Pleural Diseases — MCQs
Thoracotomy is indicated in all the following conditions except:
The ideal treatment for hemothorax with drainage greater than 200 ml/hr for 2-4 hours is:
Emergency management for Tension pneumothorax is:
What is the first line of management in tension pneumothorax?
Decreased glucose level in pleural effusion is found in:
A 10yr old boy with a known case of nephrotic syndrome since 4 years on treatment brought to the pediatric OPD with chief complaint of difficulty in breathing. There is no history of fever. On examination, respiratory system was normal except slightly reduced breath sounds on right infra-axillary region. Paediatrician thinks of pleural effusion. What is next best modality of investigation to detect pleural effusion?
A 2-month-old child with a birth weight of 2 kg presents with poor feeding, excessive sleepiness, and wheezing. What is the most likely diagnosis?
Following are the contraindications for laparoscopic female sterilization except :
A 4-year-old admitted in ward with pneumonia. He develops sudden onset of breathlessness. What is the next step in management?
Which of the following statements are correct regarding the management of gastrointestinal bleeding in children? I. Somatostatin or octreotide infusion should be given for at least 7 days after stoppage of initial bleeding to prevent rebleeding II. Endoscopic Sclerotherapy (EST) involves endoscopic injection of N -butyl-2-cyanoacrylate or iso-butyl-2-cyanoacrylate III. EST has upto 90 % efficacy in controlling acute bleeding IV. Following an episode of acute variceal bleeding, all patients should receive secondary prophylaxis to prevent rebleeding Select the answer using the code given below :
Pleural Diseases Indian Medical PG Practice Questions and MCQs
Question 1: Thoracotomy is indicated in all the following conditions except:
- A. Rapidly accumulating haemothorax
- B. Massive air leak
- C. Pulmonary contusion (Correct Answer)
- D. Penetrating chest injuries
Explanation: ***Pulmonary contusion*** - **Pulmonary contusion** is a bruise of the lung parenchyma that typically resolves with **supportive care** (oxygen, fluid management, analgesia, respiratory support) [1]. - It is generally *not* an indication for thoracotomy and is managed **conservatively** in most cases [1]. - Surgical intervention is only considered if complicated by other issues such as **uncontrolled hemorrhage**, massive hemothorax, or other injuries requiring exploration. *Penetrating chest injuries* - While approximately **85% of penetrating chest injuries** are managed conservatively with tube thoracostomy alone, **selective indications** for thoracotomy include: - **Cardiac tamponade** or suspected cardiac injury - **Great vessel injury** with hemodynamic instability - **Massive initial hemothorax** (>1500 mL) or persistent bleeding (>200 mL/hr) - **Trans-mediastinal trajectory** with suspected esophageal or major vascular injury - The key is that *specific criteria* determine need for thoracotomy, not the penetrating injury itself. *Rapidly accumulating haemothorax* - A **rapidly accumulating haemothorax** with **>1500 mL initial output** or **>200 mL/hour for 2-4 consecutive hours** indicates significant ongoing intrathoracic bleeding. - This is an **absolute indication** for thoracotomy for **source identification and hemorrhage control** [2]. - Without surgical intervention, such bleeding leads to **hemodynamic instability**, shock, and death. *Massive air leak* - A **massive persistent air leak** from chest tube, unresponsive to initial management, suggests a large **tracheobronchial injury** or major lung parenchymal disruption [3]. - This persistent leak prevents **lung re-expansion** and adequate ventilation. - Thoracotomy is indicated for **surgical repair** of the damaged bronchus, major airway, or extensive lung laceration [2].
Question 2: The ideal treatment for hemothorax with drainage greater than 200 ml/hr for 2-4 hours is:
- A. Intercostal tube
- B. Wait and watch
- C. Needle aspiration
- D. Open thoracotomy with ligation of vessels (Correct Answer)
Explanation: **Open thoracotomy with ligation of vessels** - A **hemothorax** with continued blood loss exceeding **200 ml/hr for 2-4 hours** (or initial drainage >1500 ml) indicates significant ongoing bleeding that necessitates immediate surgical intervention per **ATLS guidelines**. - **Open thoracotomy** allows direct visualization of the bleeding source, enabling **ligation of vessels** to achieve definitive hemostasis. - This is a critical indication for emergency thoracotomy to prevent exsanguination and cardiovascular collapse. *Intercostal tube* - While an intercostal tube (chest tube) is the **initial management** for hemothorax and essential for diagnosis, persistent large-volume bleeding (>200 ml/hr for 2-4 hours) indicates the drain alone is insufficient to control hemorrhage. - It serves as both a diagnostic and therapeutic tool for initial drainage but does not address significant arterial or venous bleeding requiring operative control. *Wait and watch* - **Waiting and watching** in the presence of persistent significant blood loss (>200 ml/hr for 2-4 hours) is dangerous and can lead to **hypovolemic shock**, coagulopathy, or death. - This approach is inappropriate for active, ongoing bleeding and is reserved only for stable, small hemothoraces with minimal or resolved bleeding. *Needle aspiration* - **Needle aspiration** is used for diagnostic purposes in pleural effusions or small pneumothoraces, not for significant hemothorax management. - It is completely ineffective for draining large-volume **hemothoraces** and cannot control active bleeding from damaged vessels.
Question 3: Emergency management for Tension pneumothorax is:
- A. Tracheostomy
- B. Insertion of a chest tube
- C. Needle decompression (Correct Answer)
- D. Thoracotomy
Explanation: ***Needle decompression*** - This is the immediate, **life-saving intervention** for tension pneumothorax, as it rapidly relieves the pressure on the heart and lungs. - It involves inserting a large-bore needle into the **second intercostal space** in the midclavicular line or the fourth/fifth intercostal space in the anterior axillary line to convert the tension pneumothorax into a simple pneumothorax. *Tracheostomy* - This procedure creates an opening in the trachea to secure an **airway**, primarily used for upper airway obstruction or long-term ventilation. - It does not address the underlying pathology of accumulated air in the pleural space, which is causing mediastinal shift and hemodynamic compromise. *Insertion of a chest tube* - While essential for definitive management of a pneumothorax, a chest tube requires more time to set up and insert compared to needle decompression. - In an acute tension pneumothorax, the priority is immediate pressure relief, which needle decompression provides more rapidly. *Thoracotomy* - This is a major surgical procedure involving opening the chest wall, typically reserved for **life-threatening conditions within the chest** that require direct surgical intervention, such as severe trauma or uncontrollable bleeding. - It is not the appropriate initial emergency management for tension pneumothorax, as it is too invasive and time-consuming for immediate pressure relief.
Question 4: What is the first line of management in tension pneumothorax?
- A. ICD tube in 5th intercostal space midaxillary line
- B. Emergency thoracotomy
- C. Needle in 2nd intercostal space (Correct Answer)
- D. CXR
Explanation: ***Needle in 2nd intercostal space*** - The immediate priority in **tension pneumothorax** is to relieve the life-threatening pressure in the pleural space. A **needle decompression** at the 2nd intercostal space, midclavicular line, rapidly converts it into a simple pneumothorax. - This procedure is a temporizing measure performed without waiting for imaging, as the condition is a **clinical diagnosis** and can be rapidly fatal. *ICD tube in 5th intercostal space midaxillary line* - An **intercostal drainage (ICD) tube** insertion is the definitive treatment for pneumothorax but is not the *first-line* for a tension pneumothorax where immediate decompression is critical. - It involves a larger incision and equipment, which can delay the urgent pressure relief needed. *Emergency thoracotomy* - This is a major surgical procedure typically reserved for massive chest trauma with ongoing hemorrhage or cardiac arrest due to penetrating chest injury. - It is an **overkill** and inappropriate initial treatment for a tension pneumothorax, which primarily requires pressure relief. *CXR* - A **chest X-ray (CXR)** can confirm the diagnosis of pneumothorax but should not be performed *before* needle decompression in a suspected tension pneumothorax. - Delaying treatment to obtain imaging can be detrimental and significantly worsen the patient's condition, as it is a **clinical diagnosis**.
Question 5: Decreased glucose level in pleural effusion is found in:
- A. Pulmonary embolism
- B. Parapneumonic effusion and Empyema (Correct Answer)
- C. Pulmonary embolism and Empyema
- D. Parapneumonic effusion
Explanation: ***Parapneumonic effusion and Empyema*** - In **parapneumonic effusion** and **empyema**, bacteria and inflammatory cells consume glucose, leading to decreased pleural fluid glucose levels [1]. - A pleural fluid glucose level less than **60 mg/dL** or less than 50% of serum glucose is characteristic of these conditions. *Pulmonary embolism* - Pleural effusions associated with **pulmonary embolism** are typically transudates or exudates, but usually have normal glucose levels [1]. - The effusion results from increased **capillary permeability** or **venous hypertension**, not bacterial glucose consumption. *Pulmonary embolism and Empyema* - While **empyema** is correctly associated with low pleural glucose, **pulmonary embolism** is not. - Combining these conditions as a single answer is therefore inaccurate for the question asked. *Parapneumonic effusion* - This option is partially correct as **parapneumonic effusion** does cause decreased glucose [1]. - However, it is less comprehensive than the option that also includes **empyema**, which is a more severe form of parapneumonic effusion and also presents with low glucose [2].
Question 6: A 10yr old boy with a known case of nephrotic syndrome since 4 years on treatment brought to the pediatric OPD with chief complaint of difficulty in breathing. There is no history of fever. On examination, respiratory system was normal except slightly reduced breath sounds on right infra-axillary region. Paediatrician thinks of pleural effusion. What is next best modality of investigation to detect pleural effusion?
- A. Lateral view Chest X-ray
- B. USG (Correct Answer)
- C. Erect Chest X-ray PA view
- D. Lateral decubitus view
Explanation: ***USG*** - **Ultrasound** is the **best first-line investigation** for detecting **pleural effusions** in children due to its **non-invasive nature**, lack of radiation exposure, and ability to detect even small effusions (as little as 5-10 mL). - It can effectively differentiate between pleural fluid and other pathologies (e.g., consolidation, masses) and guide aspiration if needed. - **Real-time bedside availability** makes it ideal for pediatric patients. *Lateral view Chest X-ray* - A lateral Chest X-ray only detects pleural effusion if the fluid volume is at least **75-100 mL**, which might miss smaller effusions. - While it can provide additional information about the lungs and mediastinum, it is not as sensitive as ultrasound for detecting small effusions. *Erect Chest X-ray PA view* - An erect Chest X-ray PA view requires a minimum of **200-300 mL of fluid** to blunt the **costophrenic angle**, potentially missing smaller effusions. - It involves **ionizing radiation**, a concern in pediatric patients, and is less sensitive than ultrasound for early detection. *Lateral decubitus view* - A lateral decubitus view is useful for confirming the presence of **free-flowing pleural fluid** and differentiating it from loculated effusions, typically after an initial effusion is suspected. - While sensitive for detecting small effusions (as little as **50 mL**), it is typically performed as a secondary investigation and involves radiation exposure, unlike ultrasound.
Question 7: A 2-month-old child with a birth weight of 2 kg presents with poor feeding, excessive sleepiness, and wheezing. What is the most likely diagnosis?
- A. Viral upper respiratory tract infection
- B. Severe pneumonia
- C. Bronchiolitis (Correct Answer)
- D. Congestive heart failure
Explanation: ***Bronchiolitis*** - This presentation in a 2-month-old, especially with a history of **low birth weight**, points to bronchiolitis, characterized by **poor feeding**, **excessive sleepiness**, and **wheezing**. - **Bronchiolitis** primarily affects infants under 2 years (peak 2-6 months) and presents with signs of **lower respiratory tract involvement** including wheezing, tachypnea, and respiratory distress, which can lead to fatigue and feeding difficulties. - The **wheezing** is the key distinguishing feature indicating **small airway inflammation** typical of bronchiolitis. *Incorrect: Viral upper respiratory tract infection* - While viral URTI can cause nasal congestion and rhinorrhea, it typically affects the **upper airways** (nose, pharynx). - **Wheezing** indicates **lower airway involvement**, making bronchiolitis more likely than simple URTI. - The combination of systemic symptoms (poor feeding, excessive sleepiness) with wheezing suggests more significant lower respiratory disease. *Incorrect: Severe pneumonia* - Though severe pneumonia can cause similar systemic symptoms, **crackles or rales** are more characteristic than **wheezing**. - Pneumonia typically presents with **fever**, **cough**, and **focal consolidation** on examination. - The predominant **wheezing** in this case points more toward bronchiolitis with its diffuse small airway involvement. *Incorrect: Congestive heart failure* - CHF is an important differential in low birth weight infants with poor feeding and respiratory distress. - However, CHF typically presents with **tachycardia**, **hepatomegaly**, **gallop rhythm**, and **bilateral crackles** rather than prominent wheezing. - The **wheezing** without cardiac signs makes bronchiolitis more likely than a primary cardiac cause.
Question 8: Following are the contraindications for laparoscopic female sterilization except :
- A. Respiratory dysfunction
- B. Hiatus hernia (Correct Answer)
- C. Heart disease
- D. Obesity
Explanation: ***Hiatus hernia*** - A **hiatus hernia** is **not a contraindication** for laparoscopic female sterilization. While it might increase the risk of reflux or aspiration during general anesthesia, this can be managed with appropriate precautions such as rapid sequence induction and cricoid pressure. - The surgical field and abdominal pressure changes associated with laparoscopy do not significantly impact hiatus hernia management. - **This is the correct answer** as hiatus hernia is not listed among contraindications. *Respiratory dysfunction* - **Severe respiratory dysfunction** is a **major contraindication** for laparoscopy due to the effects of **pneumoperitoneum** on respiratory mechanics. - **Increased intra-abdominal pressure** elevates the diaphragm, reducing lung capacity and increasing airway pressure, which can be detrimental in patients with compromised lung function. - Conditions like severe COPD, uncontrolled asthma, or restrictive lung disease significantly increase operative risk. *Heart disease* - **Severe heart disease**, such as **unstable angina, severe congestive heart failure, or recent myocardial infarction**, is a **major contraindication**. - The stress response to surgery, fluid shifts, and the cardiovascular effects of **pneumoperitoneum** (increased systemic vascular resistance, decreased venous return) can exacerbate cardiac conditions. - Patients with decompensated cardiac disease are at high risk of perioperative complications. *Obesity* - **Obesity** is considered a **relative contraindication** for laparoscopic sterilization, requiring careful patient assessment and surgical planning. - It increases operative challenges including difficult port insertion, reduced visualization, longer operative time, and higher risk of complications (wound infection, venous thromboembolism). - Unlike hiatus hernia, obesity requires special consideration and risk stratification before proceeding with laparoscopic sterilization.
Question 9: A 4-year-old admitted in ward with pneumonia. He develops sudden onset of breathlessness. What is the next step in management?
- A. Intercostal drainage tube insertion
- B. Emergency needle thoracostomy (Correct Answer)
- C. Decrease mechanical ventilation setting
- D. Increase mechanical ventilation setting
Explanation: ***Emergency needle thoracostomy*** - This patient, a 4-year-old with pneumonia and sudden breathlessness, likely has a **tension pneumothorax**, which is a life-threatening emergency requiring immediate decompression. The chest X-ray shows a collapsed right lung and a mediastinal shift, consistent with tension pneumothorax. - An **emergency needle thoracostomy** (needle decompression) is the immediate life-saving procedure to relieve the pressure in a tension pneumothorax before more definitive treatment can be initiated. - Performed by inserting a large-bore needle (14-16G) into the **2nd intercostal space, mid-clavicular line** on the affected side. *Intercostal drainage tube insertion* - While an intercostal drainage tube (chest tube) is the definitive treatment for pneumothorax, it takes more time to insert and is not the immediate first step for a **tension pneumothorax** in an unstable patient. - The delay in performing needle decompression could be fatal in a rapidly deteriorating patient with tension pneumothorax. *Decrease mechanical ventilation setting* - Decreasing mechanical ventilation settings would not address the underlying pathology of a tension pneumothorax, which is trapped air causing lung collapse and mediastinal shift. - This action could further compromise the patient's respiratory status if the pneumothorax is severe and the patient is already hypoxemic. *Increase mechanical ventilation setting* - Increasing mechanical ventilation settings would likely worsen a **tension pneumothorax** by forcing more air into the pleural space and increasing intrathoracic pressure. - This would further compromise venous return to the heart and reduce cardiac output, rapidly leading to **cardiovascular collapse**.
Question 10: Which of the following statements are correct regarding the management of gastrointestinal bleeding in children? I. Somatostatin or octreotide infusion should be given for at least 7 days after stoppage of initial bleeding to prevent rebleeding II. Endoscopic Sclerotherapy (EST) involves endoscopic injection of N -butyl-2-cyanoacrylate or iso-butyl-2-cyanoacrylate III. EST has upto 90 % efficacy in controlling acute bleeding IV. Following an episode of acute variceal bleeding, all patients should receive secondary prophylaxis to prevent rebleeding Select the answer using the code given below :
- A. III and IV (Correct Answer)
- B. I and III
- C. II and IV
- D. I and II
Explanation: ***III and IV*** **Statement I is INCORRECT:** Somatostatin or octreotide infusions are typically administered for **3-5 days** (not 7 days) after initial bleeding has stopped to prevent rebleeding. Prolonged use beyond this period is not generally recommended due to potential side effects and lack of additional benefit. **Statement II is INCORRECT:** Endoscopic Sclerotherapy (EST) for esophageal varices involves injection of sclerosants such as **ethanolamine oleate, sodium tetradecyl sulfate**, or polidocanol. The tissue adhesives **N-butyl-2-cyanoacrylate** or **iso-butyl-2-cyanoacrylate** are used in **endoscopic variceal obturation (EVO)** for **gastric varices**, not in standard sclerotherapy for esophageal varices. **Statement III is CORRECT:** Endoscopic Sclerotherapy (EST) demonstrates **up to 90% efficacy** in controlling acute variceal bleeding, making it a highly effective intervention for managing acute hemorrhage. **Statement IV is CORRECT:** Following an episode of acute variceal bleeding, **all patients should receive secondary prophylaxis** (typically combination of non-selective beta-blockers and endoscopic band ligation) to prevent rebleeding, which is associated with significant morbidity and mortality. *I and III* - Incorrect because Statement I is wrong about the duration of vasoactive drug therapy. *II and IV* - Incorrect because Statement II confuses sclerotherapy agents with tissue adhesives used for gastric varices. *I and II* - Incorrect because both statements I and II contain inaccuracies regarding duration of therapy and sclerosing agents respectively.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free