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MHD VI: Pulm > 11.30: Pleural Disease > Flashcards

11.30: Pleural Disease Flashcards

1
Q

Normal volume / function of pleural fluid?

A
  • 100cc
  • Lung’s elastic recoil makes them want to collapse
  • Ribs have the desire to expand
  • This tugging pulls fluid into pleural space
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2
Q

Which pleura is innervated?

A
  • Only the parietal, the visceral is not

- Important when draining fluid, ptn cannot feel if you poke lung if you hit visceral pleura

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3
Q

Blood supply to visceral pleura?

A

Arterial: bronchial and pulm arteries
Venous: through pulmonary veins to LA

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4
Q

Blood supply to parietal pleura?

A

Arterial: intercostals off aorta
Venous: through IVC to RA

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5
Q

What happens in primary left heart failure?

A
  • Extra fluid left in LV at end of diastole increase EDP
  • Pressure transferred back into pulm veins to alveoli leading to pulm edema AND movement of fluid into pleural space
  • Typically effusion is larger on the right
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6
Q

What happens in pulm htn?

A
  • Pleural effusion should not occur
  • Back up is before blood gets to interstitium so blood should back up into IVC/SVC
  • Leads to Cor pulmonale
  • **Pulm htn. can made left sided effusion worse since parietal pleura drains to IVC
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7
Q

Normal pressure in pleural space?

A
  • Negative 5 due to competing recoils of lungs and ribs
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8
Q

What can cause pleural fluid formation?

A
  1. Leaky pleura: inflammation

2. Changes in hydrostatic or oncotic pressure

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9
Q

Definition of pleural effusion?

A
  • Extra fluid in the pleural space
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10
Q

Symptoms of pleural effusion?

A
  1. None
  2. Pain: more likely if small as pain is from surfaces rubbing together, large effusion pushes them apart
  3. Dyspnea
  4. Respiratory failure
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11
Q

Exam findings in pleural effusion?

A
  1. Dullness to percussion: when tapping in chest
  2. Decreased breath sounds
  3. Decreased tactile fremitus
  4. Egophony- > E - A change
    * ***Always need to be verified with cxr
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12
Q

Signs of pleural effusion on cxr?

A
  1. Blunting of angle (costo phrenic angle of diaphragm)
  2. Meniscus sign at top
  3. White out
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13
Q

What can cause white out?

A
  1. Massive pleural effusion
  2. Atelectasis: lung has lost all its air
    * *During effusion trache will be pushed a bit away from fluid moving it
    - Will be pulled to opposite side in atelectasis
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14
Q

Different between “White out” from massive effusion and atelectasis?

A

Effusion: trachea is being pushed AWAY from white out by fluid
Atelectasis: Trachea is being pulled TOWARDS white out

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15
Q

How to tell if white on xray is from fluid?

A
  • Have ptn take x ray in lateral decubitus

- Fluid should FLOW towards side of ptn on the table

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16
Q

What are loculations?

A
  • Fluid should NORMALLY flow to diaphragm if free flowing due to gravity
  • Loculations or adhesions between pleura TRAP fluid from draining with gravity
  • ***Usually this is caused by inflammation which is hard to treat with antibiotics, surgical procedure could be needed to drain
  • Might be harder to hit with needle and pockets pay be different
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17
Q

What is thoracentesis?

A
  • Numb skin and place needle OVER ribs to drain fluid

- Can be done to diagnose or treat

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18
Q

Why is it important to go OVER rib in thoracentesis?

A
  • Neurovascular bundle runs under the rib

- Important not to hit these arteries / nerves

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19
Q

What can lead to leaky pleural place?

A
  1. Infection
  2. Inflammation
  3. Cancer
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20
Q

What can lead to increase pulm capillary pressure?

A
  1. LV failure
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21
Q

What can lead to decreased pleural pressure?

A
  • Atelectasis
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22
Q

What can lead decreases plump cap oncotic pressure?

A
  1. Cirrhosis
  2. Malnutrition
    3.
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23
Q

Diagnostic categories of pleural effusion?

A
  1. Leaky pleural space
  2. Increase pulm cap pressure
  3. Decreased pleural pressure
  4. Decreased cap oncotic pressure
  5. Direct entry of ascitic, blood, lymph, or gastric fluid
24
Q

What is transudate?

A
  • Nothing wrong with pleural space itself, there is just pressure gradient change
25
Q

What is exudate?

A
  • Leaky pleura
26
Q

How is it determined if fluid is transudate or exudate?

A
  • Thoracentesis with lab analysis
27
Q

What is light’s criteria?

A

Any 1 of these 3 criteria makes fluid exudate:

  1. Pleural protein / serum protein > .5
  2. LDH pleural / serum > .6
  3. LDH pleural > 200
    a. Cholesterol pleural > 45
    * **Can be issue since you need serum value for 2
28
Q

Should Heart failure have transudate or exudate?

A
  • Transudate
29
Q

How could heart failure lead to false positive of serum exudate?

A
  • Diuretics given to train off fluid
  • Can falsely [protein/LDH] pleural fluid making it appear exudate
  • **Cholesterol will not be falsely elevated
30
Q

DDx for transudate?

A
  1. CHF
  2. Cirrhosis
  3. Nephrotic Syndrome
  4. Atelectasis
31
Q

DDx for exudate?

A
  1. Cancer
  2. Empyema
  3. Parapneumonic effusions
  4. Pulm embolism
  5. Connective tissue disease: lupus, ra
32
Q

What is empyema?

A
  • Infection in pleural space

- Cannot be treated by antibiotics alone as they only make it to pleural space

33
Q

What are parapneumonic effusions?

A
  • Infection in LUNG leading to inflammation of pleura

- Infection is in lung so easier to treat than empyema

34
Q

Which pleural effusions are more worrisome?

A

Those with exudate

35
Q

Other test performed on thoracentesis?

A
  1. PH: if low, infection?
  2. Glucose: worrisome if low
  3. Cell counts: worrisome if puss
  4. Hematocrit: if pleura > 1/2 serum = hemothorax
  5. Cytology: tests for cancer
36
Q

Categories of exudates?

A
  1. Complicated
  2. Uncomplicated
    a. Low PH / Glucose
    b. High LDH
    * **Risk of empyema
  3. Empyema: pos gram stain, pus, or pos. culture
37
Q

How to treat uncomplicated effusion?

A

Treat the underlying cause

38
Q

Who to treat empyema?

A
  • Need to put in chest tube

- Antibiotics alone will not do the trick

39
Q

Worry with loculations?

A
  • One chest tube will not drain all the pockets

- Thoracotomy surgery usually necessary to clear plural space

40
Q

What is pleurodesis?

A
  • Chemical or mechanical irritation of visceral / parietal pleura creating adhesion and obliteration of space
  • You can live without a pleural space so this can be done for treatment
  • Surgery or chemical can be used
41
Q

Is a pleural space necessary for life?

A

No, elephants do not

42
Q

Causes of pneumo thorax

A
  • Air in pleural space from following cause:
    1. Alveoli rupture
    2. Hole in chest wall
43
Q

What happens in pneumothorax?

A
  • Lungs collapse while chest expands
44
Q

Pneumothorax symptoms?

A
  • Chest Pain
  • Dyspnea
  • Cough
  • Shock (if tension)
45
Q

Appearance of pneumothorax on cxr?

A
  • **Very hard to do
  • Hyperlucent lung fields
  • Lack of “lung markings”
  • Thin white pleural line
  • Shift of mediastinum if tension
46
Q

Physical exam in pneumothorax?

A
  • Unilateral Hyperinflation
  • Decreased Breath Sounds and Tactile Fremitus
  • Hyper-resonance - “tympanitic”
47
Q

What is Tension pneumothorax?

A
  • You keep sucking air in and can’t move it out

- Impedes venous return leading to shock and death

48
Q

Treatment of pneumothorax?

A
  • Give O2 if observing
  • Do not suck air out with needle
  • Chest tube
49
Q

Structure of chest tube?

A
  1. Chamber to catch fluid
  2. Suction chamber to move air out
  3. Water chamber to prevent from sucking air / water in
50
Q

Pleura effusion pattern in TB?

A

 Exudative, Lymphocytic,

51
Q

Pleura effusion pattern in malignancy?

A

 Exudative, Lymphocytic, RBC’s, +/- low pH/Glucose, Large

52
Q

Pleura effusion pattern in pulm embolism?

A

 85% are small, unilateral, and exudative; +/- bloody

53
Q

Pleura effusion pattern in esophageal rupture?

A

 Left sided, low pH, high amylase

54
Q

Pleura effusion pattern in Endometriosis?

A

 Bloody, PTx/Hemoptysis

55
Q

Pleura effusion pattern in “Milky” Effusions?

A

Chylothorax (TG > 110)
 Malignancy, Trauma, Mediastinal Disease (ruptured thoracic duct)
 Pseudochylothorax (TG>100 AND Chol > 200)
 Chronic Inflammatory Conditions (breakdown of cell walls)
 Empyema

56
Q

Pleura effusion pattern in “Hepatic” Effusions?

A

 Underlying cirrhosis, transudates, R > L sided, rapid re-accumulation

MHD VI: Pulm (20 decks)

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