if there’s lots of fibrosis

Question 34

two meds in addition to antibiotics that helps with empyema

Answer 34

tpa and Dnase

Question 35

CAI and HAI outcome differences in empyema

Answer 35

Question 36

pneurmothorax: • Increasing pressure can collapse the __ __ and ___ ventricle (low pressure systems/systemic ___) and cause circulatory collapse (__ ___ causes pressure on cardiac structures)

Answer 36

• Increasing pressure can collapse the vena cava and right ventricle (low pressure systems/systemic Hypotension) and cause circulatory collapse (tension pneumothorax causes pressure on cardiac structures)

Question 37

causes of pneumothorax with no damage to visceral pleura

Answer 37

1. pneumonectomy– space filled with fluid
2. trapped lung

Question 38

Answer 38

loculated pneumothorax

Question 40

on ultrasound, which one has pneumothorax? characteristic sign?

Answer 40

on right: barcode sign. pneumothoax.

on left: seashoe sign: normal– the pleural linings are sliding on one another.

Question 41

treatment of persistent air leak from chest tube.

Answer 41

pleurodesis

Question 42

4 methods of pleurodesis

Answer 42

Pleurodesis procedures
• Introducing sclerosing agents via chest tube
• Autologous blood patch
• Introducing sclerosing agents during surgery
• Mechanical abrasion of the pleural during surgery

Question 43

pleural tumors can also cause exudative effusion.

Pleural tumors
• Divided into primary or secondary (metastatic) • ___ pleural tumors are rare whereas ___ pleural disease is
common

Answer 43

Pleural tumors
• Divided into primary or secondary (metastatic) • Primary pleural tumors are rare whereas metastatic pleural disease is
common

Question 44

most common of the pirmary pleural tumors

Answer 44

mesothelioma.

Question 45

most common presentation of underlying mesothelioma

Answer 45

common presentation is maligannt pleural effusion (MPE)>

Question 46

most common types of metastatic cancers causing malignant pleural effusion

Answer 46

lung and breast

Question 47

diagnosis of MPE (malignant pleural effusion)

Answer 47

1. irregular, nodular, thickened pleura on CXR
2. thoracentesis has 60-75% sensitivity for malignancy.
3. OPEN PLEURAL BIOPSY IS GOLD STANDARD.

Question 48

management of MPE

Answer 48

we almost always use talc to promote adherence to both pleural layers

Question 49

pleural mesothelioma

• rare tumor strongly associated with ____ exposure.

3 types of pleural mesothelioma:

• Dx uaully requires pleural biopsy

Answer 49

pleural mesothelioma

• rare tumor strongly associated with asbestosis exposure.

3 types of pleural mesothelioma:

• Epithelioid
• Sarcomatoid
• Biphasic (mixed)

• Dx uaully requires pleural biopsy