Pulmonary Effusions

Question 1

How does an effusion first manifest on a CXR?

Answer 1

Gravitates at the bast of the hemidiaphragm, esp. in the back. You’ll see a blunting of the recession on a lateral CXR.

Question 2

How much fluid must be in the pleural space to form a meniscus sign on a CXR?

Answer 2

250 cc

Question 3

A bilateral effusion with cardiomegaly indicates what condition?

Answer 3

CHF

Question 4

A bilateral pleural effusion without cardiomegaly suggests….

Answer 4

A systemic disorder. Nephrotic Syndrome Cirrhosis with ascites Esophageal rupture Lupus, RA Malignancy

Question 5

A person with CHF has a pleural effusion and an EF of 30%. What do you give them?

Answer 5

Diuretics to remove excess fluid.

Question 6

A person has an isolated pleural effusion with no other radiographic abnormalities. Throw out some possibilities.

Answer 6

TB Lupus RA PE Nephrotic Syndrome Cirrhosis Viral Pleurisy Metastatic Carcinoma

Question 7

A person has a pleural effusion with other radiographic abnormalities. Throw out some possibilities. 1. Mass 2. Lymph node 3. Infarct 4.Cardiomegaly

Answer 7

1. Mass = carcinoma 2. Lymph node = lymphoma, metastasis, etc.. 3.Infarct - PE 4. Cardiomegaly = CHF

Question 8

What is the indication for a thoracentesis when the CXR shows an effusion?

Answer 8

Greater than 10mm of fluid depth

Question 9

You have the fluid sample from thoracentesis. First thing you observe is the color. What do you think when you see…. 1. Clear 2.Redish-bloody 3. Turbid,yellow 4. Cloudy and milky white 5.Pus

Answer 9

1. Clear =Transudate 2. Bloody= If not traumatic tap, suggests tumor, Pulmonary infarct, or trauma 3. Turbid,yellow = infection, including TB 4. Milky = chylothorax 5. Pus = Empyema

Question 10

What are Light’s Criteria for distinguishing transudative fluid from exudative?

Answer 10

Exudate if:

Pleural/Serum protein ratio >5

Pleural/Serum LDH >6

Pleural LDH >200

Question 11

3 common causes of transudates in the lungs.

Answer 11

CHF

Nephrotic Syndrome

Cirrhosis

Question 12

Most common causes of Exudates

Answer 12

Parapneumonic Effusion (related to pneumonia)

Malignancy

PE

TB

Pancreatitis

Collagen Vascular disease

Question 13

What is a chylothorax and how does it happen?

Answer 13

Fat in the pleural space.

Blockage of the thoracic duct.

Question 14

A pleural fluid WBC count of 10,000 indicates what?

Answer 14

Normal is <1,000 (transudate)

>5,000 Chronic exudative TB, malignancy

>10,000 substantial inflammation –> parapneumonic, pancreatitis, pulm. infarct

Question 15

A pleural fluid WBC count of 50,000 indicates what, and what only?

Answer 15

Parapneumonic effusion.

EMPYEMA!!!

Pus in the pleural space.

Question 16

Neutrophils in the pleural fluid indicate what?

How about lymphocytes?

Answer 16

Neutrophils = acute inflamm

Lymphocytes = chronic inflamm

Question 17

A pleural fluid concentration of >5% mesothelial cells rules out what disease?

Why?

Answer 17

Rules out Tuberculus pleurisy

Noone knows why

Question 18

RBCs in the pleural fluid means…..

Answer 18

Traumatic thoracentesis

Embolism

Lung trauma

Malignancy

Question 19

How do you differentiate between pathogenic blood in the pleural fluid and traumatic thoracentesis?

Answer 19

Thoracentesis blood will be non-uniform in color during aspiration. Also, the fluid will clot in minutes.

Question 20

Found in pleural fluid samples, what does each of the following indicate?

1. Malignant cells
2. • AFB culture
3. +KOH culture
4. Triglycerides over 110
5. High amylase, pH 6

Answer 20

1. Malignancy
2. TB
3. Fungal infection
4. Chylothorax
5. Esophageal rupture

Question 21

Your pleural sample has low glucose levels <60mg/dl. What do you think is going on? Throw out a differential.

Answer 21

RA

Lupus

Malignancy

Infection

Systemic diseases increase your body’s glucose usage. Also, the bacteria in an infection utilize it too.

Question 22

What does pleural fluid acidosis indicate? (pH from 5.5-7)

Answer 22

100% Esophageal rupture (pH6)

95% Empyema (5.5-7, depending on the bacteria)

85% RA (acid efflux from pleuritis or fibrosis)

Question 23

Pleural amylase/serum amylase ratio greater than or equal to 1 indicates?

Answer 23

Acute pancreatitis

Esophageal rupture

Malignancy

Ruptured ectopic pregnancy?

Question 24

Answer 24

Yep

Question 25

Most likely cause of lymphocytosis in pleural fluid.

Answer 25

TB, cancer

Question 26

Does a negative AFB culture (acid fast bacilli) rule our TB?

Answer 26

NO!

Question 27

Define the types of Pneumothorax:

1. Primary
2. Secondary
3. Traumatic
4. Iatrogenic

Answer 27

Question 28

People with primary pneumothorax have what odd underlying condition that was undetectable before modern imaging?

Answer 28

Subpleural blebs

Question 29

Who is at greater risk for a pneumothorax:

A 45 year old obese woman.

A 23 year old tall, healthy, thin man.

Answer 29

The tall healthy thin young man.

Question 30

Describe a Tension Pneumothorax

Answer 30

Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return. Positive pressure ventilation may exacerbate this ‘one-way-valve’ effect.

The classic signs of a tension pneumothorax are deviation of the trachea away from the side with the tension, a hyper-expanded chest, an increased percussion note and a hyper-expanded chest that moves little with respiration. The central venous pressure is usually raised.

Question 31

Describe the 3 CXR signs you see here and diagnose.

Answer 31

1. Lung collapse
2. Contralateral mediastinal/tracheal shift
3. Depression of the diaphragm

Question 32

How do you treat Tension Pneumothorax?

Answer 32

Emergent decompression with a large bore needle. The hole heals itself. You just need to relieve the built up air pressure accumulating in the pleural cavity