Pneuomothorax and pleural effusion

Question 1

What is a pneumothorax

Answer 1

The presence of air in the pleural space

Question 2

What is a primary pneumothorax

Answer 2

Where a pneumothorax has occured spontaneously without evidence of other lung disease

Question 3

What is a secondary pneumothorax

Answer 3

Where a pneumothorax has occurred secondary to an underlying lung disease such as COPD or CF

Question 4

Who is likely to present with a spontaneous primary pneumothorax

Answer 4

Healthy young, tall, thin man

Question 5

Where do most pneumothoraces arise from

Answer 5

The rupture of subpleural blebs or bullae at the apex of an otherwise normal lung

Question 6

Is smoking a risk factor for a pneumothorax

Answer 6

Yes

Question 7

What is a tension pneumothorax

Answer 7

Where the lung is pushed down , the mediastinum is shifted to the opposite side and the venous return tot he heart and cardiac output is impaired

Question 8

What is a key finding on a CXR of a tension pneumothorax

Answer 8

The trachea is deviated to one side

Question 9

How does a traumatic pneumothorax occur

Answer 9

Puncture of the lung by a fractured rib

Question 10

How might a Iatrogenic pneumothorax occur

Answer 10

Doctor induced - complication of invasive chest procedures such as the insertion of a catheter into the subclavian vein or during lung aspiration

Question 11

WHat are the 2 most common clinical features of a pneumothorax

Answer 11

Acute pleuritic pain and breathlessness

Question 12

What are the clinical signs of a pneumothorax

Answer 12

Reduced breath sounds and hyper-resonance on the side of the pneumothorax

Question 13

What can be seen on a CXR of a pneumothorax

Answer 13

Black space with no lung markings

Question 14

What are the limits of a small pneumothorax

Answer 14

Where the rim of air between the margin of the collapsed lung and chest wall is less than 2cm

Question 15

What defines a large pneumothorax

Answer 15

Where the rim of air between the margin of the collapsed lung and chest wall is more than 2cm

Question 16

What should be done for a small pneumothorax

Answer 16

Nothing - will resolve spontaneously

Question 17

When is aspiration appropriate and where is this performed?

Answer 17

In a large pneumothorax

Second intercostal space in the mid-clavicular line

Question 18

What is indicated if more than 2.5L of air has been aspirated

Answer 18

A persistent air leak from the lung

Question 19

What does bubbling on respiration or coughing indicate

Answer 19

Continued drainage of air

Question 20

When is surgical intervention required

Answer 20

For persistent or recurrent peumothoraces

Question 21

What is involved in a pleurectomy

Answer 21

Removal of the parietal pleura

Question 22

What is involved in a pleurectomy

Answer 22

Removal of the parietal pleura

Question 23

What is a pleural effusion

Answer 23

A collection of fluid in the pleural space

Question 24

What is the parietal pleura perfused by

Answer 24

The systemic circulation

Question 25

What is the visceral pleura perfused by

Answer 25

The pulmonary circulation

Question 26

Why does fluid not normally collect in the pleural space

Answer 26

The balance between fluid filtration by the parietal pleura and fluid absorption by the visceral pleura prevents this

Question 27

What might cause the development of a pleural effusion

Answer 27

Increased capillary pressure Reduced plasma oncotic pressure Increased capillary permeability obstruction of lymphatic drainage

Question 28

What do patients most commonly present with when they have a pleural effusion

Answer 28

Dyspnoea Sometimes pleuritic pain Often features of associated disease (cardiac faulrue or carcinoma)

Question 29

What are the signs fo pleural effusion

Answer 29

Decreased expansion on the side of the effusion STONY DULLNESS diminished breath sounds reduced tactile vocal fremitus

Question 30

What are the investgiations involved in diagnosing a pleural effusion

Answer 30

CXR: dense white shadow with a concave upper edge Ultrasound: helpful in localising loculated eddusions and in positioning chest tubes CT: helpful in detecting pleural tumours and in assessing the underlying lung and mediastinum Pleural fluid aspiration: this is the key initial investigation

Question 31

What indicate that the effision is an exudate

Answer 31

A protein level of more than 30 and a lactate dehydrogenase level of more than 200

Question 32

What does a blood stained aspirate point towards

Answer 32

Malignancy, pulmonary infarction or severe inflammation

Question 33

What does pus indicate

Answer 33

Empyema

Question 34

What does milky white fluid suggest

Answer 34

A chylothorax

Question 35

What is suggestive of a haemothorax

Answer 35

Frank blood

Question 36

What are the predominant cells in acute inflammation or infection

Answer 36

Neutrophils

Question 37

What are the cells found in chronic effusions particularly caused by TB or malignancy

Answer 37

Lymphocytes

Question 38

What is radiologically guided biopsy is particularly useful in diagnosing?

Answer 38

Malignant disease of the pleura

Question 39

What are the 4 main causes of transudative pleural effusions

Answer 39

Cardiac failure renal failure hepatic cirrhosis hypoproteinaemia (malnutrition or nephrotic syndrome)

Question 40

What relieves dyspnoea

Answer 40

Drainage of the fluid by needle aspiration or intercostal chest tube

Question 41

How is an empyema produced

Answer 41

A secondary infection of an effusion with multiplication of bacteria in the pleural space (pus in the pleural cavity)

Question 42

What is the initial antibiotic treatment for empyema

Answer 42

Co-amoxiclav with metronidaxole

Question 43

What is the key treatment for empyema?

Answer 43

Drainage of the pus

Question 44

What do connextive tissue diseases that are associated with effusions characteristically have

Answer 44

A low glucose content

Question 45

What is Dressler's syndrome ?

Answer 45

It consists of inflammatory pericarditis and pleurisy of uncertain aetiology following an MI or cardiac operation (4-6 weeks after)

Question 46

What is an unusual cause of a pleural effusion but is a medical emergency

Answer 46

Rupture of the oesophagus