PANCE Blueprint Pulmonary (10%)

Pleural Diseases (PEARLS)

The NCCPA™ PANCE Pulmonary Content Blueprint includes two pleural diseases.

Picmonic Picmonic
IM_NUR_LungSoundsPleuralFrictionRub_v1.2_ A pleural friction rub occurs near the anterior lateral lung and develops due to rubbing of the pleural surfaces. The sensation of a pleural friction rub is often uncomfortable. This lung sound is prominent during both inspiration and expiration and does not resolve with coughing.  Pleural rubs are common in pneumonia, pulmonary embolism, and pleurisy (pleuritis).

Lung Sounds - Pleural Friction Rub

Pleural effusion (ReelDx)
Patient presents as → a 58-year-old female who returns to the hospital with chest pain and difficulty breathing several weeks after being discharged following a myocardial infarction requiring immediate cardiac catheterization. She has been coughing up frothy sputum for the past three days. The patient complains of a sharp pain that worsens during inspiration. Physical exam reveals decreased tactile fremitus, dullness to percussion, and diminished breath sounds on the left side. This is seen on CXR.

ReelDx Virtual Rounds (pleural effusion)

Pleural effusion is the buildup of excess fluid between the layers of the pleura outside the lungs (pleural space)

  • Presents with dyspnea, and a vague discomfort or sharp pain that worsens during inspiration

Differentiate between exudate and transudate with pleurocentesis

  • Determine if the pleural fluid is exudative by meeting at least one of Light’s Criteria (increased protein, increased LDH)
    • Pleural fluid protein / Serum protein >0.5
    • Pleural fluid LDH / Serum LDH >0.6
    • Pleural fluid LDH > 2/3

Transudate = transient → from changes in hydrostatic pressure: cirrhosis, CHF, nephrotic syndrome, ascites, hypoalbuminemia

Exudative = protein ratio ↑, LDH ↑: infection, malignancy, immune; MC cause = pneumonia, cancer, PE, TB

Diagnose with lateral decubitus CXR, chest CT, U/S. Thoracentesis is the gold standard

  • PE shows decreased tactile fremitus and dullness to percussion in pleural effusion
  • Isolated left-sided pleural effusion likely exudative
  • Right-sided = transudative

Treatment is with thoracocentesis

  • Effusions that are chronic or recurrent and causing symptoms can be treated with pleurodesis (pleural space is artificially obliterated) or by intermittent drainage with an indwelling catheter
Picmonic Picmonic
IM_MED_Lightscriteria_V1.3_ Light's Criteria is a diagnostic tool used to determine of the cause of a pulmonary effusion; transudate versus exudate. This relies on a comparison of the chemistries in the pleural fluid to those in the blood. According to Light's criteria, a pleural effusion is likely exudative if at least one of the following exists: The ratio of pleural fluid protein to serum protein is greater than 0.5, the ratio of pleural fluid LDH and serum LDH is greater than 0.6, or the pleural fluid LDH is greater than 0.6 or 2⁄3 times the normal upper limit for serum.

Light's Criteria Picmonic

Pneumothorax (ReelDx)
Patient will present as → a 19-year-old male transported to the ED following a car crash. Upon arrival, he is alert and anxious and appears to be in respiratory distress. A quick assessment reveals that she sustained trauma to his face, neck, and chest. His left hemithorax appears to be expanding more than the right. He is receiving oxygen via nonrebreathing mask. His vital signs are: respiratory rate 36 and labored. SpO2 is 85% On physical exam, you notice decreased tactile fremitus, deviated trachea, hyperresonance, and diminished breath sounds.

ReelDx Virtual Rounds (pneumothorax)

A pneumothorax is a collapsed lung caused by an accumulation of air in pleural space

  • Presents with Acute onset ipsilateral chest pain and dyspnea with decreased tactile fremitus, deviated trachea, hyperresonance, diminished breath sounds

Can be spontaneous or traumatic

  • Primary: occurs in absence of underlying disease (tall, thin males age 10-30 at greatest risk)
  • Secondary: in presence of underlying disease (COPD, asthma, cystic fibrosis, interstitial lung disease)

Tension pneumothorax → penetrating injury → air in pleural space increasing and unable to escape

  • Mediastinal shift to the contralateral side and impaired ventilation
  • CXR = pleural air; ABG shows hypoxemia

Treatment depends on the size

  • Small - < 15% diameter of hemithorax will resolve spontaneously without the need for chest tube placement
  • Large - > 15% diameter and symptomatic pneumothoraces require chest tube placement
  • Serial CXR every 24 hours until resolved
  • Tension pneumothorax is a medical emergency! Large bore needles to allow air out of the chest; chest tube for decompression
Pulmonary nodules (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: Pleural Diseases
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