Clin Med: Disorders of the Pleural Space, mediastinum and chest wall Flashcards
A pleural effusion is
accumulation of fluid in the pleural space
between the visceral and parietal pleura
Pleural effusions 2 types
transudative
exudative
Transudative Pleural Effusion is
decreased oncotic or increased hydrostatic pressure
(too much fluid or too few proteins in fluid - fluid overload)
Exudative Pleural Effusion is
inflammation –> increased capillary permeability
“leaky capillaries”, primarily infectious agents or malignancy
Pleural effusion presentation
SOB
orthopnea
PND
CP
Cough - usually dry
PE of pleural effusion
dullness to percussion
diminished breath sounds
decreased tactile fremitus
E –> A on egophony
+/- pleural friction rub
Work up of pleural effusion
CXR (meniscus sign)
ultrasound (more sensitive)
+/- CT
thoracentesis (dx and therapeutic)
Helpful clues for Pleural effusions:
if lots of fluid think…
malignancy, CHF, ascites, TB
Helpful clues for Pleural effusions:
if bilateral think…
CHF or malignancy
Helpful clues for Pleural effusions:
if right sided think…
CHF
Helpful clues for Pleural effusions:
if left sided think…
esophageal rupture, pancreatic, post-CABG
Contraindications to a thoracentesis
overlying skin infection/ wound
small fluid accumulation
bleeding disorders
Pleural effusion treatment
treat underlying cause
therapeutic thoracentesis
+/- chest tube
+/- surgical management
Hemothorax is when
there is pooling of blood in the pleural space
(bloody pleural effusion)
Hemothorax is most commonly secondary to
trauma
Presentation of a Hemothorax
more rapid development
may not be able to provide sx/hx
may present hemodynamically unstable
if AAO - chest pain, dyspnea
Clues from MOI for Hemothorax
MCA > 35 mph
fall > 15 ft
ejection > 10 ft
LOC
work up Hemothorax
CT preferred
treatment of Hemothorax
IV, O2, monitor
less than 300mL and stable –> obs.
if unstable –> emergent decompression (usually chest tube)
Who do we open for a Hemothorax
massive - >1-1.5 L
continued bleeding - >300-500mL in first hour
worsening on CXR
persistent despite treatment
Pneumothorax is
accumulation of air in the pleural space
Pneumothorax classifications
primary
secondary
traumatic
iatrogenic
tension
Primary Pneumothorax is
spontaneous
no underlying pulm disease
usually tall, think males often with +FH and smokers, secondary to ruptured pleural blebs
Secondary Pneumothorax is
Spontaneous
underlying pulmonary disease
injury to lung parenchyma – air out of lung
Traumatic Pneumothorax is
blunt or penetrating trauma
injury to chest wall/ lungs — air in pleural space
open (chest wall injury) or closed (lung injury)
Pneumothorax: inspiration and expiration (what occurs during each)
inspiration - air into pleural space
expiration - air leaves pleural space
Iatrogenic Pneumothorax is
secondary to procedure or mechanical ventilation
Tension Pneumothorax is
usually penetrating trauma, mechanical vent, CPR, infection
pleural space pressure > lung pressures –> impaired expansion –> collapse
Pneumothorax presentation
sudden, severe, pleuritic CP on affected side
dyspnea at rest –> respiratory distress
if tension Pneumothorax treatment is ______, ______ imaging
immediately, no
workup of Pneumothorax
hypoxia (pulse ox)
chest XR
CXR on a Pneumothorax will show
lung markings don’t extend to chest wall
visible pleural edge
increased radiolucency (darker) on chest wall periphery
Tension Pneumothorax CXR will show a shift of
contralateral mediastinal shift
Pneumothorax treatment:
small (>15%) and stable –>
bigger and stable –>
resp distress –>
tension pneumo –>
supportive treatment - upright positioning, analgesia, O2 as needed
small and stable –> obs
bigger and stable –> chest tube
resp distress –> mechanical vent and chest tube
tension pneumo –> immediate needle thoracostomy
Mediastinal disease 3 main processes
mediastinal masses
pneumomediastinum
Mediastinitis
treatment of pneumothorax if recurent
consider pleurodesis
(taking up the lung)
mediastinum is the area
between the lungs
Anterior mediastinum can present with
thymoma, lymphoma
Middle mediastinum can present with
vascular, lymphadenopathy
Posterior mediastinum can present with
neurogenic, esophagus
Mediastinum masses:
Peds usually present
adults mostly present
symptomatic
asymptomatic
Mediastinum masses workup
mostly found incidentally on CXR
CT chest is test of choice
What condition is linked with mediastinal tumors
myasthenia gravis
Definitive dx of mediastinum masses
bx
Mediastinum masses treatment
treat underlying cause
Treatment of a thymoma
surgical resection
+/- chemo and radiation
Thymoma sx
phrenic nerve palsy
cough
dyspnea
CP
hoarseness
SVC syndrome
Pneumomediastinum is
air in the mediastinal space
rare - young adults, M
Pneumomediastinum presentation
sudden severe retrosternal CP
chest pain radiating to back/ neck
cough
dyspnea
increased work of breathing
voice changes
dx Pneumomediastinum
CXR
CT to confirm
Pneumomediastinum treatment
most resolve on its own - air reabsorbs
treat underlying disorder
sx treatment
Mediastinitis is
inflammation of the mediastinal space
Mediastinitis is m/c secondary to
infection
esophageal rupture or chest surgery
Mediastinitis presentation
sudden or insidious onset severe CP, dyspnea and fever
Mediastinitis dx
CXR or chest CT
Mediastinitis treatment
abx - clindamycin and ceftriaxone
