Pleural Disorders & FB aspiration

What is a pleural effusion?

Abnormal accumulation of fluid in the pleural space.

What is the most common symptom of pleural effusion?

Dyspnea.

What are the classic PE findings of pleural effusion?

Decreased breath sounds, dullness to percussion, decreased tactile fremitus.

What are the classic CXR findings of pleural effusion?

Blunted costophrenic angle, meniscus sign, dependent opacity.

What is the initial imaging study for pleural effusion?

Chest X-ray.

What imaging is most sensitive for small pleural effusions?

Thoracic ultrasound.

What is the difference between transudative and exudative pleural effusions?

Transudative = pressure imbalance; exudative = inflammation or increased permeability.

What is the most common cause of transudative pleural effusion?

Congestive heart failure.

What are other causes of transudative pleural effusion?

Cirrhosis, nephrotic syndrome, hypoalbuminemia.

What are common causes of exudative pleural effusion?

Pneumonia, malignancy, pulmonary embolism, tuberculosis.

What are Light's criteria for an exudative pleural effusion?

Pleural/serum protein >0.5 OR pleural/serum LDH >0.6 OR pleural LDH >2/3 serum LDH upper limit of normal.

How many Light's criteria are needed to classify an effusion as exudative?

Only ONE.

What does neutrophil-predominant pleural fluid suggest?

Acute infection.

What does lymphocyte-predominant pleural fluid suggest?

Tuberculosis or malignancy.

What does positive pleural fluid cytology suggest?

Malignancy.

When is diagnostic thoracentesis indicated?

New unexplained effusion, unilateral effusion, suspected infection or malignancy.

When is therapeutic thoracentesis indicated?

Large symptomatic pleural effusion causing dyspnea.

Where should the thoracentesis needle be inserted relative to the rib?

Just superior to the rib to avoid the neurovascular bundle.

What is re-expansion pulmonary edema?

Pulmonary edema following rapid re-expansion of a collapsed lung.

How does re-expansion pulmonary edema present?

Acute dyspnea, hypoxemia, cough, crackles after drainage.

How is re-expansion pulmonary edema managed?

Stop drainage, provide oxygen and supportive respiratory care.

What is a hydrothorax?

Serous fluid in the pleural space; commonly CHF or cirrhosis.

What is a hemothorax?

Blood in the pleural space; commonly trauma.

How is a significant hemothorax treated?

Chest tube drainage.

What is a chylothorax?

Milky lymphatic fluid in the pleural space due to thoracic duct injury or lymphoma.

What is Meigs' syndrome?

Benign ovarian fibroma + ascites + pleural effusion.

What is empyema?

Pus in the pleural space, usually caused by bacterial pneumonia.

What is the most common cause of empyema?

Bacterial pneumonia.

What are the classic symptoms of empyema?

Fever, pleuritic chest pain, dyspnea, cough.

What are the characteristic pleural fluid findings of empyema?

Purulent fluid, pH

What are the TWO essential components of empyema treatment?

IV antibiotics + chest tube drainage.

What antibiotics are used for community-acquired empyema?

Ceftriaxone + metronidazole or an appropriate beta-lactam/beta-lactamase inhibitor regimen.

What antibiotics are used for hospital-acquired empyema?

Vancomycin + piperacillin-tazobactam OR vancomycin + cefepime + metronidazole.

What is the treatment for persistent loculated empyema despite drainage?

Intrapleural tPA + DNase; consider VATS.

What is the most common cancer causing malignant pleural effusion?

Lung cancer.

What type of effusion is typically associated with malignancy?

Exudative.

What is the most common symptom of malignant pleural effusion?

Progressive dyspnea.

What imaging findings suggest malignant pleural effusion?

Recurrent effusion, pleural thickening/nodularity, possible lung mass.

What is the initial treatment for symptomatic malignant pleural effusion?

Therapeutic thoracentesis.

What is pleurodesis?

Procedure that adheres visceral and parietal pleura to prevent recurrent fluid accumulation.

What agent is most commonly used for pleurodesis?

Talc.

When is pleurodesis indicated?

Recurrent symptomatic malignant pleural effusion with expandable lung.

When is an indwelling pleural catheter preferred?

Recurrent malignant effusion with trapped/nonexpandable lung or failed pleurodesis.

What is the primary benefit of an indwelling pleural catheter?

Repeated outpatient drainage and relief of dyspnea.

What is a pneumothorax?

Air in the pleural space causing lung collapse.

What is the classic patient with primary spontaneous pneumothorax?

Young, tall, thin male; smoking increases risk.

What causes primary spontaneous pneumothorax?

Rupture of a subpleural bleb.

What causes secondary spontaneous pneumothorax?

Underlying lung disease, especially COPD.

What are common causes of iatrogenic pneumothorax?

Thoracentesis, central venous line placement, lung biopsy.

What is the classic presentation of pneumothorax?

Sudden unilateral pleuritic chest pain and dyspnea.

What are the classic PE findings of pneumothorax?

Decreased/absent breath sounds, hyperresonance, decreased tactile fremitus.

What are the classic CXR findings of pneumothorax?

Visible pleural line with absent peripheral lung markings.

What are the ultrasound findings of pneumothorax?

Absent lung sliding, absent B-lines, possible lung point.

What is the pathophysiology of tension pneumothorax?

Trapped air increases intrathoracic pressure, decreases venous return and causes obstructive shock.

What are the classic findings of tension pneumothorax?

Severe dyspnea, hypotension, tachycardia, absent unilateral breath sounds, possible tracheal deviation.

What type of shock occurs in tension pneumothorax?

Obstructive shock.

What differentiates tension pneumothorax from simple pneumothorax?

Hemodynamic instability due to impaired venous return.

What is the immediate treatment of tension pneumothorax?

Immediate decompression WITHOUT waiting for imaging.

What is the definitive treatment of tension pneumothorax?

Chest tube thoracostomy.

How is a small, stable primary spontaneous pneumothorax managed?

Observation, monitoring, follow-up.

How is a symptomatic primary spontaneous pneumothorax managed?

Needle aspiration or pleural drainage/chest tube.

How is a large or symptomatic secondary spontaneous pneumothorax typically managed?

Chest tube drainage and treatment of underlying lung disease.

Who is at greatest risk for foreign body aspiration?

Young children, older adults, patients with impaired consciousness or dysphagia.

What objects are commonly aspirated by children?

Peanuts, seeds, popcorn, grapes, small toys.

What objects are commonly aspirated by adults?

Food, meat, dental prostheses, teeth.

Where do aspirated foreign bodies most commonly lodge in adults?

Right mainstem bronchus.

Why is the right mainstem bronchus the most common aspiration site?

It is shorter, wider, and more vertical.

What is the classic presentation of foreign body aspiration?

Sudden choking, coughing, dyspnea, wheezing or stridor.

What PE finding suggests a retained foreign body?

Unilateral wheezing or decreased breath sounds.

Can a normal CXR exclude foreign body aspiration?

No; many aspirated objects are radiolucent.

What is the definitive diagnostic and therapeutic procedure for foreign body aspiration?

Bronchoscopy.

How is partial airway obstruction with effective coughing managed?

Encourage coughing, monitor and arrange evaluation for retained foreign body.

How is severe airway obstruction managed in a conscious adult?

Alternate 5 back blows with 5 abdominal thrusts.

How is severe airway obstruction managed in an infant younger than 1 year?

Alternate 5 back blows with 5 chest thrusts.

What are delayed complications of foreign body aspiration?

Recurrent pneumonia, bronchiectasis, lung abscess, chronic cough.

What is obstructive sleep apnea (OSA)?

Recurrent upper airway collapse during sleep causing intermittent hypoxemia and sleep fragmentation.

What are the major risk factors for OSA?

Obesity, male sex, older age, large neck circumference, enlarged tonsils.

What is the classic triad of OSA?

Loud snoring, witnessed apneas, excessive daytime sleepiness.

What daytime symptoms are associated with OSA?

Morning headaches, fatigue, poor concentration, excessive sleepiness.

What screening tool is used for OSA?

STOP-BANG.

What is the gold-standard diagnostic test for OSA?

Polysomnography.

What AHI confirms OSA in a symptomatic patient?

AHI ≥5 events/hour.

What AHI can diagnose OSA even without symptoms?

AHI ≥15 events/hour.

What is the first-line treatment for moderate-to-severe OSA?

CPAP.

What are alternative treatments for OSA?

Weight loss, positional therapy, oral appliances, selected surgical procedures.

What are major cardiovascular complications of untreated OSA?

Hypertension, arrhythmias, CAD, stroke, heart failure, pulmonary hypertension.

What is obesity hypoventilation syndrome (OHS)?

Obesity with awake daytime hypercapnia (PaCO2 >45 mmHg), sleep-disordered breathing, and no alternative cause.

What is another name for obesity hypoventilation syndrome?

Pickwickian syndrome.

What is the key difference between OSA and OHS?

OHS causes awake daytime hypercapnia; OSA alone does not necessarily cause daytime hypercapnia.

What are the major risk factors for OHS?

Obesity, OSA, large neck circumference, severe sleep-disordered breathing.

What are the classic symptoms of OHS?

Daytime sleepiness, morning headaches, dyspnea, fatigue, reduced exercise tolerance.

What diagnostic test confirms daytime hypercapnia in OHS?

Arterial blood gas showing PaCO2 >45 mmHg.

What other tests are useful in evaluating OHS?

Serum bicarbonate, polysomnography, PFTs and tests to exclude alternative causes.

What is first-line treatment for stable OHS with coexisting severe OSA?

CPAP.

When is BiPAP preferred in OHS?

Predominant hypoventilation without severe OSA or acute-on-chronic hypercapnic respiratory failure.

What is the difference between CPAP and BiPAP?

CPAP delivers one continuous pressure; BiPAP delivers higher inspiratory and lower expiratory pressures.

What is the most important long-term treatment for OHS?

Substantial weight loss and adherence to positive airway pressure.

What degree of weight loss may resolve OHS in many patients?

Approximately 25-30% of actual body weight.

What are the major complications of untreated OHS?

Pulmonary hypertension, cor pulmonale, chronic respiratory failure.