Pleural Effusion

Question 1

occurs when systemic factors that influence the formation and absorption of pleural fluid are altered. The leading causes of are left ventricular failure and cirrhosis

Answer 1

transudative pleural effusion

Question 2

occurs when local factors thatinfluence the formation and absorption of pleural fluid are altered. The leading causes are bacterial pneumonia,malignancy, viral infection, and pulmonary embolism.

Answer 2

exudative pleural effusion

Question 3

Exudative pleural effusions meet at least one of the Following criteria, whereas transudative pleural effusions meet none:

Answer 3

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

Question 4

These criteria misidentify ~__% of transudates as exudates.

Answer 4

~25%

Question 5

If one or more of the exudative criteria are met and the patient is clinically thought to have a condition producing a transudative effusion, the difference between the protein levels in the serum and the pleural fluid should be measured. If this gradient is >___, the exudative categorization by these criteria can be ignored because almost all such patients have a transudative pleural effusion.

Answer 5

> 31 g/L (3.1 g/dL)

Question 6

The most common cause of pleural effusion is

Answer 6

left ventricular failure

Question 7

In heart failure, diagnostic thoracentesis should be performed if the effusions are

Answer 7

not bilateral and comparable in size,
if the patient is febrile,
or-if the patient has pleuritic chest pain

Question 8

A pleural fluid N-terminal pro-brain natriuretic peptide(NT-proBNP) value of ____ is virtually diagnostic that the effusion is-secondary to congestive heart failure.

Answer 8

> 1500 pg/mL

Question 9

The effusion is usually right-sided and frequently is large enough to produce severe dyspnea. Pleural effusions occur in ~5% of patientswith cirrhosis and ascites.

Answer 9

Hepatic Hydrothorax

Question 10

Efffusion that are associated with bacterial pneumonia, lung abscess, or bronchiectasis and are probably the most common cause of exudative pleural effusion in the “United States. “

Answer 10

Parapneumonic Effusion

Question 11

refers to a grossly purulent effusion

Answer 11

Empyema

Question 12

Patients with pleural effusion that presents with an acute febrile illness consisting of chest pain, sputum production, and leukocytosis.

Answer 12

aerobic bacterial pneumonia

Question 13

Patients with present with a subacute illness with weight loss, a brisk leukocytosis, mild anemia, and a history of some factor that predisposes them to aspiration

Answer 13

anaerobic infections

Question 14

If the free fluid separates the lung from the chest wall by >__ mm, a therapeutic thoracentesis should be performed

Answer 14

> 10mm

Question 15

Factors indicating the likely need for a procedure more invasive than a thoracentesis or CTT (in increasing order of importance) include the following: increasing order of importance

Answer 15

1. Loculated pleural fluid
2. Pleural fluid pH <7.20
3. Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
4. Positive Gram stain or culture of the pleural fluid
5. Presence of gross pus in the pleural space

Question 16

If the fluid recurs after the initial therapeutic thoracentesis and if any of the factors or characteristics is present, what should be performed?

Answer 16

a repeat thoracentesis

Question 17

If the fluid cannot be completely removed with the therapeutic thoracentesis, consideration should be given to:

Answer 17

inserting a chest tube and instilling the combination of a fibrinolytic agent (e.g., tissue plasminogen activator, 10 mg) and deoxyribonuclease (5 mg) or performinga thoracoscopy with the breakdown of adhesions.

Question 18

should Be considered when ( inserting a chest tube and instilling the combination of a fibrinolytic agent and deoxyribonuclease or performing a thoracoscopy with the breakdown of adhesions)these measures are ineffective:

Answer 18

Decortication

Question 19

are the second most common Type of exudative pleural effusion.

Answer 19

Malignant pleural effusions secondary to metastatic disease

Question 20

The three tumors that cause ~75%of all malignant pleural effusions are

Answer 20

1. lung carcinoma
2. breast carcinoma
3. lymphoma

Question 21

The diagnosis usually is made via cytology of the pleural fluid. If the initial cytologic examination is negative,what is the best next procedure if malignancy is strongly suspected.

Answer 21

thoracoscopy
Or
Need biopsy of the pleura

Question 22

True or false

most malignancies associated with pleural effusion Are not curable with chemotherapy.

Answer 22

True

Question 23

In effusion sec to malignancy, If the patient’s lifestyle is compromised by dyspnea and if the dyspnea is relieved with a therapeutic thoracentesis, one of the following procedures should be considered:

Answer 23

1) insertion of a small indwelling catheter or

2) tube thoracostomy with the instillation of a sclerosing agent such as doxycycline (500 mg).

Question 24

The chest radiograph reveals a pleural effusion, generalized pleural thickening, and a shrunken hemithorax and most are related to asbestos exposure

Answer 24

Mesothelioma

Question 25

Effusion Secondary to Pulmonary Embolization is diagnosed by

Answer 25

spiral CT scan orpulmonary arteriography

Question 26

In many parts ofthe world, the most common cause of an exudative pleural effusion

Answer 26

Tuberculous pleuritis

Question 27

In tuberculous pleuritis, The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid

Answer 27

adenosine deaminase >40 IU/L
or
Gamma interferon γ >140 pg/mL)

Question 28

occurs when the thoracic duct is disrupted and chyle accumulates in the pleural space.

Answer 28

chylothorax

Question 29

What is the most common cause of chylothorax is (most frequently thoracic surgery) but it also may result from tumors in the mediastinum

Answer 29

trauma

Question 30

The Thoracentesis of chylothorax reveals milky fluid, and biochemical analysis reveals a triglyceride level that exceeds

Answer 30

1.2 mmol/L(110 mg/dL)

Question 31

Patients with chylothorax and no obvious trauma should have what diagnostics to assess the mediastinum for lymph nodes?

Answer 31

lymphangiogram and a mediastinal CT scan

Question 32

The treatment of choice for most chylothoraxes is

Answer 32

insertion of a chest tube plus the administration of octreotide

Question 33

Alternative treatment for chylothorax are

Answer 33

1. Implantation of pleuroperitoneal shunt or percutaneous transabdominal thoracic duct blockage
2. ligation of the thoracic duct.

Question 34

Patients with chylothoraxes should not undergo prolonged tube thoracostomy with chest tube drainage because this will lead to

Answer 34

malnutrition
and
immunologic incompetence

Question 35

When a diagnostic thoracentesis reveals bloody pleural fluid, a hematocrit should be obtained on the pleural fluid. If the hematocrit is more than one-half of that in the peripheral blood, thepatient is considered to have a

Answer 35

hemothorax.

Question 36

If the bleeding in hemothorax exceeds 200 mL/h, consideration should be given to

Answer 36

angiographic coil embolization, thoracoscopy or thoracotomy

Question 37

Most patients with hemothorax should be treated with what procedure which allows continuous quantification of bleeding

Answer 37

tube thoracostomy

Question 38

In patients with pleural effusion , if the patient is febrile, has predominantly polymorphonuclearcells in the pleural fluid, and has no pulmonary parenchymal abnormalities, what should be considered?

Answer 38

an intraabdominal abscess

Question 39

Transudative Pleural Effusions

Answer 39

1. Congestive heart failure
2. Cirrhosis
3. Nephrotic syndrome
4. Peritoneal dialysis
5. Superior vena cava obstruction
6. Myxedema
7. Urinothorax