9.2 - Pneumothorax And Pleural Effusion Flashcards
What is a pneumothorax?
Air within the pleural cavity
What complications can be caused by a pneumothorax?
Disruption of the pleura (visceral or pleural) -> air flows from higher pressure to lower pressure -> disruption of the balance -> lung collapses.
What is a simple pneumothorax?
Small to moderate size
Haemodynamic stable patient
What is a tension pneumothorax?
Causes haemodynamic instability (tachycardic, hypertensive)
Caused by the one-way flow of air into the pleural cavity causing increase of pressure in the thoracic cavity
What is a primary pneumothorax?
Spontaneous
No underlying lung pathology
What are the risk factors for a primary pneumothorax?
Male
Young
Family history of pneumothorax
Smoking
What is secondary pneumothorax?
Pneumothorax secondary to pre existing lung pathology
What lung pathologies are associated with secondary pneumothorax?
COPD (70%) Asthma Bronchiectasis – inc cystic fibrosis Lung cancer Infections : TB, pneumonia Marfan’s syndrome, Ehler’s Danlos syndrome RA, SLE (systemic lupus erythematosus)
What are the 3 aetiologies of a pneumothorax?
Spontaneous - sub plural bless / bulla (air-filled sacs) burst
Iatrogenic - insertion of central lines (esp to internal JV) / cardiac pacing wires
Trauma - stab wound/ gunshot wound/ rib fracture puncturing visceral pleura
What are the presenting symptoms of a simple pneumothorax?
Chest pain - pleuritic in nature, sudden onset, sharp pain
SOB
History of trauma/lung disease
What are the clinical signs of a simple pneumothorax?
Trachea deviation- Normal
Chest movement - Reduced on affected side
Percussion - Hyper-resonant or resonant on affected side
Auscultation - Reduced/absent on affected side
Vocal/tactile resonance - Reduced on affected side
How does a simple pneumothorax present of a CRX?
Hyper-lucent (ie appear darker)
Absent lung markings
Collapsed lung borders seen
How does a CT of a simple pneumothorax appear?
Absent lung markings
Collapsed lung borders seen
What are the 3 ways of managing pneumothorax?
Conservative treatment
Pleural aspiration
Chest drain
When is conservative treatment for a pneumothorax adequate?
Small pneumothorax
Send home, bring back at later date
See if symptoms resolved and Xray improved
What is pleural aspiration the correct treatment of a pneumothorax?
Maximum amount you can drain = 2.5L
How is a chest drain inserted
By ultrasound guidance
Where is a chest drain inserted?
Safe triangle borders:
Superior: Base of the axilla
Inferior: 6th rib / 5th intercostal space
Anterior: lateral edge of pectoralis major muscle
Posterior: lateral edge of latissimus dorsi muscle
Where does a chest drain drain into?
Underwater seal - allows air to leave pleural cavity but not re-enter.
Why does air move into the pleural space?
As external air pressure is higher than in the pleural cavity
Why is a tension pneumothorax a medical emergency?
As build up of pressure in the thoracic cavity compresses the SVC/IVC.
Blood supply in heart interrupted. Can cause hypotension, tachycardia, cyanosis, and hypoxaemia.
Can lead to cardiac arrest and death
What are the presenting signs and symptoms of a tension pneumothorax?
Similar to simple pneumothorax but also have: Respiratory distress Cyanosis Marked tachycardia Hypoxemia
What are the clinical signs of a tension pneumothorax?
Trachea deviation - Away from the affected side
Chest movement - Reduced on affected side
Auscultation - reduced/absent on affected side
Percussion - hyper resonant or resonant on affected side
Vocal/tactile resonance -reduced on affected side
How do we treat tension pneumothorax?
Emergency needle decompression - needle in pleasurable cavity in the 2nd intercostal space in the mid-clavicular line
What is a pleural effusion?
Excess fluid in the pleural cavity - imbalance between rate of production of pleural fluid from systemic capillaries and absorption into the lymphatic system
What are the 4 main types of pleural effusion?
Simple Effusion: When the fluid is pleural fluid – can be transudate or exudate
Haemothorax: When the fluid is blood (e.g. trauma)
Chylothorax: When the fluid is lymph (e.g. leak from lymphatic duct)
Empyema: When the fluid is pus (secondary to resistant infection)
What are the presenting symptoms of pleural effusion?
SOB - gradual onset
Exercise intolerance
Pleuritic chest pain
Features of underlying clinical disease such as breathlessness, peripheral/pulmonary oedema - congestive cardiac failure, lung malignancy
What are the clinical signs of pleural effusion
Trachea Deviation - Away from affected side if large
Chest movement - Reduced on affected side
Percussion note - “Stony” dull on affected side due to fluid not transmitting sound waves
Breath sounds - (Vesicular) reduced /absent on affected
side
Vocal Resonance - Reduced on affected side
What are the causes of pleural effusion?
Trauma - heamothorax and chylothorax
Infective cause - empyema
How do we investigate a pleural effusion?
CXR Ultra sound guided pleural aspiration Send fluids off for: Protein levels Glucose levels LDH (lactate dehydrogenase MC&S (microscopy, culture and sensitivity) PH
If the pH of the fluid effusion is low what does this indicate?
Empyema - indicative of pus
How do we differentiate transudate vs exudate?
Light’s criteria - based on protein and LDH levels
Comparison between the effusion fluid and blood values.
If there is a lot of protein, this is an exudate.
What are the main causes of transudate simple pleural effusion?
Congestive Cardiac Failure
Hypoproteinaemia
• Nephrotic syndrome
• Liver cirrhosis
What are the main causes of an exudate simple pleural effusion
Infection (TB, pneumonia) Lung malignancy Pulmonary infarction
How do we treat pleural effusion?
Chest aspiration
Recurrent effusions (malignant cause) =
Indwelling pleural catheter (IPC) for intermittent drainage
Pleurodesis: Obliteration of the pleural space
