Pleural Effusion

Question 1

Causes of Exudative Pleural Effusion (4)

Answer 1

1. Bacterial pneumonia
2. Malignancy
3. Viral Infection
4. Pulmonary Embolism

Question 2

Lights Criteria (3)

Answer 2

AT LEAST ONE

1. PLEURAL fluid protein/ SERUM fluid >0.5
2. PLEURAL fluid LDH/SERUM LDH >0.6
3. Pleural Fluid LDH more than two-thirds normal upper limit for serum

Question 3

Light’s Criteria misidentify transudates as exudates by how many %?

Answer 3

~25% are misidentified as exudates

Question 4

Protein Gradient Value to Disregard Exudate based on Lights Criteria?

Answer 4

PROTEIN GRADIENT > 31 g/L (3.1g/dL) then EXUDATE is IGNORED! Because almost all patients with the above gradient have a TRANSUDATIVE effusion.

Question 5

Additional Diagnostics in Exudative Effusions

Answer 5

1. Description of the appearance
2. Glucose Level
3. Differential Cell count
4. Microbiologic Studies
5. Cytology

Question 6

MOST COMMON CAUSE of Pleural effusion

Answer 6

Left Ventricular Failure

Question 7

Indications for Thoracentesis in Patients with Heart Failure (3)

Answer 7

1. Effusions are NOT BILATERAL and COMPARABLE in size
2. Patient Febrile
3. Pleuritic Chest pain

Question 8

Pleural Pro-BNP level diagnostic of effusion from heart failure?

Answer 8

> 1500 pg/mL of Pleural fluid NT proBNP (N-terminal pro-brain natriuretic peptide) is virtually diagnostic of effusion from heart failure

Question 9

Most Common Cause of Exudative Effusion in the United States

Answer 9

Parapneumonic Effusion

Question 10

Common Causes of Parapneumonic Effusion? (3)`

Answer 10

1. bacterial pneumonia
2. lung abscess
3. bronchiectasis

Question 11

Minimum depth indicating a therapeutic thoracentesis?

Answer 11

> 10 mm

IF the free fluid separates the lung from the chest wall >10 mm a THERAPEUTIC thora should be performed

Question 12

INDICATIONS for CTT/INVASIVE (increasing importance) (5)

Answer 12

1. Loculated pleural fluid
2. Pleural pH <7.20
3. Pleural fluid glucose <3.3 mmol (<60 mg/dL)
4. POSITIVE Gram stain OR Culture of fluid
5. Gross Pus in the pleural space

Question 13

Other considered interventions if empyema cannot be completely removed by thoracentesis?

Answer 13

CONSIDER chest tube insertion and instilling a FIBRINOLYTIC Agent OR Thoracoscopy
If ineffective, consider DECORTICATION

Question 14

SECOND MOST COMMON of EXUDATIVE effusion

Answer 14

Malignant Pleural Effusion

Question 15

Top three tumors causing ~75% of all malignant effusions:

Answer 15

1. Lung Carcinoma
2. Breast Carcinoma
3. Lymphoma

Question 16

In suspected Malignant Effusions with negative cytology what is the next best procedure?

Answer 16

Thoracoscopy.

ALTERNATIVE to Thoracoscopy
CT or UTZ guided biopsy of pleural thickening or nodules.

Question 17

Most Common Symptom of Pulmonary Embolism?

Answer 17

Dyspnea

Question 18

Characteristic of pleural effusion in Pulmo Embo?

Answer 18

Exudative (ALWAYS.)

Question 19

Most Common cause of Exudative Pleural Effusion

Answer 19

TB

Question 20

TB Markers in Pleural Fluid

Answer 20

Adenosine Deaminase >40 IU/L
Interferon Gamma >140 pg/mL

ALTERNATIVES
pleura fluid TB culture
needle biopsy of pleura
thoracoscopy

Question 21

Most common cause of chylothorax?

Answer 21

Trauma from thoracic surgery

Question 22

Pleural Fluid Triglyceride Level for Chylothorax?

Answer 22

Triglyceride >1.2 mmol/L (110mg/dL)

Question 23

Treatment of Choice in Chylothorax?

Answer 23

Chest tube PLUS Octreotide
if they fail:
percutaneous transabdominal thoracic duct blockage
Alternatives:
ligation of thoracic duct

Question 24

Pleural Hematocrit for diagnosing hemothorax?

Answer 24

> 50% of peripheral blood = HEMOTHORAX

Question 25

Components of Meigs Syndrome (3)

Answer 25

1. benign ovarian tumor 2. ascites 3. pleural effusion also can be due to ovarian hyperstimulation syndrome

Question 26

CABG associated Effusion seen WHEN? and Characteristic?

Answer 26

FIRST week = LEFT SIDED and BLOODY respond to 1 or 2 thera thoras AFTER first few weeks = left sided, clear yellow, tend to recur

Question 27

Hemothorax Volume indicating thoracostomy?

Answer 27

>200 ml/h | consider angiogaphic coil embolization, Thoracoscopy or thoracotomy

Question 28

Fibrinolytic Agents (2)

Answer 28

1. Tissue plasminogen activator 10 mg | 2. Deoxyribonuclease 5 mg

Question 29

DDx of Transudative Pleural Effusions (7)

Answer 29

1. CHF 2. Cirrhosis 3. Nephrotic Syndrome 4. Peritoneal Dialysis 5. SVC obstruction 6. Myxedema 7. Urinothorax

Question 30

Medical Manipulations that Induce Pleural Effusions

Answer 30

1. CABG 2. abdominal Sx 3. Radiation Therapy 4. Liver, Lung or Heart Transplantation 5. Intravascular insertion of central lines

Question 31

Reasons for Hemothorax (2)

Answer 31

1. Trauma | 2. rupture of a blood vessel or tumor

Question 32

Initial recommended treatment for Primary Spontaneous Pneumothorax? Alternatives If not responsive?

Answer 32

Simple aspiration If not responsive or recurrent: thoracoscopy with stapling of blebs and pleural abrasion (almost 100% in preventing reccurrences)

Question 33

Management of Iatrogenic Traumatic Pneumothorax (3)

Answer 33

1. Supplemental Oxygen 2. Aspiration 3. Tube thoracostomy

Question 34

Describe Chest tube placement in Hemopneumothorax

Answer 34

One chest tube in the superior part of hemithorax to evacuate air ANOTHER chest tube placed inferior part of the hemithorax to remove the blood

Question 35

Initial Treatment or Maneuver for Tension Pneumothorax

Answer 35

Large bore needle into pleural space through the second anterior intercostal space

Question 36

PE findings in Tension Pneumothorax (3)

Answer 36

1. Enlarged hemithorax with no breath sounds 2. Hyperresonance to percussion 3. Shift of mediastinum to contralateral side

Question 37

Signs strongly suggesting Tension Pneumothorax (2)

Answer 37

1. Difficulty in ventilation during resuscitation | 2. High Peak Inspiratory pressures during mechanical ventilation