Chapter 288 - Disorders of the Pleura Flashcards
Plural fluid enters the pleural space from?
- Capillaries in the parietal pleura
- Interstitial spaces of the lung
- Peritoneal cavity via small holes in the diaphragm
2 mechanism by which pleural effusion may develop
- excess pleural fluid formation
2. decreased removal by the lymphatics
Diagnostic gold standard in detecting pleural effusion
Ultrasound of the hemithorax
Enumerate the Light’s criteria
- Pleural fluid protein/serum protein >0.5
- Pleural fluid LDH/serum LDH >0.6
- Pleural fluid LDH more than two-thirds the normal upper limit for
serum
Light’s criteria can misidentify transudates as exudates by how many percent?
25%
When can exudative categorization be ignored?
When patient iOS clinically thought to have a transudative effusion, and the serum-PF protein gradient in >3.1 g/dL
The most common cause of pleural effusion
Left ventricular failure
In patients with heart failure , what are the instances when diagnostic thoracentesis is performed?
- febrile
- pleuritic chest pain
- effusions are not bilateral and comparable in size
What is virtually diagnostic of an effusion secondary to CHF?
[pleural fluid NT proBNP >1500 pg/mL
How many percent of patients with cirrhosis and ascites develop pleural effusions?
5%
Describe the pleural effusion in patients with hepatic hydrothorax
usually right sided
large enough to produce severe dyspnea
Most common cause of exudative pleural effusion in the US
Parapneumonic effusion
Refers to grossly purulent effusion
empyema
Differentiate bacterial pleural effusions caused by aerobic vs anaerobic bacteria.
aerobic: acute febrile illness with chest pain, sputum production, leukocytosis
anaerobic: subacute illness w/ weight loss, brisk leukocytosis, mild anemia, hx of aspiration
When is a therapeutic thoracentesis performed in parapneumonic effusion?
when free fluid separates the lung from the chest wall by >10 mm
Factors indicating the likely need for a procedure more invasive than a tho- racentesis (in increasing order of importance)
- Loculated pleural fluid
- Pleural fluid pH <7.20
- Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
- Positive Gram stain or culture of the pleural fluid
- Presence of gross pus in the pleural space
If the fluid recurs after the initial therapeutic thoracentesis, what is done first?
- Repeat thoracentesis
- CTT and tPA 10mg + deoxyribonuclease 5mg if still cannot be completely removed
- Decortication
Considerations of pleural fluid glucose <60
Malignancy
Bacterial Infections
Rheumatoid pleuritis
Second most common type of pleural effusion
Effusion secondary to metastatic disease
tumors causing malignant pleural effusion (occurs in 75%)
Lung
Breast
Lymphoma
If malignant is suspected and initial cytology is negative, what is the next best step?
Thoracoscopy
alternative: CT- or ultrasound-guided needle biopsy of pleural thickening or nodules
If the patient’s lifestyle is compromised by dyspnea and if the dyspnea is relieved with a therapeutic thoracentesis, what interventions are considered?
- insertion of a small indwelling catheter or
2) tube thoracostomy with the instillation of a sclerosing agent such as doxycycline (500mg).
Mesothelioma is associated with exposure to which chemical?
asbestos
Diagnosis most commonly overlooked in the differential diagnosis of a patient with undiagnosed pleural effusion
pulmonary embolism
Most common cause of exudative pleural effusion in many parts of the world
TB effusion
Pathophysiology of TB effusion
hypersensitivity reaction to tuberculous protein in the pleural space
markers of TB effusion
PF ADA >40 IU/L
PF IFN gamma >140 pg/ml
Percentage of undiagnosed exudative pleural effusion and likely cause
20%
probably viral infections
most common cause of chylothorax
trauma (most frequently thoracic surgery)
Findings in the pleural fluid of chylothorax
milky fluid
triglyceride level >1.2 mmol/L or 110 mg/dL
Diagnostic evaluation of patients with chylothorax with no obvious trauma
lymphangiogram
mediastinal CT scan
Treatment of Choice for chylothorax
- CTT with octreotide
2. if fails, percutaneous transabdominal thoracic duct blockage
Complications of patients with chylothorax on prolonged tube thoracostomy
Malnutrition
Immunologic incompetence
Diagnosis of hemothorax
PF hematocrit more than one half of that in the peripheral blood
Treatment of hemothorax
CTT - allows continuous quantification of bleeding
When is angiographic coil embolization indicated?
pleural hemorrhage exceeding 200ml/h
Diagnosis of an elevated pleural fluid amylase
Esophageal rupture
pancreatic disease
Diagnosis of a febrile patient, has predominantly polymorphonuclear cells in the pleural fluid, and has no pulmonary parenchymal abnormalities
intraabdominal abscess
Characteristics of Pleural effusion after CABG
first week: left-sided and bloody, with large numbers of eosinophils, and respond to one or two therapeutic thoracenteses.
after first week: left-sided and clear yellow, with predominantly small lymphocytes, and tend to recur.
Seven causes of a transudative pleural effusion
- Congestive heart failure
- Cirrhosis
- Nephrotic syndrome
- Peritoneal dialysis
- SVC obstruction
- Myxedema
- Urinothorax
Drug induced pleural disease
a. Nitrofurantoin
b. Dantrolene
c. Methysergide
d. Bromocriptine
e. Procarbazine
f. Amiodarone
g. Dasatinib
Pneumonthorax occurring without antecedent trauma
Spontaneous
Pneumothorax occurring in the absence of underlying lung disease
Primary
pneumothorax in which the pressure in the pleural space is positive throughout the respiratory cycle.
Tension
Most common cause of primary spontaneous pneumothorax
rupture of apical pleural blebs
Primary spontaneous pneumothorax occurs almost exclusively among ____
smokers
Percent of patients with an initial primary pneumothorax having recurrence
approx 50%
initial recommend treatment for primary spontaneous pneumothorax
simple aspiration
Indications of doing thoracoscopy with stapling of blebs and pleural abrasion
- lung does not expand after aspiration
2. recurrent pneumothorax
Most common cause of secondary pneumothorax
COPD
Treatment of patients with secondary pneumothorax
CTT
intervention for hemopneumothorax
one chest tube placed in the superior part of the hemithorax to evacuate the air and another in the inferior part to remove the blood
Leading causes of iatrogenic pneumothorax
- transthoracic needle aspiration
- thoracentesis
- insertion of central intravenous catheters
Pathophysiology why tension pneumothorax is life threatening
positive pressure transmitted to the mediastinum –> decreased venous return –> reduced cardiac output
Interventions for Tension pneuothorax
- needling in the second anterior ICS
2. CTT
