Pulm-Pleural Disease

Question 1

What diagnostic imaging modalities are good ways to assess pleural fluid?

Answer 1

Chest radiograph or thoracic ultrasound

Question 2

Light criteria for pleural fluid analysis

Answer 2

An effusion is considered an exudate if:

Pleural fluid total protein/serum total protein >0.5
Pleural fluid LDH/serum LDH >0.6
Pleural fluid LDH >2/3 the upper limit of normal for serum LDH

Question 3

Pleural effusions with glucose <60

Answer 3

rheumatoid
complicated parapneumonic effusion or empyema
malignant effusion
tuberculosis pleurisy
lupus pleuritis
esophageal rupture

Question 4

Tests for tuberculosis effusions

Answer 4

• Lymphocyte-predominant exudative effusion
• Smear and culture of pleural fluid for acid-fast bacilli -are very specific but have a low sensitivity (5-20%)
• Adenosine deaminase is an enzyme present in lymphocytes that is elevated in most TB pleural effusions

Question 5

Tests for pleural malignancy

Answer 5

Cytology

Thorascopy with biopsy

Question 6

What is a parapneumonic effusion?

Answer 6

A parapneumonic effusion is an exudative pleural effusion that occurs adjacent to a bacterial pneumonia and results from migration of excess interstitial lung fluid across the visceral pleura

Question 7

What is an empyema

Answer 7

It is clear infection of a pleural space with the presence of pus

Question 8

Define an uncomplicated pleural effusion

Answer 8

small
free flowing
pH >7.2
Glucose >6

Question 9

Define a complicated pleural effusion

Answer 9

Loculated or thickened pleura

pH<7.2 -OR- glucose <60

Question 10

Define an Empyema

Answer 10

Bacterial organisms seen on Gram Stain or aspiration of pus on thoracentesis

Question 11

Treatment for a malignant pleural effusion

Answer 11

Palliative. If <3 months to live, then repeat thoracentesis or pleurX catheter

Question 12

Management os a primary spontaneous pneumothorax

Answer 12

<2cm on radiograph, minimal symptoms: observation alone, can be managed as an outpatient if easy access to medical care is available if symptoms worsen

• > 2cm on CXR, breathlessness, and chest pain: needle aspiration, of reaccumulation then insertion of a small-bore thoracotomy tube
• Clinical instability regardless of size: Emergent needle decompression followed by a thoracotomy tube insertion