Pleural Disease

Front 1

What is pleural fluid?

Which side of the pleura is more important for pleural fluid homeostasis?

Back 1

filtrate from high pressure vessels

parietal side is more important

Front 2

Fluid arises predominantly from _____ of parietal pleura

Fluid is absorbed mostly by parietal side ______

Back 2

Fluid arises predominantly from systemic vasculature of parietal pleura

Fluid is absorbed mostly by parietal side lymphatics

Front 3

What artery from the visceral side contributes to the pleural fluid?

What artery from the parietal side contributes to the pleural fluid?

Back 3

Visceral = bronchial

parietal = intercostal

Front 4

Is CXR sensitive for pleural effusion?

Back 4

not really; can get alot of fluid in there before it shows up

Front 5

How can you increase your ability to determine how much fluid there is in a pleural effusion using xray?

Back 5

lateral decubitus xray

Front 6

How do you use a lateral decubitus xray to determine if you should do thoracocentesis?

Back 6

If pleural fluid on a lateral chest X-ray is > 5cm in height, thoracentesis should be performed and pleural fluid sent for culture.

Front 7

Pleural fluid colors and what they suggest:

Slightly yellow =

Red =

White =

Brown =

Black =

Yellow-green =

Back 7

Slightly yellow = normal

Red = malignancy, BAPE, PCIS, pulmonary infarction, trauma

White = chylothorax

Brown = amoebic liver abscess, chronic blood

Black = aspergilliosis

Yellow-green = empyema, rheum. arth.

Front 8

Increased lymphocytes in pleural fluid indicates?

Back 8

Increased in TB, lymphoma, sarcoid, rheumatoid, chylothorax

Front 9

mesothelial cells >5% in pleural fluid?

Back 9

>5% excludes TB

Front 10

Lots of PMNs in pleural fluid?

Back 10

infection

Front 11

high amount of RBCs in pleural effusion?

Back 11

hemothorax

Front 12

Normal pH of pleural fluid? When is it decreased?

Back 12

normal = 7.60

Decreased (<7.20) in:

– Infection
– Malignancy
– Eosphageal perforation – RA
– Lupus

Front 13

Criteria used to determine transudate vs exudate? (5)

Back 13

Light’s Criteria:
– Pleural fluid /serum protein ratio > 0.5
– Pleural fluid / serum LDH > 0.6
– Pleural fluid LDH greater than 2/3 upper limit of normal (around 250)

– Cholesterol greater than 45
– Pleural fluid protein >2.9g/dL

Front 14

Causes of transudates?

Back 14

• CHF
• Ascites
• Nephrotic syndrome
• Peritoneal dialysis
• Low albumin state
• Urinothorax
• Atelectasis
• Constrictive pericarditis

• Trapped lung
• Duro-pleural fistula
• CVC leak
• SVC obstruction

Front 15

Causes of exudates

Back 15

• Infection
• Malignancy
• Hemothorax
• Chylothorax
• Pancreatitis
• Esophagealperforation
• Connectivetissue diseases

• PE
• Post-cardiotomy

Front 16

Describe the typical cellular and biochemical characteristics of pleural effusions due to:

Congestive heart failure

Back 16

CHF normally = transudate

except when you are on diruetics bc the diruetic removes some of the fluid and makes it technically an exudate

More commonly bilateral. If unilateral slight right sided predominance.

Front 17

Describe the typical cellular and biochemical characteristics of pleural effusions due to:

Infection - uncomplicated parapneumonic

Back 17

Uncomplicated:

neg. micro,

pH>7.20,

Cell count ~10,000

Front 18

Describe the typical cellular and biochemical characteristics of pleural effusions due to:

Infection - complicated parapneumonic

Back 18

Complicated:

cell count ~50,000,

pH <7.20,

LDH high,

glucose low,

gram stain/ cx sometimes positive

Front 19

Describe the typical cellular and biochemical characteristics of pleural effusions due to:

Infection - empyema

Back 19

Empyema:

pus in pleural space,

pH<7.20,

cell count ~100,000,

positive gram stain,

glucose low (can be <10mg/dL)

Front 20

Describe the typical cellular and biochemical characteristics of pleural effusions due to:

Infection - TB

Back 20

2000-8000 cells nucleated cells, with >90% lymphocytes

<5% mesothelial cells

Usually pH<7.2

Usually does NOT grow TB

High adenosine deaminase = ADA

Front 21

Describe the typical cellular and biochemical characteristics of pleural effusions due to:

Carcinoma metastastic to pleura

Back 21

-Variable- can be transudates or exudates
-Usually large volume (>1000cc) in 60%
-Cytology usually positive

-Low pH or glucose = poorer survival

Front 22

Characteristically, an effusion follows a “gradient” of highly ______ at the lung base, and gradually becomes less _______ when moving more superiorly.

Back 22

Characteristically, an effusion follows a “gradient” of highly dense (white) opacities at the lung base, and gradually becomes less dense (black) when moving more superiorly.

Front 23

traumatic pneumothorax.

Back 23

caused by A penetrating wound of the chest wall or a rib fracture with lung puncture

can cause tension pneumo = shift to opposite side

Front 24

iatrogenic pneumothorax

Back 24

complication of positive pressure ventilation or a procedure like thoracentesis or subclavian venopuncture

Front 25

If you have a pneumothorax due to atelectasis, which way will the mediastinal contents shift?

Back 25

to the side of the affected lung

Front 26

If you have spontaneous pneumo that results in negative pressure on the side of the collapsed lung, which way will the contents shift?

Back 26

to the side of the affected lung

Front 27

If you have a spontaneous pneumo that converts to a TENSION pneumo, as it does in 1-2% of pts (pg 26-7) which way will the contents shift?

Back 27

to the side OPPOSITE the affected lung

tension is always opposite, no matter the cause.