chylothorax, empyema, hemothorax, pneomothorax, pleural effusion

Question 1

what are the MC causes of chylothorax

Answer 1

non traumatic - malignancy MC
traumatic - thoracic surgery MC

Question 2

what are the s/s of a chylothorax

Answer 2

• dyspnea
• chest heaviness
• fatigue
• weight loss

fever and chest pain are RARE

Question 3

what i sthe diagnostic for chylothorax

Answer 3

• initial is chest xray showing pleural effusion
• confirmatory is pleural fluid analysis with lipid analysis

Question 4

what would the pleural fluid show that is confirmatory of chylothorax

Answer 4

pleural fluid TG concentration >110

Question 5

what is an empyema

Answer 5

infection in the pleural space

Question 6

would you see transudative or exudative effusions in empyema?

Answer 6

exudative (high protein, secondary to inflammation)

Question 7

what is the clinical presentation of an empyema

Answer 7

same as pleural effusion but with fever

dyspnea, cough, pleuritic chest pain

Question 8

what is the physical exam for empyema

Answer 8

same as pleural effusion
* diminishd/absent breath sounds
* dull percussion
* decreated tactile fremitus

Question 9

what would you see on imaging of an empyema

Answer 9

• CXR: blunting of costrophrenic angles (only if >175ml fluid)
• CT chest: good for small effusions and finding underlying cause

Question 10

what is the treatment for an empyema

Answer 10

• tube thoracostomy
• ABX: rocephin + Metro OR bactrim

levo + metro for pcn allergy

Question 11

what are the s/s of plerual effusion

Answer 11

dyspnea, cough, pleuritic chest pain + symptoms of underlying cause

Question 12

physical exam for pleural effusion

Answer 12

• diminishd/absent breath sounds
• dull percussion
• decreated tactile fremitus
• • signs of underlying cause

Question 13

diagnosis of pleural effusion

Answer 13

CXR
CT Chest if small

Question 14

what are indications for thoracentesis in pleural effusions

Answer 14

• new onset without apparent cause
• atypicla presentation in CHF pt

Question 15

what are the absolute contraindications to a thoracentesis

Answer 15

• cutaneous disease over puncture site
• pt refusal

Question 16

where is thoracentesis performed

Answer 16

• between 7th and 9th ribs
• midaxillary line if supine
• posterior midscapular line if upright/seated
• insert needle just ABOVE rib to avoid neurovascular bundle

Question 17

what is lights criteria for pleural fluid analysis

Answer 17

if 1 or more of the following is met then its an exudative fluid
1. pleural fluid protein: serum protein ratio >0.5
2. pleural fluid LDH: serum LDH >0.6
3. Pleural fluid LDH>2/3 the UNL

Question 18

what is the treatment of recurrent pleural effusions (typically secondary to malignancy)

Answer 18

pleurodesis

sclerosing agent.

Question 19

what is the difference between primary, secondary and traumatic pneumothorax

Answer 19

• primary - in absence of underlying lung disease (MC in smokers, tall, thin males)
• secondary - complication of preexisting pulm disease (copd, asthma, ect)
• traumatic - penetrating or blunt trama (rib fracture, stab wound, ect)

iatrogenic = caused by PEEP. tension pneumo = emergency caused by CPR or blunt trauma

Question 20

what is the presentation of pneumothorax

Answer 20

• tachypnea
• pleuritic chest pain
• O2<90%
• diminished breath sounds and tactile fremitus
• tympanic percussion

tension = tracheal deviation, PMI displce, severe respiratory compromise

Question 21

what is the diagnostic for pneumothorax

Answer 21

expiratory or lateral decubitus CXR

Question 22

what is the management of primary spontaneous pneumothorax

Answer 22

• o2 supplementation
• observation (as long as stable, first PSP, small (<3cm) and no pleural effusion)
• repeat CXR after 6 hours

Question 23

what are indications for needle or catheter aspiration of a primary spontaneous pneumothorax

Answer 23

ALL must be present:
1. large (>3cm)
2. stable vital signs
3. first PSP
4. provider expertise available

if cant do these go to thoraostomy

Question 24

where does needle/catheter aspiration take place

Answer 24

2nd ICS in the midclavicular line

always repeat CXR after 4 hours, then again after 2 hours

Question 25

where is a thoracostomy tube placed

Answer 25

4th or 4th ICS in the anterior axillary or midaxillary line

Question 26

what is the management of a secondary spontaneous pneumothorax

Answer 26

oxyegn, thoracostomy, and admission for pulm consult

Question 27

what is the management for tension pneumothorax

Answer 27

needle decompression with large bore needle at 2nd anterior ICS at midclavicular line

Question 28

what is the MCC of a hemothorax

Answer 28

blunt force chest trauma

can also be by malignancy but not as common

Question 29

How is seeing a hemothorax different from a pleural effusion on CXR? how does this effect diagnostic modality of choice?

Answer 29

• hemothorax will not show on CXR unless >300mL of fluid. pleural effusion will show at 175mL
• due to this, US is a more dependent diagnostic

Question 30

what is the management for a hemothorax

Answer 30

• > 300mL = thoracostomy
• <300 = other drainage option such as needle drainage