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WI-18 Pulmonary > Disease States 2 > Flashcards

Disease States 2 Flashcards

1
Q

accumulation of fluid between parietal and visceral pleura

A

Pleural Effusion

MC pleural dz in US

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2
Q

Pleural Effusion types

A

excess fluid production (transudative)

decreased fluid absorption (exudative)

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3
Q

Pleural space fluid

A

typically 20 cc

maintained by hydrostatic and oncotic forces, lymphatic drainage

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4
Q

Pleural Effusion common etiology

A
  1. altered permeability of pleural membranes or capillaries/vascular disruption
  2. reduction in intravascular oncotic pressure (nephrotic syndrome, cirrhosis)
  3. increased capillary hydrostatic pressure (HF)
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5
Q

Pleural Effusion less common etiology

A
  1. reduction in pleural space (trapped lung)
  2. decreased lymphatic drainage or complete blockage (malignancy, trauma)
  3. increased peritoneal fluid with migration across diaphragm via lymphatics or structural defect
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6
Q

Pleural Effusion s/s

A

progressively worsening dyspnea (as effusion is more severe)

chest wall pain and mild, non-productive cough

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7
Q

general PE findings for Pleural Effusion

A

found at >300 cc
dullness to percussion
egophony
superior aspect and diminished/absent sounds

*** must confirm with imaging

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8
Q

imaging of pleural space CXR

A

250cc of fluid to see effusion, 500 mL will obscure diaphragm

decubitus films

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9
Q

decubitus films

A

CXR with pt lying on side

clarifies if fluid is free flowing or loculated (in pockets)

loculated = complicated/empyema

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10
Q

imaging of pleural space CT scan

A

differentiates between effusion and atelectasis

done to evaluate for presence of malignancy

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11
Q

imaging of pleural space US

A

quantifies amount of pleural fluid

guiding diagnostic and therapeutic thoracentesis

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12
Q

Pleural Effusion care

A

observation alone if suspected cause and no symptoms

unknown cause = thoracentesis

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13
Q

when is a thoracentesis indicated in Pleural Effusion

A

a new effusion of unknown cause

drain pleural fluid

therapeutic/symptoms relief

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14
Q

thoracentesis procedure

A

+/- US

done by IR, pulmonology, and CV surgery

Pulse ox monitored, no sedation, post procedure CXR and analysis

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15
Q

transudative pleural effusion

A

caused by imbalance of hydrostatic or oncotic forces

MAY BE movement of peritoneal fluid

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16
Q

exudative pleural effusion

A

caused by inflammation of the pleura or blockage of lymphatic drainage

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17
Q

determine type of pleural effusion

A

LIGHT’s criteria

evaluation of pleural fluid chemistry via thoracentesis

misclassify transudates as exudates in 15-30% of cases (diuretics HF)

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18
Q

LIGHT’s criteria measures

A

serum and pleural fluid lactate dehydrogenase (LDH) and protein

ratio of serum to pleural fluid

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19
Q

LIGHT’s criteria

A
  1. pleural fluid to serum protein ratio > 0.5
  2. Pleural fluid LDH to serum LDH ratio > 0.6
  3. Pleural fluid LDH > 2/3 upper limit of normal

AT LEAST 1 = Exudate (more present, more likely)

ALL NEG - transudative

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20
Q

tests on fluid when diagnosis unknown? (6)

A
  1. fluid glucose
  2. fluid pH
  3. cell count and differential
  4. cytology
  5. gram stain and culture
  6. color and consistency
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21
Q

specific pleural fluid test

A
  1. fluid amylase (ruptured esophagus or pancreatic origin)
  2. fluid triglyceride (milky - chylothorax)
  3. ANA/RF - collagen vascular dz/ connective tissue disorder
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22
Q

transudative etiologies

A
  1. HF
  2. Atelectasis (CA or PE)
  3. Hepatic hydrothorax (cirrhosis)
  4. hypoalbuminemia (protein calorie malnutrition, liver failure, nephrotic syndrome)
  5. peritoneal dialysis
  6. myxedema coma
  7. urinothorax
  8. migration of devices/iatrogenic
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23
Q

exudative pleural effusion etiologies

COMMON (7)

A 
PNA 
Malignancy 
Tuberculosis 
collagen vascular disorders (SLE, RA) 
pancreatitis 
Empyema 
pulmonary embolus
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24
Q

clues of pleural effusion fluid based on appearance:

frank purulence

A

empyema

lung abscess

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25
clues of pleural effusion fluid based on appearance milky opalescent fluid
chylothorax | lymphatic CA obstruction, thoracic duct injury
26
clues of pleural effusion fluid based on appearance grossly bloody fluid
trauma, CA, asbestos must get Hct of fluid -- >50% serum = hemothorax, chest tube
27
clues of pleural effusion fluid based on appearance high LDH
>1000 IU/L empyema, malignancy, collagen vascular dz
28
clues of pleural effusion fluid based on appearance glucose
<30- empyema, rheumatoid 30-50 = SLE
29
clues of pleural effusion fluid based on appearance wbc
50-70% lymphs= malignancy >90 = TB, sarcoid, TA, chylothorax
30
mild pleural effusion medical tx
HF - loop diuretic parapnumonic effusion - ABX medical intervention prior to invasive procedure
31
Booerhave syndrome
esophageal rupture (forceful vomiting) causes entry of air/esophogastric fluid into mediastinum and pleural space high amylase on analysis tx: surgical intervention to repair rupture and IV ABX
32
parapneumonic effusions
caused by pneumonia 1. uncomplicated 2. complicated 3. empyema
33
uncomplicated parapneumonic effusions
progressively worsening URI exudative effusion, neutrophils clear fluid, no organisms on GS pH > 7.3, glucose >60 resolves gradually with appropriate ABX
34
complicated parapneumonic effusions
bacterial invasion (but rapid clearing) from pleural space GS negative for organisms pH < 7.2, glucose < 60
35
empyema
GS positive for organisms pH <7.2
36
TB effusion
night sweats and weight loss, increasing SOB MC in developing world fluid will NOT show acid fast diagnosis based on history, HIGH adenosine deaminase tx: surgical intervention and anti-TB meds
37
rheumatologic effusions
rash and exposed to sun, joint pain common complications of SLE and RA will have high ANA titers in pleural fluid very low pleural fluid glucose
38
malignant effusions
POOR prognosis small pulmonary nodules bilaterally on CXR most common cause of pleural effusion in > 60 yrs must find clinical features, worsened prognosis if pH < 7.3, glucose < 60
39
recurrent malignant effusions
consideration for placement of tunnel pleural catheter (Pleural catheter) to drain the fluid 3
40
pleurodesis
obliterates pleural space to prevent recurrent pleural effusion or PTX drains effusion or air then causes intrapleural inflammation and fibrosis instills chemical irritant or performs mechanical abrasion during thoracoscopy
41
virchow's triad
endothelial injury/damage venous stasis (bed rest, post-op patients) hypercoagulatbilty (factor V, malignancy)
42
pathogenesis of PE
start in leg as DVT clot grows proximally causes break off that travels into pulmonary A. blockage of blood flow to lung
43
blockage of blood flow to lung causes
1. hypoxia (ventilation-perfusion mismatch) 2. increased strain on R heart to overcome resistance 3. decreased preload to left heart causing low output heart failure
44
PE s/s
abrupt onset of dyspnea pleuritic chest pain tachypnea, tachycardia, hypoxia* syncope fever cough asymptomatic
45
steps determining PE
1. Well's criteria to determine likelihood 2. D -dimer assay ( < 500 no PE), >500 3. CTA to diagnose
46
modified wells 3 pos, 1.5 pts, 1 pt
PE likely if >4 points (unlikely <4 points)
47
D- DImer
given to pt's with LOW probably of PE reliably excludes PE if not suspected positive D Dimer means CTA
48
CT angiography
imaging study of choice for PE must consider risk of AKI definitive choice
49
VQ scan
measures discordance between perfusion (technetium labeled albumin) and ventilation (xenon or technetium) no perfusion but ventilation suggests PE Low prob. = < 20% chance Intermediate = 20-80@ chance high probability >80%
50
additional diagnosis PE CXR, troponin, EKG
cxr - abnormal bu non specific, can't be used troponin - elevated in 50%, R heart strain EKG - sinus tach, non specific changes
51
additional diagnostics in PE echo, venous u/s, ABG
echo - not used, but can evaluate strain venous US - look for DVT ABG_ hypoxemia, hypocapnea, respiratory alkalosis
52
alveolar arterial gradient
content of O2, typically 5-10 NO increased if lack of O2 due to respiratory INCREASED if lack of O2 due to low blood flow (PE)
53
tx of pE
anticoagulation and hospital admission telemetry bed, ICU NOACs, warfarin, LMWH have NO effect on embolus, they prevent extension of formed clot and further embolism
54
NOACS
req. loading dose, no pre tx rivaroxaban/xarelto apaxiban/eliquis dabigitran/pradaxa edoxaban/savaysa (not good if CrCL is high/low)
55
LMWH is preferred in who? PE tx
pts w/ malignancy pts who can't take coumadin/NOACS (malignancy, preg)
56
warfarin
jantoven UFH, LMWH, or fondaparinox dc after INR is 2.0 BUT after 5 days of warfarin initiation to prevent skin necrosis
57
unstable pt tx PE
persistent HoTN, elevated troponin thrombolysis and surgical thromobectomy if life threatening
58
stable pt PE, cannot anticoagulant
IVC/greenfield filter removable filter placed, should be removed as soon as patient is no longer at risk or can take anticoagulant
59
duration of anticoagulation PE 3 months
if first PE due to reversible, precipitating factor
60
duration of anticoagulation on PE 3+
first PE, unprovoked 3 months then reassess risk/benefit (likely 6 months)
61
PE duration of anticoagulation indefiniate
recurrent PE or first PE with irreversible risk factor
62
accumulation of air in pleural space
penumothroax via ruptured bleb or thru external chest wall lung becomes compressed -- collapsed
63
pneumothorax types
primary spontaneous secondary spontaneous iatrogenic traumatic tension
64
primary spontaneous pneumothorax
occurs without known lund dz or inciting event 18-40, tall thin, smoking ass. w/ genetic factors, inherited disorders (marfan;s), pregnancy
65
secondary spontaneous pneumothorax
underlying pulmonary dz alters normal lung structure enters via distended, damaged, compromised alveoli
66
iatrogenic pneumothorax
accidentally caused during chest procedures (pleural or lung nodule biopsy, thoracentesis, central line insertion)
67
pulmonary blebs/bullae
large tissue in lung that can easily rupture seen in COPD and other lung dz (margin, congential/genetic) destruction of connective tissue
68
traumatic pneumothorax
blunt or penetrating trauma to chest wall, barotrauma (PEEP_ =/- rib fractures
69
tension pneumothorax
LIFE THREATENING draws air into space via ruptured bleb, but air can't escape so it accumulates compression of heart, vena cava, decreased blood flow and CO, = shock, death
70
tension PTX tx
emergent chest tube placement
71
s/s PTX
acute onset dyspnea and chest pain tachypnea, tachycardia, decreased/absent breathe sounds HoTN, JVD, tracheal deviation
72
subcutaneous emphysema
air under skin that is a sign of pneumothorax feels like rice crisps
73
PTX dz
CXR imaging of choice, may miss trauma (so do a CT) can asses underlying contributors and determine severity
74
PTX Tx
observation +/- O2 simple aspiration emergency needle decompression tube throacostamy surgical pleurodesis
75
too for all PSP >15% and secondary spontaneous PTX
tube throacostamy air removed via continuous suction

WI-18 Pulmonary (11 decks)

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