Chapter 25: Pleural Diseases

Answer Key for the Workbook

CHAPTER OBJECTIVES

1. Describe important anatomic features and physiologic function of the

visceral and

parietal pleural membranes. (Q: 18, 19, 20, 21)

2. Describe how pleural effusions occur and the difference between

transudative and

exudative effusions. (Q: 23, 24)

3. Identify common causes of transudative and exudative pleural effusions.

(Q: 22, 25)

4. Write definitions of chylothorax, hemothorax, and pneumothorax. (Q: 25)

5. Describe the impact of moderate to large pleural effusions on lung

function. (Q: 26)

6. State the role of the chest radiograph in recognizing pleural effusions. (Q:
28, 29)

7. State the purpose of thoracentesis and the potential complications. (Q:

15, 30)

8. Identify the definitions of spontaneous, secondary, and tension

pneumothorax. (Q: 33, 34, 35, 36, 37)

9. Describe the diagnosis and treatment of pneumothorax. (Q: 36, 44, 45,
46)

WORD WIZARD

1. B. air leak from the lung to the pleural space

2. D. pleural fluid rich with triglycerides from a ruptured thoracic duct

3. F. puss-filled pleural effusions

4. A. pleural effusion high in protein

5. G. blood in the pleural space

6. C. membrane covering the surface of the chest wall

7. H. abnormal collection of fluid in the pleural space

8. E. pleural pain

9. K. procedure that fuses the pleura to prevent Pneumothorax

10. L. air in the pleural space

11. I. pneumothorax without underlying lung disease

12. M. occurs when the lung is rapidly inflated after compression by pleural fluid

13. N. pneumothorax that occurs with underlying lung disease

14. J. air under pressure in the pleural space

15. P. chest wall puncture for diagnostic or therapeutic purposes

16. O. low-protein effusion caused by CHF or cirrhosis

17. Q. membrane that lines the lung sureface

THE PLEURAL SPACE

18. Reference: Page 565

The pleural spaces of the buffalo are connected. Humans are separate. For the
buffalo, this meant that puncture of either lung resulted in collapse of both lungs.
Humans are put in this situation following lung volume reduction surgery and
bilateral lung transplantation surgery.

19. Reference: Page 565

The space is about 10 to 20 microns in width and is filled with a small amount

of pleural fluid.

20. Reference: Page 565

Pressure is negative relative to atmospheric pressure and results in a net

movement of fluid into the pleural space when it is in communication with adjacent
sites.

21. Reference: Page 565

The weight of the lung and gravity are pulling the lung down so that the
visceral pleura at the top is pulled away from the parietal pleura, which causes the
pressure to become more negative. The opposite effect occurs at the base.

PLEURAL EFFUSIONS

22. Reference: Page 566

 A. Elevated pulmonary venous pressure forces fluid into the interstitium and
reduces removal of fluid via intercostal veins.

B. Low protein levels in blood allow fluid to leak out of vessels into the
interstitial
space.

C. Ascites forces fluid into the pleural space via small holes in the diaphragm.

D. Normal drainage is slowed by blocked lymphatics.

E. Accidental placement into the pleura.

23. Reference: Page 567

Congestive heart failure

24. Reference: Page 568

Inflammation in the lung or adjacent pleura

25. Reference: Pages 568-569

A. Increased lung water and pleural fluid from inflammation. Complicated

effusions

have fibrin clots.

B. Any cancer that metastasizes into the pleura

C. Rupture or blockage of the thoracic duct

D. Bleeding into the pleural space, usually after trauma

26. Reference: Page 570

Restrictive changes, marked by a decrease in FVC

27. Reference: Page 570

The costophrenic angles are typically blunted or disappear.

28. Reference: Page 570

Lateral decubitus film

29. Reference: Page 570

Ultrasound is less invasive, but CT is the most sensitive (with contrast)

30. Reference: Page 570

A. Intercostal artery laceration

B. Infection

C. Pneumothorax

31. Reference: Page 571

A. Fluid collection chamber- holds fluid draining out of the chest.

B. Water seal chamber- prevents air from moving back into the pleural space.

C. Suction chamber- standardizes pressure against lung

PNEUMOTHORAX

32. Reference: Page 572

A. Sharp chest pain (nearly every patient)

B. Dyspnea (two thirds of all cases)

33. Reference: Page 572

Iatrogenic pneumothorax; treatments include biopsy, thoracentesis, and line

insertion. Usually not treated unless it is large or symptomatic.

34. Reference: Page 573

 Penetrating chest trauma (noniatrogenic) is usually caused by knife or gunshot
wounds. Blunt trauma can fracture ribs, which tear the lung, or may rupture the
alveoli. Treatment for penetrating trauma is usually a chest tube, unless
uncontrolled bleeding occurs. Blunt trauma may not require a chest tube if it results
in only minor alveolar rupture.

35. Reference: Page 573

Transillumination

36. Reference: Page 573

Primary spontaneous pneumothorax occurs without lung disease, probably rupture

of a small bleb. Usually occurs in tall, slender, young males, 90% of whom are
smokers. Secondary spontaneous pneumothorax occurs in patients with underlying
pulmonary disease. This may occur in COPD patients who have emphysema or in
hyperinflated asthmatics or cystic fibrosis patients. Some pulmonary fibrosis
patients may experience spontaneous pneumothorax.

37. Reference: Page 574

A. Air in the pleural space at greater than atmospheric pressure

B. Mediastinal shift away from the affected side, diaphragm depression, and rib
expansion on the affected side

C. Hypotension, hypoxemia, tachycardia, decreased breath sounds, and

hyperresonance to percussion

D. Needle decompression, then a chest tube

38. Reference: Page 574

Mortality rate is low (7%) with early recognition. Delay by as little as 30 minutes
raised mortality to over 30%.

39. Reference: Page 574

Most of the gas in a pneumothorax is nitrogen. Oxygen replaces the nitrogen and is
absorbed since this increases the pressure gradient for nitrogen from the pleural
space into the tissue

40. Reference: Page 575

A. large prolonged air leak due to the bronchopleural fistula

B. Positive-pressure adds air to the pleural space

C. Use minimal tidal volumes, PEEP, and PIP to maintain the patient. Avoid

autoPEEP. NOT IN EGAN: some hospitals use double-lumen endotracheal

tubes that allow independent lung ventilation. The good lung would be

ventilated normally while the poor lung receives lower tidal volume, PEEP,

and PIPs. Some hospitals may add PEEP to chest tubes, which helps to

stabilize the leak and may promote healing of the BPF.

CASE STUDIES

Case 1

Reference: Page 566

41. A. right-sided pleural effusion

1. Mild hypoxemia

2. Right opacification on chest film

3. There is a dull percussion note on the right side

4. There is a mediastinal shift to the left

5. History of CHF which is the most common cause of pleural effusions

42. Administer oxygen.

43. As this is most likely caused by CHF the most important step to resolve this is
treatment of this underlying disorder. Thoracentesis or placement of a chest tube
may be necessary if the effusion is as large as described or does not resolve.

Case 2

Reference: Page 572

44. A. right pneumothorax

1. Chest radiograph dark area without lung markings

2. Increased resonance to percussion

3. Pain on inspiration

4. Tall, thin, young male

5. Decreased breath sounds on right

45. Put the patient on oxygen. All patients with pneumothorax should be placed on
oxygen. Besides the respiratory distress and mild hypoxemia, O 2helps resolve the
pneumothorax.

46. If the pneumothorax were small, it might resolve spontaneously. Otherwise,

simple aspiration may be successful, or insertion of a chest tube.

WHAT DOES THE NBRC SAY?

47. Reference: Page 572

B. chest radiograph

48. Reference: Page 571

A. water seal

49. Reference: Page 574

 D. pneumothorax

50. Reference: Page 574

B. lateral decubitus chest film

51. Reference: Page 574

A. pulmonary edema in the right lung

52. Reference: Page 574

D. lung compliance measurement

53. Reference: Page 575

B. Initiate oxygen

54. Reference: Page 573

C. Recommend a chest radiograph

FOOD FOR THOUGHT

55. Reference: Page 568

Ascites is fluid accumulated in the abdomen. It restricts downward movement of the

diaphragm.

56. Reference: Page 574

No more than 1000 mL should be removed at one time.

57. Reference: Page 573

Subcutaneous emphysema is the presence of air in the soft tissues, and under the
skin. It means that alveolar disruption has occurred, probably from barotrauma. It
may or may not occur with a pneumothorax, but you should look for one.