Pleural Effusion Flashcards
____has replaced the lateral decubitus x-ray in the evaluation of suspected pleural effusions and as a guide to thoracentesis.
Chest ultrasound
A ____occurs when systemic factors that influence the formation and absorption of pleural fluid are altered.
transudative pleural effusion
An ___occurs when local factors that influence the formation and absorption of pleural fluid are altered. T
exudative pleural effusion
The leading causes of exudative pleural effusions are _____
bacterial pneumonia
malignancy
viral infection
pulmonary embolism.
Exudative pleural effusions meet at least one of the following criteria, whereas transudative pleural effusions meet none:
Pleural fluid protein/serum protein >0.5
Pleural fluid LDH/serum LDH >0.6
Pleural fluid LDH more than two-thirds the normal upper limit for serum
If this gradient [difference between the protein levels in the serum and the pleural fluid] is ____ the exudative categorization by these criteria can be ignored because almost all such patients have a transudative pleural effusion.
> 31 g/L (3.1 g/dL),
A patient with a pleural effusion has pleural fluid protein/serum protein = 0.7, pleural fluid LDH/serum LDH = 0.8, and pleural fluid LDH above two-thirds the normal upper serum limit. How should the effusion be classified?
A. Transudative
B. Exudative
C. Indeterminate
D. Reactive
B
Which imaging modality has replaced the lateral decubitus x-ray in evaluating pleural effusions?
A. Chest MRI
B. Chest CT
C. Chest ultrasound
D. Chest fluoroscopy
C
In a pleural effusion with clinical suspicion of a transudative process but exudative lab findings, what additional test can help determine the correct classification?
A. Pleural fluid pH
B. Serum-to-pleural fluid protein gradient
C. Pleural fluid amylase
D. Chest CT scan
B
Which of the following is NOT commonly associated with exudative pleural effusion?
A. Bacterial pneumonia
B. Malignancy
C. Cirrhosis
D. Pulmonary embolism
C
A patient has pleural fluid LDH/serum LDH = 0.4 and pleural fluid protein/serum protein = 0.3. What is the most likely classification of the pleural effusion?
A. Exudative
B. Transudative
C. Indeterminate
D. Reactive
B
Which of the following values would correctly identify a pleural effusion as exudative using Light’s criteria?
A. Pleural fluid protein/serum protein = 0.4
B. Pleural fluid LDH/serum LDH = 0.5
C. Pleural fluid LDH = 60% of the upper normal serum LDH limit
D. Pleural fluid LDH = 70% of the upper normal serum LDH limit
D
What is the most appropriate next step in the diagnostic evaluation after confirming the presence of a pleural effusion on chest ultrasound?
A. Start empiric antibiotics
B. Perform thoracentesis and fluid analysis
C. Order a repeat ultrasound in 2 weeks
D. Schedule a CT-guided biopsy
B
What is the first diagnostic step after identifying a pleural effusion?
A. Obtain a CT scan of the chest
B. Perform diagnostic thoracentesis and measure pleural fluid protein and LDH
C. Perform a spiral CT to check for pulmonary embolism
D. Start empiric treatment for tuberculosis
B
What classification is assigned if pleural fluid LDH is greater than two-thirds of the upper normal serum LDH limit?
A. Transudative effusion
B. Exudative effusion
C. Parapneumonic effusion
D. Tuberculous effusion
B
Which of the following findings in pleural fluid would lead to consideration of malignancy, bacterial infection, or rheumatoid pleuritis?
A. Glucose <60 mg/dL
B. Pleural fluid LDH/serum LDH >0.6
C. Pleural fluid protein/serum protein >0.5
D. Absence of TB markers
A
The most common cause of pleural effusion is___
left ventricular failure.
A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) level ____pg/mL is virtually diagnostic of an effusion that is secondary to congestive heart failure.
> 1500
Hepatic Hydrothorax is usually ____ sided
Right
____ refers to a grossly purulent effusion.
Empyema
If the free fluid separates the lung from the chest wall by ____, a therapeutic thoracentesis should be performed.
> 10 mm
Factors indicating the likely need for a procedure more invasive than a thoracentesis (in increasing order of importance) include the following:
- Loculated pleural fluid
- Pleural fluid pH <7.20
- Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
- Positive Gram stain or culture of the pleural fluid
- Presence of gross pus in the pleural space
If the fluid cannot be completely removed with the therapeutic thoracentesis, consideration should be given to inserting a ____ and instilling the combination of a ____or performing a ___
chest tube
fibrinolytic agent (e.g., tissue plasminogen activator, 10 mg) and deoxyribonuclease (5 mg)
thoracoscopy with the breakdown of adhesions.
Patients with ____ bacterial pneumonia and pleural effusion present with an acute febrile illness consisting of chest pain, sputum production, and leukocytosis.
Patients with ____ infections present with a subacute illness with weight loss, a brisk leukocytosis, mild anemia, and a history of some factor that predisposes them to aspiration.
aerobic
anaerobic
____ are the second most common type of exudative pleural effusion.
Malignant pleural effusions secondary to metastatic disease
The three tumors that cause ~75% of all malignant pleural effusions are ____
lung carcinoma
breast carcinoma
lymphoma
Patients with a malignant pleural effusion are treated symptomatically for the most part, since the presence of the effusion indicates ____ and most malignancies associated with pleural effusion are not curable with chemotherapy.
disseminated disease
Malignant mesotheliomas are primary tumors that arise from the mesothelial cells that line the pleural cavities; most are related to ____ exposure.
asbestos
The most common symptom of pulmonary embolism
dyspnea
The pleural fluid is almost always an ____ in pulmonary embolism
exudate
In many parts of the world, the most common cause of an exudative pleural effusion is ____
tuberculosis (TB)
The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid (_____).
adenosine deaminase >40 IU/L or interferon γ >140 pg/mL
The most common cause of chylothorax is ____ (most frequently thoracic surgery), but it also may result from tumors in the mediastinum.
trauma
Thoracentesis reveals milky fluid, and biochemical analysis reveals a triglyceride level that exceeds ___
1.2 mmol/L (110 mg/dL).
The treatment of choice for most chylothoraces is ___
insertion of a chest tube plus the administration of octreotide.
When a diagnostic thoracentesis reveals bloody pleural fluid, a ____ should be obtained on the pleural fluid.
hematocrit
If the hematocrit is _____ of that in the peripheral blood, the patient is considered to have a hemothorax.
more than one-half
Most patients with hemothorax should be treated with____, which allows continuous quantification of bleeding.
tube thoracostomy
If the pleural hemorrhage exceeds _____, consideration should be given to angiographic coil embolization, thoracoscopy, or thoracotomy.
200 mL/h
If the pleural fluid ____ level is elevated, the diagnosis of esophageal rupture or pancreatic disease is likely.
amylase
If the patient is febrile, has predominantly polymorphonuclear cells in the pleural fluid, and has no pulmonary parenchymal abnormalities, an ____ should be considered.
intraabdominal abscess
