Deck 27: Pleural Diseases

Question 1

At what point is intrapleural pressure most negative?

A) End-exhalation
B) FRC
C) Inspiration
D) Maximal expiration

Answer 1

C
Explanation: The pleural space is under negative pressure except during forced expiration. The intact thoracic rib cage provides elastic recoil pressure outward, whereas the intrinsic recoil pressure of the lung is inward toward the lung hilum. The diaphragm further decreases the intrapleural pressure below the atmospheric pressure to allow inspiration to occur.

Question 2

For which type of pneumothorax is pleurodesis most commonly indicated?

A) Iatrogenic
B) Bronchopleural fistula
C) Spontaneous
D) Traumatic

Answer 2

C
Explanation: Patients who have had one pneumothorax are more likely than the general population to have a second. The recurrence rate is greater than 30% among patients with primary spontaneous pneumothorax and approximately 40% among patients with secondary spontaneous pneumothorax. These high recurrence rates indicate that prevention of recurrence of pneumothorax should be undertaken, particularly for patients in whom pneumothorax may be life threatening. Preventing recurrence involves production of adhesions between the parietal and the visceral pleura in the involved area and is termed pleurodesis.

Question 3

A patient with nephritic syndrome is noted to have a large right-sided pleural effusion and a small to medium-sized left-sided pleural effusion. What would explain this finding?

A) The nephrosis is complicated by CHF.
B) The nephrosis is complicated by pulmonary emboli.
C) This is a common finding in patients with nephrosis.
D) This just a complicated case of nephrosis.

Answer 3

B
Explanation: Patients with nephrosis are at increased risk of deep venous thrombosis and pulmonary emboli. In nephrosis, protein S, which keeps blood from clotting, becomes deficient from leaking into the urine. Therefore, the presence of large or asymmetric pleural effusions should raise the possibility of the presence of pulmonary emboli. Pleural effusions associated with pulmonary emboli usually are exudates and contain large numbers of red blood cells.

Question 4

Pleural fluid with a total protein concentration of less than ____________ of the serum total protein level is one of the indications of transudative pleural effusion.

A) 20%
B) 30%
C) 40%
D) 50%

Question 5

What is the most likely cause of a large unilateral pleural effusion in a 70-year-old patient?

A) Congestive heart failure
B) Malignancy
C) Pneumonia
D) Tuberculosis

Question 6

Which of the following statements about pleural fluid is false?

A) Fluid can move easily between each hemithorax.
B) Normal protein concentration is between 1.3 and 1.4 g/dl.
C) The total volume is approximately 16 ml.
D) Total protein concentration is similar to that of interstitial fluid elsewhere in the body.

Question 7

The chest radiograph showed the presence of a meniscus in the right chest together with a blunted right costophrenic angle. Which of the following procedures would you recommend at this point to treat Ms. Paul?

A) Anterior chest tube thoracostomy
B) Chest needle decompression
C) Video-assisted thoracoscopy (VAT)
D) Posterior chest tube thoracostomy

Question 8

What is a common clinical finding even with small pleural effusions?

A) Air bronchograms
B) Arrhythmias
C) Dyspnea
D) Tachycardia

Question 9

What is a common cause of persistent fever in intensive care unit (ICU) patients with pneumonia?

A) Congestive heart failure
B) Most exudative effusions
C) Parapneumonic effusions
D) Transudative effusions

Question 10

Which of the following procedures would you recommend to assess her situation at this time?

A) Chest x-ray
B) Auto-PEEP maneuver
C) Measure her compliance manually
D) CT scan of the chest

Question 11

Which of the following pathologies is the most common cause of pleural effusions in clinical practice?

A) Hepatic disease
B) Acute renal failure
C) Congestive heart failure
D) Cor pulmonale

Question 12

Forty-eight hours after the chest tube insertion Ms. Paul remains on mechanical ventilation. While assessing the chest tube system, you note small bubbles in the water seal chamber generated during peak inspiration. This is an indication of which of the following:

A) normal functioning of the water seal chamber.
B) bronchopleural fistula.
C) low water level in the chamber.
D) high suction pressure from the suction chamber.

Question 13

What is the most common cause of pleural effusion in the clinical setting?

A) Acute renal failure
B) Congestive heart failure
C) Liver disease
D) Lung cancer

Question 14

Which of the following conditions is most closely associated with exudative pleural effusion?

A) Cirrhosis of the liver
B) Congestive heart failure
C) Nephrotic syndrome
D) Tuberculosis

Question 15

What type of pleural problem is most likely to develop from rupture of the thoracic duct?

A) Chylothorax
B) Hemothorax
C) Hydrothorax
D) Pneumothorax

Question 16

What is the most common cause of hemothorax?

A) Chest trauma
B) Malignancy
C) Pulmonary embolism
D) Surgery

Question 17

How much pleural fluid does a normal healthy adult have in each hemithorax?

A) 5 ml
B) 8 ml
C) 12 ml
D) 16 ml

Question 18

What is the most common cause of a chylothorax?

A) Chest trauma
B) Malignancy
C) Pulmonary embolism
D) Surgery

Question 19

What is the most common cause of pleural effusion that occurs due to lymphatic obstruction within the mediastinum?

A) Cancer that has metastasized to the mediastinum
B) Hepatic hydrothorax
C) Malignant pleural effusion
D) Tuberculous pleurisy

Question 20

What is a common complication of pleurodynia?

A) Atelectasis
B) Insomnia
C) Pneumonia
D) Pneumothorax

Question 21

Which of the following could be early warning signs that a pneumothorax is enlarging?
1) Desaturation of pulse oximetry reading
2) Development of a fever
3) Increased respiratory rate
4) Mental confusion

A)1, 2, and 3 only
B)1 and 3 only
C)2 only
D)1, 2, 3, and 4

Question 22

What method of chest tube removal has been associated with the lowest level of pneumothorax recurrence?

A) Clamp the chest tube for 4 hr; if chest radiograph is good, remove the tube.
B) Clamp chest tube for 24 hr; if clinically stable, remove the tube.
C) Remove the chest tube as soon as the air leak resolves.
D) Remove the chest tube 48 hr after the air leak resolves.

Question 23

If accurate sizing on a pneumothorax is desired, what diagnostic technique would be most appropriate?

A) Chest radiography
B) Computed tomography
C) PET scan
D) Ultrasonography

Question 24

When using a small-bore catheter with a one-way valve such as a Heimlich valve, how can you determine definitively that there is or is not a small air leak?

A) Connect to an underwater seal.
B) Increase the FiO₂ and note clinical changes.
C) Listen for air movement.
D) Watch the valve to see if it moves.

Question 25

What agent has proved to be the most successful in pleurodesis?

A) Mixture of saline and Mucomyst
B) Acetaminophen in suspension
C) Saline solution mixed with heparin
D) Talc suspended in saline

Question 26

What size of chest tube would you use in the management of trauma-related pneumothoraces?

A) Large
B) Medium
C) Small
D) Size is immaterial

Question 27

Which of the following findings on a radiologic report would indicate the presence of a tension pneumothorax?

A) Bilateral inversion of diaphragm, long narrow heart, and flattened ribs
B) Blunting of costophrenic angles, marked interstitial infiltrates, and apical free air
C) Contralateral mediastinal shift, diaphragmatic depression, and flattening of ribs
D) Ipsilateral mediastinal shift, sail-shape noted right hemithorax, and marked interstitial infiltrates right sided

Question 28

At what anatomic position should an 18-gauge IV catheter be placed to relieve a tension pneumothorax?

A) Just inferior to the second rib
B) Just inferior to the third rib
C) Just superior to the second rib
D) Just superior to the fourth rib

Question 29

Describe a secondary spontaneous pneumothorax.

A) Pneumothorax that occurs secondary to cardiac complications
B) Pneumothorax that occurs without trauma or any underlying disease
C) Pneumothorax that results from nonpenetrating chest trauma
D) Pneumothorax that results from underlying lung disease

Question 30

What diagnostic procedure or technique is most sensitive for the identification of pleural effusion?

A) Chest radiography
B) Computed tomography
C) Pleurodesis
D) Thoracoscopy

Question 31

Which of the following medications is known to cause drug-induced pleural disease?
1) Bleomycin
2) Amiodarone
3) Advair
4) Vilanterol

A)1 and 2 only
B)2 and 4 only
C)4 only
D)1, 2, and 3 only

Question 32

In what age group is a primary spontaneous pneumothorax most commonly seen?

A) Under 15 years
B) 18 to 25 years
C) 35 to 45 years
D) Over 60 years

Question 33

The most common symptom of pneumothorax that occurs in nearly every patient is:

A) shortness of breath.
B) chest pain.
C) dizziness.
D) syncope.

Question 34

What is the primary risk factor associated with spontaneous pneumothoraces?

A) Cigarette smoking
B) Heavy exercise
C) Obesity
D) Urban living

Question 35

Which of the following are typical complications of thoracentesis?
1) Infection
2) Intercostal artery laceration
3) Rib fracture
4) Pneumothorax

A)1, 2, and 4 only
B)2 and 3 only
C)3 and 4 only
D)1, 2, 3, and 4

Question 36

What anatomical position is most likely to show the presence of a small pleural effusion in the upright chest radiograph?

A) Apical regions
B) Costophrenic angles
C) Fissures
D) Subdiaphragmatic region

Question 37

What underlying lung disease is most often present in a patient with secondary spontaneous pneumothorax?

A) Asthma
B) Chronic obstructive pulmonary disease (COPD)
C) Interstitial pulmonary fibrosis
D) Pneumonia

Question 38

What diagnostic procedure or technique is most commonly used to diagnose the presence of a pleural effusion?

A) Chest radiography
B) Pleuroscopy
C) Thoracentesis
D) Thoracoscopy

Question 39

Pleural effusions that occur secondarily to _____ are most often treated with pleurodesis.

A) ascites
B) congestive heart failure
C) malignancy
D) nephrotic syndrome

Question 40

What are the functions of a chest tube in a patient with chest trauma that causes bleeding and pneumothorax?
1) To measure the rate of bleeding
2) To improve ventilation
3) To allow lung reexpansion
4) To allow for application of bleeding control medication

A)1 and 4 only
B)2 and 3 only
C)4 only
D)1, 2, and 3 only

Question 41

What complication often occurs following rapid lung reexpansion due to the evacuation of air or fluid from the pleural space?

A) Arrhythmias
B) Pulmonary edema
C) Pulmonary emboli
D) Systemic hypotension

Question 42

What is the primary tool used to diagnose a pneumothorax?

A) Chest radiography
B) Computed tomography
C) PET scan
D) scanning