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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
Q

clues of pleural effusion fluid based on appearance

milky opalescent fluid

A

chylothorax

lymphatic CA obstruction, thoracic duct injury

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26
Q

clues of pleural effusion fluid based on appearance

grossly bloody fluid

A

trauma, CA, asbestos

must get Hct of fluid – >50% serum = hemothorax, chest tube

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27
Q

clues of pleural effusion fluid based on appearance

high LDH

A

> 1000 IU/L

empyema, malignancy, collagen vascular dz

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28
Q

clues of pleural effusion fluid based on appearance

glucose

A

<30- empyema, rheumatoid

30-50 = SLE

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29
Q

clues of pleural effusion fluid based on appearance

wbc

A

50-70% lymphs= malignancy

> 90 = TB, sarcoid, TA, chylothorax

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30
Q

mild pleural effusion medical tx

A

HF - loop diuretic
parapnumonic effusion - ABX

medical intervention prior to invasive procedure

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31
Q

Booerhave syndrome

A

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
Q

parapneumonic effusions

A

caused by pneumonia

  1. uncomplicated
  2. complicated
  3. empyema
33
Q

uncomplicated parapneumonic effusions

A

progressively worsening URI

exudative effusion, neutrophils

clear fluid, no organisms on GS

pH > 7.3, glucose >60

resolves gradually with appropriate ABX

34
Q

complicated parapneumonic effusions

A

bacterial invasion (but rapid clearing) from pleural space

GS negative for organisms

pH < 7.2, glucose < 60

35
Q

empyema

A

GS positive for organisms

pH <7.2

36
Q

TB effusion

A

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
Q

rheumatologic effusions

A

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
Q

malignant effusions

A

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
Q

recurrent malignant effusions

A

consideration for placement of tunnel pleural catheter (Pleural catheter) to drain the fluid 3

40
Q

pleurodesis

A

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
Q

virchow’s triad

A

endothelial injury/damage

venous stasis (bed rest, post-op patients)

hypercoagulatbilty (factor V, malignancy)

42
Q

pathogenesis of PE

A

start in leg as DVT

clot grows proximally causes break off that travels into pulmonary A.

blockage of blood flow to lung

43
Q

blockage of blood flow to lung causes

A
  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
Q

PE s/s

A

abrupt onset of dyspnea
pleuritic chest pain

tachypnea, tachycardia, hypoxia*

syncope
fever cough

asymptomatic

45
Q

steps determining PE

A
  1. Well’s criteria to determine likelihood
  2. D -dimer assay ( < 500 no PE), >500
  3. CTA to diagnose
46
Q

modified wells

3 pos, 1.5 pts, 1 pt

A

PE likely if >4 points (unlikely <4 points)

47
Q

D- DImer

A

given to pt’s with LOW probably of PE

reliably excludes PE if not suspected

positive D Dimer means CTA

48
Q

CT angiography

A

imaging study of choice for PE

must consider risk of AKI

definitive choice

49
Q

VQ scan

A

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
Q

additional diagnosis PE

CXR, troponin, EKG

A

cxr - abnormal bu non specific, can’t be used

troponin - elevated in 50%, R heart strain

EKG - sinus tach, non specific changes

51
Q

additional diagnostics in PE

echo, venous u/s, ABG

A

echo - not used, but can evaluate strain

venous US - look for DVT

ABG_ hypoxemia, hypocapnea, respiratory alkalosis

52
Q

alveolar arterial gradient

A

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
Q

tx of pE

A

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
Q

NOACS

A

req. loading dose, no pre tx

rivaroxaban/xarelto
apaxiban/eliquis
dabigitran/pradaxa
edoxaban/savaysa (not good if CrCL is high/low)

55
Q

LMWH is preferred in who? PE tx

A

pts w/ malignancy

pts who can’t take coumadin/NOACS (malignancy, preg)

56
Q

warfarin

A

jantoven

UFH, LMWH, or fondaparinox dc after INR is 2.0 BUT after 5 days of warfarin initiation to prevent skin necrosis

57
Q

unstable pt tx PE

A

persistent HoTN, elevated troponin

thrombolysis and surgical thromobectomy if life threatening

58
Q

stable pt PE, cannot anticoagulant

A

IVC/greenfield filter

removable filter placed, should be removed as soon as patient is no longer at risk or can take anticoagulant

59
Q

duration of anticoagulation PE

3 months

A

if first PE

due to reversible, precipitating factor

60
Q

duration of anticoagulation on PE

3+

A

first PE, unprovoked

3 months then reassess risk/benefit (likely 6 months)

61
Q

PE duration of anticoagulation

indefiniate

A

recurrent PE or first PE with irreversible risk factor

62
Q

accumulation of air in pleural space

A

penumothroax

via ruptured bleb or thru external chest wall

lung becomes compressed – collapsed

63
Q

pneumothorax types

A

primary spontaneous

secondary spontaneous

iatrogenic

traumatic

tension

64
Q

primary spontaneous pneumothorax

A

occurs without known lund dz or inciting event

18-40, tall thin, smoking

ass. w/ genetic factors, inherited disorders (marfan;s), pregnancy

65
Q

secondary spontaneous pneumothorax

A

underlying pulmonary dz alters normal lung structure

enters via distended, damaged, compromised alveoli

66
Q

iatrogenic pneumothorax

A

accidentally caused during chest procedures (pleural or lung nodule biopsy, thoracentesis, central line insertion)

67
Q

pulmonary blebs/bullae

A

large tissue in lung that can easily rupture

seen in COPD and other lung dz (margin, congential/genetic)

destruction of connective tissue

68
Q

traumatic pneumothorax

A

blunt or penetrating trauma to chest wall, barotrauma (PEEP_

=/- rib fractures

69
Q

tension pneumothorax

A

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
Q

tension PTX tx

A

emergent chest tube placement

71
Q

s/s PTX

A

acute onset dyspnea and chest pain

tachypnea, tachycardia, decreased/absent breathe sounds

HoTN, JVD, tracheal deviation

72
Q

subcutaneous emphysema

A

air under skin that is a sign of pneumothorax

feels like rice crisps

73
Q

PTX dz

A

CXR imaging of choice, may miss trauma (so do a CT)

can asses underlying contributors and determine severity

74
Q

PTX Tx

A

observation +/- O2

simple aspiration

emergency needle decompression

tube throacostamy

surgical

pleurodesis

75
Q

too for all PSP >15% and secondary spontaneous PTX

A

tube throacostamy

air removed via continuous suction

WI-18 Pulmonary (11 decks)

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