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A. MLA Map Acute and Emergency > Pneumothorax/ Pleural Effusion > Flashcards

Pneumothorax/ Pleural Effusion Flashcards

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1
Q

A pneumothorax translates to air in the thorax, specifically air between the lungs and chest walls called the pleural space. This pleural space is filled with what?

1 - lubricant
2 - blood
3 - nothing
4 - air

A

1 - lubricant

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2
Q

The pleural space is filled with lubricant between the visceral (stuck to the lungs) and parietal (chest wall) pleura. Which 2 of the following are responsible for maintaining an equilibrium in the pressure in the pleural space?

1 - small ligaments between the visceral and parietal pleura
2 - muscle tension chest wall and diaphragm
3 - elastic properties of lung parenchyma
4 - compliant properties of lung parenchyma

A

2 - muscle tension chest wall and diaphragm
3 - elastic properties of lung parenchyma

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3
Q

The muscle tension of the chest wall and diaphragm and elastic properties of lung parenchyma create a balanced equilibrium of pressure in the parietal space of the lungs. This creates a vacuum of pressure in the parietal space. What is the normal pressure in the parietal space?

1 - -5cm of water
2 - +5cm of water
3 - 50cm of water
4 - -500cm of water

A

1 - -5cm of water
- minus 5

  • the pressure in the thoracic cavity and lungs is 0cm of water
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4
Q

A pneumothorax is typically when the seal of parietal space has been lost. The negative pressure of -5 of water is lost. This causes the lung to be collapse, the chest wall expands and the parietal space fills with air. Typically in a pneumothorax does O2 and CO2 levels in the body change?

A
  • yes
  • O2 reduces
  • CO2 increases
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5
Q

A pneumothorax is typically when the seal of parietal space has been lost. The negative pressure of -5 of water is lost. This causes the lung to be collapse, the chest wall expands and the parietal space fills with air. There are a number of pneumothorax, which of the following is a spontaneous pneumothorax?

1 - parietal pleura is broken from the outside but air can move in and out
2 - bullae (large air pocket) is perforated
3 - parietal pleura is broken but can only move into parietal space
4 - all of the above

A

2 - bullae (large air pocket) is perforated

  • bullae form when the alveoli develop tiny leaks
  • alveoli can typically heal, but if they don’t it causes a pneumothorax
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6
Q

A pneumothorax is typically when the seal of parietal space has been lost. The negative pressure of -5 of water is lost. This causes the lung to be collapse, the chest wall expands and the parietal space fills with air. A spontaneous pneumothorax is when a bullae (large air pocket) is perforated, which can be primary or secondary. Which of the following patients is likely to have a primary spontaneous pneumothorax?

1 - tall, thin, athletic young male with underlying lung condition
2 - small, overweight female with no underlying lung disorder
3 - tall, overweight female with no underlying lung disorder
4 - tall, thin, athletic young male with no underlying lung condition

A

4 - tall, thin, athletic young male with no underlying lung condition

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7
Q

A pneumothorax is typically when the seal of parietal space has been lost. The negative pressure of -5 of water is lost. This causes the lung to be collapse, the chest wall expands and the parietal space fills with air. A spontaneous pneumothorax is when a bullae (large air pocket) is perforated, which can be primary or secondary. Which of the following patients is likely to have a secondary spontaneous pneumothorax?

1 - tall, thin, athletic young male with underlying lung condition
2 - small, overweight female with no underlying lung disorder
3 - tall, overweight female with no underlying lung disorder
4 - tall, thin, athletic young male with no underlying lung condition

A

1 - tall, thin, athletic young male with underlying lung condition

  • underlying lung conditions could be Marfans syndrome (connective tissue disorder), cystic fibrosis, emphyema and lung cancer.
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8
Q

A pneumothorax is typically when the seal of parietal space has been lost. The negative pressure of -5 of water is lost. This causes the lung to be collapse, the chest wall expands and the parietal space fills with air. There are a number of pneumothorax, which of the following is a traumatic pneumothorax?

1 - parietal pleura is broken from the outside but air can move in and out
2 - bullae (large air pocket) is perforated
3 - parietal pleura is broken but can only move into parietal space
4 - all of the above

A

1 - parietal pleura is broken from the outside but air can move in and out

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9
Q

A pneumothorax is typically when the seal of parietal space has been lost. The negative pressure of -5 of water is lost. This causes the lung to be collapse, the chest wall expands and the parietal space fills with air. There are a number of pneumothorax, which of the following is a tension pneumothorax?

1 - parietal pleura is broken from the outside but air can move in and out
2 - bullae (large air pocket) is perforated
3 - parietal pleura is broken but can only move into parietal space
4 - all of the above

A

3 - parietal pleura is broken but can only move into parietal space

  • during inspiration air moves into pleural space
  • during exhalation air is trapped in the pleural space
  • essentially the pneumothorax increases in size unless treated
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10
Q

Of the following types of pneumothorax, which is most dangerous?

1 - tension
2 - traumatic
3 - spontaneous primary
4 - spontaneous secondary

A

1 - tension
- this can put pressure on large vessels, deviate the trachea and compress the heart
- reduces cardiac out so very dangerous
- MEDICAL EMERGENCY

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11
Q

In patients with a pneumothorax (collapsed lung), which of the following symptoms will they NOT present with?

1 - sudden shortness of breathe
2 - sudden pleuritic chest pain
3 - sudden deterioration if known lung disease in patient
4 - all of the above

A

4 - all of the above

  • the key is the SUDDEN ONSET
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12
Q

In patients with a pneumothorax (collapsed lung), which of the following clinical signs will they NOT present with?

1 - increased dullness
2 - reduces breathe sounds
3 - hyper resonance
4 - decreased lung expansion

A

1 - increased dullness

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13
Q

Boyles Law states that as the volume of a container increases, the pressure within the enlarged container decreases. As we inhale the diaphragm and intercostal muscles contract, pulling the lungs down and out, increasing the volume of the lungs and decreasing the pressure in the lungs. Is the air from outside that we inhale therefore likely to move in or out of the lungs?

A
  • into the lungs
  • air pressure is higher outside the lungs so moves down the pressure/concentration gradient into the lungs
  • pressure outside lungs = 750 mmHg
  • pressure in lungs during inhalation = 757 mmHg
  • pressure in lungs during exhalation = 763 mmHg
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14
Q

What may be present on an X-ray in a patient with a pneumothorax?

1 - large space (darker area where lung should be)
2 - difference size between lungs
3 - tracheal deviation
4 - all of the above

A

4 - all of the above

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15
Q

Which of the following is NOT a risk factor for a primary spontaneous pneumothorax?

1 - tall
2 - male
3 - thin
4 - asthma

A

4 - asthma
- primary spontaneous pneumothorax has no underlying lung disease

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16
Q

Which of the following is NOT a risk factor for a secondary spontaneous pneumothorax?

1 - asthma
2 - COPD
3 - thin
4 - pulmonary fibrosis
5 - cystic fibrosis

A

3 - thin
- secondary spontaneous pneumothorax has an underlying lung disease

In COPD, if a large bullae bursts, it can lead to a pneumothorax

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17
Q

When managing a primary spontaneous pneumothorax (no underlying lung disease), if the patient has dyspnea and the rim (edge of the lung) is >2cm from the parietal pleura what is the initial management of the patient?

1 - HRCT
2 - aspirate the pneumothorax
3 - consider discharge and review in 2-4 wks
4 - admit and monitor

A

2 - aspirate the pneumothorax
- if this is unsuccessful a chest drain will be needed
- if successful, discharge the patient and review in 2-4 weeks
- also give the patients 10L of oxygen

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18
Q

When managing a primary spontaneous pneumothorax (no underlying lung disease), if the patient does not have dyspnea and the rim (edge of the lung) is <2cm from the parietal pleura what is the initial management of the patient?

1 - HRCT
2 - aspirate the pneumothorax
3 - consider discharge and review in 2-4 wks
4 - admit and monitor

A

3 - consider discharge and review in 2-4 wks

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19
Q

When managing a secondary spontaneous pneumothorax (underlying lung disease), if the patient has dyspnea and the rim (edge of the lung) is >2cm from the parietal pleura what is the initial management of the patient?

1 - HRCT
2 - aspirate the pneumothorax
3 - consider discharge and review in 2-4 wks
4 - chest drain

A

4 - chest drain

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20
Q

When managing a secondary spontaneous pneumothorax (underlying lung disease), if the patient does not have dyspnea and the rim (edge of the lung) is 1-2cm from the parietal pleura what is the initial management of the patient?

1 - HRCT
2 - aspirate the pneumothorax
3 - consider discharge and review in 2-4 wks
4 - chest drain

A

2 - aspirate the pneumothorax
- if unsuccessful then do a chest drain
- if successful admit for 24h to observe with O2

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21
Q

When managing a secondary spontaneous pneumothorax (underlying lung disease), if the patient does not have dyspnea and the rim (edge of the lung) is <1cm from the parietal pleura what is the initial management of the patient?

1 - admit and monitor for 24h with O2
2 - aspirate the pneumothorax
3 - consider discharge and review in 2-4 wks
4 - chest drain

A

1 - admit and monitor for 24h with O2

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22
Q

When managing a tension pneumothorax (underlying lung disease), what is the initial management of the patient?

1 - admit and monitor for 24h with O2
2 - aspirate the pneumothorax
3 - insert large bore cannula into 2nd intercostal space and allow air to drain
4 - chest drain

A

3 - insert large bore cannula into 2nd intercostal space and allow air to drain
- in mid-clavicular line
- use saline so it bubbles and we can see air escaping
- DO NOT WAIT FOR OTHER INVESTIGATION

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23
Q

If a patient has had a pneumothorax, they are contraindicated to fly for a set period of time. What is the standard time they are advised to wait following a pneumothorax providing there is no residual air in the pleural space?

1 - 2 days
2 - 1 week
3 - 2 weeks
4 - 6 weeks

A

3 - 2 weeks
- in scuba diving patients are advised never to do this again following a pneumothorax

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24
Q

Pleural = space between visceral (attached to lungs) and parietal (attached to thoracic wall and effusion = collection of fluid. So essentially pleural effusion means collection of fluid in the pleural space. In normal physiology there is a continuous fluid turnover (aprox 1L) in the pleural space, which is drained by what?

1 - capillaries
2 - diffusion into surrounding tissues
3 - lymphatics
4 - veins

A

3 - lymphatics

25
Q

If too much fluid is produced by the body, this can drain into the pleural space. There are 2 key types of pleural fluid. Which 2 of the following are correct forms of pleural effusion?

1 - exudate
2 - transudate
3 - prolongate
4 - phantomgate

A

1 - exudate
2 - transudate
- there can also be a lymphatic effusion

26
Q

Which of the following is NOT a characteristic of an exudate (remember think E for EXIT incorrectly)?

1 - fluid is from circulatory system
2 - inflammation is primary cause
3 - low protein
4 - high lactate dehydrogenase (similar to blood)

A

3 - low protein
- protein is normally high

27
Q

What is the level of protein content to make it an exudate pleural effusion?

1 - >0.1
2 - >0.3
3 - <0.5
4 - >0.5

A

4 - >0.5
- >35g/L
- 2/3 upper limit of normal serum levels of protein

28
Q

Why is protein typically >0.5 in an exudate?

1 - blood vessels leak proteins
2 - inflammation damages tissue and proteins leak into pleural space
3 - increased hydrostatic pressure forces protein into pleural space
4 - all of the above

A

2 - inflammation damages tissue and proteins leak into pleural space

  • if the inflammation is due to an infection, this can lead to the pleural effusion becoming infected, like a giant abscess
29
Q

What do the levels of lactate dehydrogenase (LDH) need to be to make the pleural effusion an exudate?

1 - >0.1
2 - >0.3
3 - <0.6
4 - >0.6

A

4 - >0.6
- 2/3 upper limit of normal serum levels of protein

30
Q

How does exudative fluid generally look?

1 - clear
2 - cloudy
3 - like milk

A

1 - clear
- contains immune cells so looks cloudy

31
Q

What is lactate dehydrogenase?

1 - enzyme involves in cholesterol synthesis
2 - enzyme involved in glycolysis
3 - enzyme involved in aerobic metabolism
4 - enzymes that converts pyruvate to lactate

A

4 - enzymes that converts pyruvate to lactate
- enzyme is present in all cells

32
Q

Which of the following is NOT a characteristic of an transudate (remember think T for transverse the membrane)?

1 - thinner fluid than exudate
2 - extravascular fluid
3 - generally due to high hydrostatic or low osmotic pressures
4 - high in LDH and protein

A

4 - high in LDH and protein
-typically low in LDH and protein

33
Q

What is the less of protein content to make it a pleural effusion a transudate?

1 - >0.1
2 - >0.3
3 - <0.5
4 - >0.5

A

3 - <0.5
- <25g/L

34
Q

What do the levels of lactate dehydrogenase (LDH) need to be to make the pleural effusion a transudate?

1 - >0.1
2 - >0.3
3 - <0.6
4 - >0.6

A

3 - <0.6

35
Q

How does transudative fluid generally look?

1 - clear
2 - cloudy
3 - like milk

A

1 - clear

36
Q

How does lymphatic fluid generally look?

1 - clear
2 - cloudy
3 - milky

A
  • 3 - milky
  • lipids give it this colour
37
Q

What are mesothelioma cells?

A
  • simple squamous cells originating from mesoderm
  • cells lining pleural walls
  • secrete pleural fluid
38
Q

What is a common cause of thickening of the pleura and mesothelioma?

A
  • exposure to chemicals and toxins
  • specifically asbestos
39
Q

What is the only way to test if fluid in the pleural space is an exudate or transudate?

A
  • pleural aspiration guided by ultrasound
  • pleural drainage can be used if lots of fluid
40
Q

When analysing pleural fluid, which of the following tests is required?

1 - biochemistry (protein and lactate dehydrogenase)
2 - microbiology (rule out TB)
3 - cytology (rule out cancer)
4 - all of the above

A

4 - all of the above
- identifies if the pleural effusion is a transudate or exudate by comparing with serum levels

41
Q

To sample the pleural effusion, a thoracentesis is required (needle into the pleural space). What is the typical location for this?

1 - 1-2 intercostal spaces above pleural effusion border following percussion
2 - 1-2 intercostal spaces below pleural effusion border following percussion
3 - anywhere where pleural effusion is confirmed following percussion

A

2 - 1-2 intercostal spaces below pleural effusion border following percussion

  • give patient 10-15ml lidocaine
  • extract 10-30ml of the effusion
42
Q

When inserting a needle to do drain a pleural effusion, do we go above or below the rib?

A
  • above
  • intercostal neurovascular bundle is contained below ribs in the costal groove
  • top to bottom = vein, artery, nerve (VAN)
43
Q

Which criteria is used to distinguish between a transudate and exudate pleural effusion?

1 - Lights criteria
2 - Duke criteria
3 - Modified Glasgow score
4 - CURB-65 score

A

1 - Lights criteria
- accurate diagnosis of pleural effusions
- determines if effusion is transudate or exudate

44
Q

Add some questions about lights criteria norms here

A
45
Q

Hydrostatic pressure is the pressure exerted on blood vessel walls by blood. Which of the following conditions can increase hydrostatic pressure of pulmonary blood vessels?

1 - congestive heart failure
2 - right or left sided heart failure
3 - pulmonary hypertension
4 - all of the above

A

4 - all of the above
- increased hydrostatic pressure forces fluid into pleural space

46
Q

Oncotic pressure is a solute concentration dependent pressure in blood vessels, where fluid moves to high solute concentrations, such as albumin (high albumin in blood keeps fluid in blood vessels). Which 2 of the following can cause a drop in oncotic pressure and lead to fluid leaking out of blood vessels?

1 - congestive heart failure
2 - right or left sided heart failure
3 - liver cirrhosis
4 - nephrotic syndrome

A

3 - liver cirrhosis
4 - nephrotic syndrome

  • essentially means less albumin is present in the blood so fluid transverses the membrane into the pleural space
47
Q

Which of the following is NOT a cause of an transudative pleural effusion?

1 - heart failure
2 - malignancy
3 - cirrhosis
4 - nephrotic syndrome
5 - hypoalbuminaemia
6 - hypothyroidism

A

2 - malignancy

48
Q

Exudate pleural effusions are essentially due to inflammation, where the capillaries become leaky and allow fluid, immune cells and large proteins (LDH) to leak out. Which of the following is NOT a cause of an exudative pleural effusion?

1 - malignancy
2 - infection (pneumonia, TB, emphysema)
3 - autoimmune disease (RA, SLE)
4 - pneumonia
5 - cirrhosis

A

5 - cirrhosis

  • all the others cause inflammation
49
Q

Which of the following is NOT a clinical signs that a patient has a pleural effusion?

1 - ⬇️ chest wall movement on side of effusion
2 - ⬇️ ventilation on side of effusion
3 - dullness on percussion (MOST reliable finding)
4 - increased tactile vocal fremitus and vocal resonance on side of perfusion
5 - bronchial breathing above perfusion
6 - tracheal deviation away from perfusion
7 - dyspnea with pleuritic chest pain

A

4 - increased tactile vocal fremitus and vocal resonance on side of perfusion

  • these are normally decreased as resonance does not travel through fluid as well
50
Q

What is the main investigation in a patient with a suspected pleural effusion?

1 - ABG
2 - Chest-Xray
3 - ultrasound
4 - microbiology

A

2 - Chest-Xray

51
Q

In a patient with a suspected pleural effusion, we would do an X-ray to confirm the diagnosis. What are we likely to see on the X-ray?

1 - blunting of the costophrenic angles
2 - fluid in the lung fissures
3 - meniscus of the lung (curving)
4 - tracheal deviation if pleural effusion is large
5 - all of the above

A

5 - all of the above

52
Q

What is the term given when pus has collected in the pleural space?

1 - emphysema
2 - empyema
3 - haemothorax
4 - chylothorax

A

2 - empyema
- essentially means pocket of pus that collect in the body

53
Q

When performing a pleural aspiration in a patient with suspected empyema, which is essentially pockets of pus that collect in the body, which of the following is NOT a characteristic of the pus that will be drained?

1 - low pH <7.2
2 - high glucose
3 - high LDH
4 - all of the above

A

2 - high glucose
- glucose will be low as the microorganisms will be using the glucose

54
Q

What is the term given when chyle (lymphatic fluid) has collected in the pleural space?

1 - emphysema
2 - empyema
3 - haemothorax
4 - chylothorax

A

4 - chylothorax

55
Q

What is the term given when blood has collected in the pleural space?

1 - emphysema
2 - empyema
3 - haemothorax
4 - chylothorax

A

3 - haemothorax

56
Q

In a small effusion, what would the appropriate initial management be?

1 - pleural aspiration with repeats
2 - conservative management
3 - chest drain
4 - admit and observe with no treatment

A

2 - conservative management
- if caused by infection, then treat the infection and the patients symptoms

57
Q

In small effusion that is symptomatic or a larger effusion, which 2 of the following would be an appropriate initial management plan?

1 - pleural aspiration with repeats
2 - conservative management
3 - chest drain
4 - admit and observe with no treatment

A

1 - pleural aspiration with repeats
3 - chest drain

58
Q

When draining a pleural effusion we should not drain all the fluid immediately as this can cause re-perfusion pulmonary effusion, which can be dangerous. How much is recommended to be drained in 24h?

1 - 250-500ml
2 - 500-1L
3 - 500-1.5L
4 - 1L-3L

A

3 - 500-1.5L

59
Q

When inserting a chest drain, which of the following is NOT part of the safe triangle (which is not really a triangle)?

1 - inferior border = 2nd intercostal space
2 - superior border = base of axilla
3 - medial border = lateral edge of pectoralis major
4 - lateral border = anterior edge of latissimus dorsi

A

1 - inferior border = 2nd intercostal space
- it is the 5th intercostal space

A. MLA Map Acute and Emergency (42 decks)

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