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Question 1

Primary vs secondary pneumothorax

Answer 1

Primary - tall people
Secondary - in someone with lung conditions

Question 2

Iatrogenic pneumothorax causes

Answer 2

NIV, CVC insertion

Question 3

What is another cause of pneumothorax

Answer 3

Trauma

Question 4

How do you manage pneumothorax

Answer 4

If primary and under 2cm - discharge
If over 2cm - chest drain

If secondary and 1-2cm - needle aspiration with 14G needle
if over 2cm - chest drain

Question 5

Discharge and follow up advice in pneumothorax

Answer 5

F/U in 2 to 4 weeks

Discharge - no air travel until 1 week after and x ray is clear
No scuba diving unless bilateral surgical pleurectomy and normal CT

Question 6

Complications of chest drain

Answer 6

Immediately- failure, pain, pneumothorax, haemothorax
Later - infection, haematoma, long thoracic nerve palsy
Later than that - scar

Question 7

What is a flail chest

Answer 7

3 rib fractures which cause asymmetrical breathing - as seen on chest x ray
Manage with analgesia, chest physio and surgical fixation

Question 8

Pleural effusion - management

Answer 8

21 G needle + 50ml syringe for aspiration

If the contents are cloudy or if the pH of the contents are less than 7.2 with suspected infection, insert a chest drain.

Treat underlying cause

Question 9

What do you do with the pleural effusion aspirate

Answer 9

Check:
Protein level - raised above 30g/L in exudative causes
LDH (marker of cell damage) - raised in exudative causes
pH
Send for MC&S
Glucose - if low - RA or TB
Blood - TB, PE or mesothelioma
Amylase - raised in pancreatitis or oesophageal perforation

Question 10

What criteria do you use to tell you if this is transudative or exudative if the protein isn’t above 30g/L exactly?

Answer 10

Light’s criteria:

pleural fluid protein divided by serum protein >0.5
pleural fluid LDH divided by serum LDH >0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

Question 11

How do you treat recurrent pleural effusion?

Answer 11

Pleurodesis
Repeat aspirations
SOB drugs
Indwelling pleural catheter

Question 12

What is pleurodesis

Answer 12

Where a drug is put into the lung pleura space to obliterate it so that nothing collects there

Question 13

How would you differentiate between cancer vs infective cause of pleural effusion?

Answer 13

Lymphocytes - malignancy (chronic)
Neutrophils mainly - infection (acute)

Question 14

How do you differentiate between tension pneumothorax and simple pneumothorax?

Answer 14

Tension pneumothorax - hypotension and SOB, tracheal deviation
Simple pneumothorax - pleuritic chest pain

Question 15

How do you deal with a tension pneumothorax?

Answer 15

14G needle immediately, second intercostal space - skip the cxr

Question 16

Where do you insert the needle for the tension pneumothorax?

Answer 16

You go ABOVE the THIRD rib, MCL, to avoid the nerve, artery, vein bundle that runs UNDER The ribs

(always aim high, above, over)

Question 17

Cystic fibrosis - symptoms / other conditions

Answer 17

Aspergillus - ABPA

Bronchiectasis

Chest infections
Clubbing
Cirrhosis - jaundice

Diarrhoea / constipation
Diabetes mellitus

Meconium ileus
Malabsorption
Male sterility

Nasal polyps / sinusitis

Question 18

What is the most common gene mutation for CF?

Answer 18

F508, class 2 mutation aka incorrect folding of the CFTR protein

more than 900 gene mutations

Question 19

What is the problem with CF?

Answer 19

CF transmembrane conductance regulator, a cAMP dependent chloride channel, chromosome 7

Question 20

Investigations for CF

Answer 20

Sweat test - NaCl high in sweat, over 60
Guthrie heel prick test for Immunoreactive trypsinogen
CXR

Question 21

What do you see on CXR on someone with CF?