Benign Pleural Disease

Question 1

MCC of spontaneous pneumothorax

Answer 1

ruptured apical subpleural bleb

• MC in males (6:1 ratio)
• Other conditions predisposing to spontaneous ptx:
  
  • cystic fibrosis
  • COPD

Question 2

T/F

Tension pneumothorax common after spontaneous ptx

Answer 2

False:

tension pneumothorax rare as collapsed segmetn usually closes off leak

Question 3

Rare causes of secondary ptx

Answer 3

• catamenial ptx (d/t pleural endometriosis)
• lymphangiomatosis
  
  • proliferation of spindle cells along bronchioles resulting in air trapping and thin walled cysts

Question 4

Appearance of minimal and moderate ptx on CXR

Answer 4

• Minimal
  
  • rim of air surrounds lung
• Moderate
  
  • lung is collapsed half way to heart boarder

Question 5

Early treatment options for spontaneous ptx

Answer 5

• Observation
• Aspiration
• Tube thoracostomy (water seal or Heimlich valve)
• Percutaneous thoracostomy

Question 6

Indications for operative intervention of spontaneous ptx

Answer 6

• Persistent air leak >= 1 week
• Second recurrence
• Patients with only 1 lung
• High risk patients for recurrence where recurrence is dangerous
  
  • Piolets
  • Divers

Question 7

Chance of recurrence after resoluation of primary spontaneous ptx

Answer 7

20-50%

Question 8

Surgical interventions for spontaneous ptx

Answer 8

• VATS blebectomy
  
  • Some groups advocate apical resection (even in absence of blebs)
• Talc or doxycycline pleurodesis (VATS vs. open)

Question 9

Complications of talc or doxycycline pleurodesis

Answer 9

• Fever
• Pleuritic chest pain (more common with doxycycline)

Question 10

Best treatment for fibrothorax

Answer 10

Prevention

Question 11

MCC of fibrothorax

Answer 11

Failure to recognize and treat hemothorax, empyema or large pleural effusions

*Regardless of effusion character, resultant inflammatory response eventually leads to dense, avascular collagen matrix

Question 12

Dx characteristics of fibrothorax

Answer 12

• PE:
  
  • collapsed intercostal spaces (decreased thorax size)
• CXR:
  
  • radiodensities in dependent portions of chest
• PFTs:
  
  • restrictive ventilatory defect
  • reduced TLC, VC, FEV1
  • normal DLCO
• Maybe confused with mesothelioma of malignant process of pleura (r/o with VATS pleural biopsy before definitive treatment)

Question 13

Surgical treatment of fibrothorax

Answer 13

Decortication

• Three main steps
  
  • Blunt dissection of the parietal peel
    
    • Plane between endothoracic fascia and parietal pleura
  • Pleural cavity entered and fluid/debris evacuated
  • Visceral pleua is dissected
    
    • Plane between visceral pleura and fibrous peel
• Avoid injury to phrenic nerve

Question 14

Definition of emypema

Answer 14

Pleural effusion with positive bacteriologic cultures

Question 15

Pleral fluid characteristics of empyema

Answer 15

• pH < 7
• glucose < 50 mg/dL
• LDH > 1000 IU/L

Question 16

Etiology of empyema

Answer 16

• PNA
• Trauma
• Instrumentation
• Spread from other sites of infection
• BPF
  
  • can either be an etiology or complicaton of empyema

Question 17

3 stages of empyema

Answer 17

1. Stage I: parapneumonic effusion (exudative)
2. Stage II: fibrinopurulent phase (includes bacteria invasion)
3. Stage III: chronic phase (organizing phase)
   
   1. includes in-growth of fibroblasts and capillaries

Question 18

MC organisms responsible for empyema

Answer 18

• S. aureus
• GN bacteria
• Anaerobes

50% polymicrobial

Question 19

Surgical TOC for empyema

Answer 19

• Prompt drainage
  
  • often tube thoracostomy insufficient (requires VATS or open drainage)
• Full lung re-expansion (to close off potential space where infection can collect)
• Decortication
  
  • chronic empyema with entrapped lung

Question 20

Often requires open pleural drainage procedure (Clagett window or Eloesser flap)

Answer 20

BPF or severe empyema

Question 21

Priniples of Clagett window or Eloessar flap drainage

Answer 21

• Continued drainage
• Irrigation
• Frequent dressing changes
• Eloessar flap considered more permanent because skin is sutured to pleura to epithelialize tract

Question 22

Alternative option to obliterate space lost to infection during surgical treatment of empyema

Answer 22

Muscle flap coverage (latissimus most common)