2B Week 4/7 - Pleural And Pulmonary Vascular Diseases Flashcards
1
Q
How many layers in the pleura
A
2
2
Q
What are the pleural membranes called
A
Visceral pleura and parietal pleura
3
Q
How does the chest stay inflated
A
Negative pressure in the pleura
4
Q
Consequence of air in the pleural space
A
Pneumothorax
5
Q
How many types of pneumothorax
A
4
6
Q
What are the types of pneumothorax
A
Primary Spontaneous
Secondary Spontaneous
Iatrogenic
Trauma
7
Q
Ley term of pneumothorax
A
Collapsed lung
8
Q
How do people with pneumothorax present
A
Acute chest pain, acute SOB, smokers? - particularly cannabis
9
Q
Why does smoking and cannabis cause pneumothorax
A
Lung develops air filled pocket - bleb develops if bigger than 1cm is a bulla. Lots of smoking many bulla. Air in pleural cavity
10
Q
What would you see if you examine a pneumothorax
A
- Trachea/Mediastinum : Pushed
- Reed/Absent expansion
- Percussion: Hyper resonant
- Reduced / Absent Breath sounds
- Hypoxemia esp if underlying Lung disease
- Reps rate of over 30
11
Q
What is a secondary pneumothorax
A
Someone who has an underlying lung disease and gets pneumothorax e.g. smoker
No underlying pathology is primary pneumothorax
12
Q
Procedures which can result in pneumothorax
A
Lung biopsy, CPAP too much pressure, pacemaker insertion
13
Q
Pneumothorax from a procedure is a what…
A
Latrogenic pneumothorax
14
Q
What is the percentage risk of smoking and pneumothorax
A
12% - compared with 0.1% of non-smokers
15
Q
Lung conditions which are a risk of SPS
A
1.COPD 2.PJP 3.CF 4.T.B
Marfans
16
Q
What would you see on a CXR
A
A ‘black out’ of a lung
A plural separation from the chest wall
17
Q
What is tension pneumothorax
A
Medical emergency, too much pressure compromising cardiovascular system (low bop, low hr), deviation of trachea
18
Q
What do you do in tension pneumothorax
A
Needle into second intercostal space - emergency needle decompression
19
Q
When is a pneumothorax big enough to intervene
A
More than 2 cm at the level of the Hilum laterally
20
Q
When would you discharge a patient with a pnumothorax
A
Less than 2cm and patient is well - see again in a few weeks
21
Q
What do you do if pneumothorax is larger than 2 cm and is primary spontaneous
A
Aspirate up to 2.5 litres and if still bad put in chest drain
22
Q
What do you do if a secondary pneumothorax larger than 2 cm what do you do
A
immediate chest drain (don’t aspirate)
23
Q
What do you do if a secondary pneumothorax between 1-2cm
A
Admit patient - give high flow O2 observe for 24hr
24
Q
What do you do if secondary pneumothorax less than 1cm
A
Aspirate, up to 2.5 litres, if unsuccessful chest drain
25
What is the safe triangle
It is in fact a square…
Anterior: Lateral border of Pec Major
Superior: Base of Axilla
Lateral: Lat edge of Lat Dor
Inferior: line of 5th ICS
26
What are possible complications of chest drain
Infection/Pain: Variable
Drain Dislodgement : 20%
Drain blockage : 2- 18%
Visceral Injury : 0-2%
Death : Rare (<1%)
27
If chest drain scar does not close and heal in 5 days what do you do?
VATS - video assisted thoracoscopy surgery
28
How long till you can fly after a pnumothorax
4 weeks really but advise 1 week - due to pressurised cabin
29
Is scuba diving ok after pneumothorax?
never - pressure is very high
30
What do you do if you get recurrent pneumothorax with frail person
Medical chemical pleurodesis (talc)- generated inflammatory response to stick the pleura together - VATS has too high mortality rate
31
34 year old fit and well man presents with a large R pneumothorax. Never smoked SpO2 95% bop and r fine. What is the management:
CT chest
Pleural aspiration
Chest drain
VATS
Pleural aspiration
32
What of the following conditions predisposes to pneumothorax
Heart failure
Lymphoma
Idiopathic pulmonary fibrosis
All the above
IPF
33
58 year old man presents with moderate L pneumothorax. Known to have airway obstruction and emphysema what is the best management of patient:
Pleural aspiration
Chest drain
VATS
CT chest
Secondary pneumothorax
Chest drain
If doesn’t work CT chest and VATS
34
77 yr old man with L lower lobe mass. CT guided biopsy results in 1.5cm pneumothorax. Observations are ok. What is the next best steps for management:
Admit for repeat CXR in 24 hrs
Discharge and reassure
Pleural aspiration
Chest drain
Reality is admit and repeat CXR in 24hrs
But for exam do pleural aspiration
35
Cardiac causes of chest pain
myocardial ischamia/infarcion, pericardiis, aoric dissecion
36
Respiratory causes of chest pain
pulmonary embolism, pneumothorax, pneumonia, pleural inflammaion
37
Gastrointestinal causes of chest pain
oesophageal spasm, dysmoility/relux, oesophgeal rupture (Boerhaave’s)
38
Musculoskeletal causes of chest pain
rib fracture/metastasis, muscle spasm/strain, costochondriis
39
What investigations should you do if a patient presented with chest pain
bloods - FBC, Uand E, LFT, CRP
ECG
CXR and/or further imaging CT
40
How would chest pain present in MI
HINT - use SOCRATES
S - central/retrosternal
O – suddent onset, building up
C – dull/aching
R – neck, jaw, let shoulder, arm
A – nausea, SOB, dizziness/palpitaions
T – persistent, increasing
E – exerion
S – 6/10 - > 10/10
Always look at patient history as well and how patient looks (pale clammy etc)
41
What investigation would you do in MI
Blood invesigaions – Troponin T or I – proteins released from myocytes in the context of ischemia
ECG – Changes of ischemia or infarcion
Ischemia (ST depression) - reversable
Infarction (ST elevation)- irreversable
CXR - Can be normal or abnormal
42
How would pericarditis pain present
HINT use Socrates
44 year old with chest pain, preceded by viral illness
S – let sided
O – sudden onset
C – sharp, worse with breathing
R – to the back
A – nausea, SOB, dizziness/palpitaions
T – persistent, intermitent
E – at rest, worse on lying down, eased on leaning forward
S – 5-6/10
43
What investigations would you do for pericarditis
Bloods – Creainine kinase enzyme
ECG - saddle shaped ST segment
CXR – May be normal
44
How would a pneumothorax present
HINT use Socrates
18 year old male, tall and thin, smoker
S – right sided
O – sudden onset
C – sharp
R – right shoulder
A –SOB
T – persistent, increasing
E – exerion, breathing
S –10/10
45
What investigations would you do for a pneumothorax
Blood invesigaions - normal
ECG – Sinus tachycardia
CXR - black out
46
How would chest pain from a pulmonary embolism present - use SOCRATES
45 year old lady, returned from holiday 3 days ago. Woke up with chest pain
S – right sided
O – sudden onset
C – sharp
R – none
A –SOB, palpitaions
T – persistent, increasing
E – exerion, breathing
S –10/10
NB: more common to be SOB not chest pain
47
What investigations would you do with PE
Blood invesigaions– D-dimer (fibrin degradation product)
ECG– Sinus tachycardia, S1Q3T3
CXR– Normal or pleural efusion
48
How would oesophageal rupture present
75 year old diabetes, elevated BMI
S – central, retrosternal
O – after eating
C – burning
R – back/epigastrium
A –SOB, abdominal bloaing/discomfort
T – persistent, increasing
E – spicy meals/takeaway
S –10/10
49
67 lady, 4 weeks of progressive shortness of breath. PMH: Breast
cancer 15yrs ago underwent curative treatment. What indicates a diagnosis of pleural efusion in the R side
1. Reduced Expansion right side, tracheal shifted to the right
2. Reduced Expansion right side, tracheal shift to left
3. Reduced Expansion right side, tracheal shift to left, stony dullness in
right side
Reduced Expansion right side, tracheal shift to left, stony dullness in
right side
50
What is lights test for
LDH and protein
51
What exactly is lights criteria
Effusion protein/serum protein ratio greater than 0.5.
Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6.
Effusion LDH level greater than two-thirds the upper limit of the laboratory's reference range of serum LDH.
52
Heart failure, renal failure with give a what (transudate or exudate)
Transudate
53
Malignancy, RA and infection with g five what (transudate or exudate)
exudate
54
57 year old man presented with Left lower lobe pneumonia. 7 days in
to admissionon IV benzyl penicillin, spiking fever and has left pleuritic
chest pain. What is the most likely diagnosis
Empyma, Left sided pleural effusion
55
What is an empyema?
pockets of pus that have collected inside a body cavity. They can form if a bacterial infection is left untreated, fails to respond to treatment. - medical emergency
56
What is the treatment for a secondary pneumothorax?
Chest drain
57
If a chest drain fails or after 5 days there is still a pneumothorax what do you do
Surgery - VATS
58
In a primary spontaneous pneumothorax more than 2 cm what do you do?
aspirate - up to 2.5 litres
59
49 year old lady, BMI 45 kg/m2, prev history of DVT 3 yrs ago, stopped
anticoagulation in 3 months. Now presented with pleuritic chest pain, collapse , Tachycardia ,Pa02 8
kpa on Air, Examination Normal
What is the most likely diagnosis
1. Pneumonia
2. Pulmonary embolism
3. Myocardial infarction
4. Pneumothorax
5. Pleural efusion
PE
60
What is the key mechanism of Hypoxemia in a PE - IN EXAM
1. Ventilatory failure
2. Anatomical Shunting
3. Physiological Shunting
4. Physiological dead space
Physiological dead space
61
What is the key mechanism of hypoxaemia in pneumonia - IN EXAM
1. Ventilatory failure
2. Anatomical Shunting
3. Physiological Shunting
4. Physiological dead space
Physiological shunting
62
54 year old HGV driver presents with Excessive day time sleepiness
(ESS: 14/24). He gives history of Snoring and unrefreshed feeling on waking. Sleep
studies show Severe sleep apnoea : AHI 78 /hr. Which of the following are risk factors of Obstructive sleep apnoea
1. Enlarged tonsils
2. Morbid obesity
3. Acromegaly
4. Retrognathia
Enlarged Tonsils
Morbid obesity
Acromegaly
And Retrognathia
63
What is mild sleep apnoea
5-15
64
What is moderate sleep apnoea
15-30
65
What is severe sleep apnoea
30+
66
45 year old man is referred for snoring, Epworth Score 9/24. BMI 26 kg/m2, His Sleep study shows Mild Sleep apnoea AHI 7hr , DI 7 /hr
What is the best therapeutic option
1. Weight loss only
2. No treatment needed
3. CPAP
4. Mandibular advancement device
Mandibular advancement device
- patient not that big and is very mild sleep apnoea
Or do nothing if patient is completely asymptomatic
67
57 year old lady has history of Connective tissue disease, presents with
increasing breathlessness over few months. Sp02 92% air, desaturates
to 85% on walking 200 meters. O/E Bilateral pedal edema, Raised JVP.
CXR shows no ILD. What is the more appropriate next investigation
1. CT chest
2. Echocardiogram
3. Lung function test
The diagnosis is pulmonary arterial hypertension - associated with scleroderma (limited and diffuse), this is limited scleroderma.
Therefore do ECG then ECHO - CT and lung function after the ECHO
68
Which of the following conditions may lead to Pulmonary Arterial
Hypertension
1.
2. Systemic Sclerosis
3. Fenluramine - weight loss pill
4. Obesity Hypoventilation Syndrome
5. COPD/Emphysema
6. Massive Pulmonary Embolism
ALL
69
56 man, hypertension, diabetes, dull
chest pain - what is likely diagnosis:
Pulmonary arterial hypertension
Aortic dissection
Left pleural efusion
Pneumothorax
Chronic ventilatory failure
Acute coronary syndrome
Acute coronary syndrome - MI
70
76 lady breathless for weeks, left dull
chest pain, dull to percuss left hemithorax
Left pulmonary effusion
71
man, obese , chest and Right sided Pneumothorax
interscapular pain
Aortic dissection
