chylothorax, empyema, hemothorax, pneomothorax, pleural effusion Flashcards
what are the MC causes of chylothorax
non traumatic - malignancy MC
traumatic - thoracic surgery MC
what are the s/s of a chylothorax
- dyspnea
- chest heaviness
- fatigue
- weight loss
fever and chest pain are RARE
what i sthe diagnostic for chylothorax
- initial is chest xray showing pleural effusion
- confirmatory is pleural fluid analysis with lipid analysis
what would the pleural fluid show that is confirmatory of chylothorax
pleural fluid TG concentration >110
what is an empyema
infection in the pleural space
would you see transudative or exudative effusions in empyema?
exudative (high protein, secondary to inflammation)
what is the clinical presentation of an empyema
same as pleural effusion but with fever
dyspnea, cough, pleuritic chest pain
what is the physical exam for empyema
same as pleural effusion
* diminishd/absent breath sounds
* dull percussion
* decreated tactile fremitus
what would you see on imaging of an empyema
- CXR: blunting of costrophrenic angles (only if >175ml fluid)
- CT chest: good for small effusions and finding underlying cause
what is the treatment for an empyema
- tube thoracostomy
- ABX: rocephin + Metro OR bactrim
levo + metro for pcn allergy
what are the s/s of plerual effusion
dyspnea, cough, pleuritic chest pain + symptoms of underlying cause
physical exam for pleural effusion
- diminishd/absent breath sounds
- dull percussion
- decreated tactile fremitus
- signs of underlying cause
diagnosis of pleural effusion
CXR
CT Chest if small
what are indications for thoracentesis in pleural effusions
- new onset without apparent cause
- atypicla presentation in CHF pt
what are the absolute contraindications to a thoracentesis
- cutaneous disease over puncture site
- pt refusal
where is thoracentesis performed
- between 7th and 9th ribs
- midaxillary line if supine
- posterior midscapular line if upright/seated
- insert needle just ABOVE rib to avoid neurovascular bundle
what is lights criteria for pleural fluid analysis
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
what is the treatment of recurrent pleural effusions (typically secondary to malignancy)
pleurodesis
sclerosing agent.
what is the difference between primary, secondary and traumatic pneumothorax
- 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
what is the presentation of pneumothorax
- tachypnea
- pleuritic chest pain
- O2<90%
- diminished breath sounds and tactile fremitus
- tympanic percussion
tension = tracheal deviation, PMI displce, severe respiratory compromise
what is the diagnostic for pneumothorax
expiratory or lateral decubitus CXR
what is the management of primary spontaneous pneumothorax
- o2 supplementation
- observation (as long as stable, first PSP, small (<3cm) and no pleural effusion)
- repeat CXR after 6 hours
what are indications for needle or catheter aspiration of a primary spontaneous pneumothorax
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
where does needle/catheter aspiration take place
2nd ICS in the midclavicular line
always repeat CXR after 4 hours, then again after 2 hours
where is a thoracostomy tube placed
4th or 4th ICS in the anterior axillary or midaxillary line
what is the management of a secondary spontaneous pneumothorax
oxyegn, thoracostomy, and admission for pulm consult
what is the management for tension pneumothorax
needle decompression with large bore needle at 2nd anterior ICS at midclavicular line
what is the MCC of a hemothorax
blunt force chest trauma
can also be by malignancy but not as common
How is seeing a hemothorax different from a pleural effusion on CXR? how does this effect diagnostic modality of choice?
- 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
what is the management for a hemothorax
- > 300mL = thoracostomy
- <300 = other drainage option such as needle drainage
