Pulmonary Cases

Question 1

Pleural Effusion X-Ray findings

Answer 1

CXR:

May demonstrate blunting of the costophrenic angle (see Figure 16.6).

Decubitus films help determine if fluid is free flowing or loculated. A finding of > 1 mm of fluid on decubitus CXR suggests a significant amount of fluid.

Question 2

Pleural Effusion

• Diagnostic Thoracentesis (what test to preform)
• Light’s Criteria

Answer 2

Exudative fluid is more similar to serum than transudative

Diagnostic thoracentesis:

1. Performed on clinically significant effusions; can distinguish transudate from exudate using Light’s criteria (see below).
2. Also send for Gram stain, bacterial/fungal/mycobacterial cultures, and cytology.
3. Pleural fluid amylase, triglycerides, cholesterol, and hematocrit may be analyzed if appropriate (see Table 16.14).

Light’s criteria:

Pleural effusion is exudative if any of these criteria are met:

1. Pleural fluid/serum Protein ratio > 0.5. (plasma n=7g/dl)
2. Pleural fluid/serum LDH ratio > 0.6.
3. Pleural fluid LDH > 2/3 the upper limit of normal for serum LDH.

Question 3

Pleural Effusion

- Pleural Fluid Test modifications

1. pH
2. Hct
3. Glc
4. TG
5. LYM
6. EOS
7. Adenosine

Answer 3

pH

<7.2

-> Parapneumonic Effusion => Drainage required

<7.2

-> Pleural Inflamation

Hct

>50%

-> Hemothorax

Glc

<60 mg/dL

• > Complicated Parapneumonic Effusion
• > Malignancy

<30 mg/dL

-> Rheumatoid

TG

>110 mg/dL

-> Chylothorax (thoracic duct disruption) [milky white]

Lymphoma / Cancer / Trauma / Lymphangioleiomyomatosis.

LYM

>50%

-> TB or malignancy.

EOS

>10%

• > Seen in air or blood is present
• > Pneumothorax (common)
• > Drug Reaction
• > Asbestos
• > Paragonimiasis
• > Churg - Strauss syndrome
• > Pleural Effusion

High adenosine sugests TB

Question 4

Bronchiectasis

-Most feared complications

Answer 4

1. Lung Abscesses
2. Life-threatening Hemoptysis

Question 5

1. Pancoast Syndrome
2. Horner Syndrome
3. SVC Syndrome

Answer 5

1. Pancoast syndrome

Brachial plexus compression due to apex tumor

Is characterised by shoulder pain radiating into the arm in an ulnar distribution and is caused by tumour invasion of the eighth cervical and first thoraic nerves

Can cause (parhesthesias, pain, weakness in right arm)

2. Horner Syndrome
   * Sympathetic trunk compression

PAM

1. Ptosis
2. Anhidrosis
3. Miosis
4. SVC Syndrome

Compression of SVC due to tumor => Plethora on rising arms above the head; colateral veins on thorx