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Clin Med2: Pulmonology > disorders of the pleural space, mediastinum and chest wall > Flashcards

disorders of the pleural space, mediastinum and chest wall Flashcards

1
Q

what is an accumulation of fluid in between the visceral and parietal space?

A

pleural effusion

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2
Q

that is transudative pleural effusion

A

due to decreased oncotic or increased hydrostatic pressure
- too much fluid or too few proteins in fluid
-think fluid overload (CHF, liver failure, CKD)

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3
Q

what is exudative pleural effusion

A

due to inflammation -> increased capillary permeability
‘leaky capillaries’
primarily infectious agent of malignancy

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4
Q

what is Chyle

A

milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids.
formed in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically known as lacteals.

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5
Q

what are the underlying pathophysiologic mechanisms of fluid accumulation

A
  1. decreased intravascular oncotic pressure
  2. increased intravascular hydrostatic pressure
  3. increased capillary permeability
  4. decreased lymphatic clearance
  5. infection (empyema)
  6. bleeding in the pleural space (hemothorax)
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6
Q

what are examples of transudative pleural effusions

A

CHF
CKD
Nephrotic syndrome
Liver disease/cirrhosis

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7
Q

what are example of exudative pleural effusions

A

infection
malignancy
trauma

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8
Q

What is the presentation of pleural effusion

A

SOB
Orthopnea
PND
chest pain (Pleuritic or ‘heaviness’)
cough - usually dry

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9
Q

what is seen on PE with pleural effusion

A

dullness to percussion (over fluid)
diminished breath sounds (over fluid)
decreased tactile fremitus (over fluid)
E-> A on egophony (over fluid)
+/- pleural friction rub

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10
Q

how are pleural effusions worked up

A

CXR - fluid accumulates in dependent areas
US is more sensitive
+/- chest CT
thoracentesis - dx and therapeutic

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11
Q

what is both diagnostic and therapeutic for pleural effusion

A

thoracentesis

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12
Q

if a patient presents with bilateral pleural effusion - what are you thinking

A

CHF or malignancy

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13
Q

if a patient presents with a lot of fluid with pleural effusion what are you thinking

A

malignancy, CHF, ascites, TB

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14
Q

if a patient presents with right sided pleural effusion what are you thinking

A

CHF

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15
Q

if a patient presents with left sided pleural effusion - what are you thinking

A

esophageal rupture, pancreatic, post -CABG

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16
Q

what are the contraindications of thoracentesis

A

overlying skin infection/wound
small fluid accumulation
bleeding disorders

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17
Q

what are some potential complications of thoracentesis

A

pneumothorax
bleeding
empyema/infection
spleen/liver puncture
vasovagal event
SOB/Cough
re-expansion Pulmonary edema

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18
Q

What is the standard fluid workup for pleural effusion

A

RBC
WBC
protein
Glucose
Lactate dehydrogenase
pH
cytology
gram stain and culture (+AFB)
+/- amylase/triglyceride levels
+/- Hct if bloody

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19
Q

What is Lights Criteria

A

used to determine if the effusion is transudative or exudative for pleural effusion

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20
Q

what is the treatment of pleural effusion

A

treat underlying cause
therapeutic thoracentesis
+/- chest tube
+/- surgical management

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21
Q

what is a pooling of blood in the pleural space

A

hemothorax

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22
Q

what is the cause of hemothorax

A

most secondary to trauma
#1: blunt trauma, may be due to penetrating trauma
can be non-traumatic cause: iatrogenic, vascular, neoplastic, coagulopathy, infection

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23
Q

what is the presentation of a hemothorax

A

more rapid development
may not be able to provide history/symptoms
may present as hemodynamic instability
if AAO: chest pain, dyspnea

24
Q

what is found on PE with hemothorax

A

decreased/absent breath sounds
dullness to percussion
increased work of breathing
hypoxia
tacypnea
tachycardia
respiratory distress
hypotension
asymmetric chest wall expansion
tracheal deviation

25
Q

how do you work up a hemothorax

A

CT preferred - hard to differentiate btwn pleural effusion and hemothorax
if unstable can use portable CXR
may also use eFAST/POCUS

26
Q

what is the treatment for hemothorax

A

IV, O2, Monitor
if less than 300mL and stable - observation
if unstable - emergent decompression: usually chest tube

27
Q

who do we open up for hemothorax

A

massive hemothorax (>1-1.5L)
continued bleeding
worsening on CXR
persistent despite treatment
inability to ventilate
hypotension despite adequate resuscitation
decompression

28
Q

what is the accumulation of air in the pleural space

A

pneumothorax

29
Q

what are the classifications of pneumothorax

A

primary (spontaneous)
secondary (spontaneous)
traumatic
Iatrogenic
Tension

30
Q

what is a primary spontaneous pneumothorax

A

no underlying pulmonary disease
usually tall, thin males ages 10-30
often with + FH and smokers
secondary to ruptured pleural blebs

31
Q

what is a secondary pneumothorax

A

underlying pulmonary disease - COPD, asthma, ILD, CF, PNA, TB, etc
M > F, ages 60-65
injury to lung parenchyma - air out of lung

32
Q

what is traumatic pneumothorax

A

blunt or penetrating trauma
injury to chest wall/lungs - air into pleural space
inspiration: air into pleural space
expiration: air leaves pleural space

33
Q

What is iatrogenic penumothorax

A

secondary to procedure or mechanical ventilation
- thoracentesis, lung biopsy, central lines, etc

34
Q

what is a tension pneumothorax

A

usually penetrating trauma, mechanical ventilation, CPR, infection
pleural space pressure > lung pressures - impaired expansion - collapse
‘check valve’ mechanism

35
Q

what is the ‘check valve’ mechanism

A

air pulled in through ‘wound’ with negative pressure
‘wound’ pushed closed with expiration so air cant leave
increasing pressure

36
Q

what is the presentation of pneumothorax

A

sudden, severe, pleuritic chest pain on affected side
dyspnea (at rest - respiratory distress)

37
Q

what is seen on PE with pneumothorax

A

if small - may be normal +/- mild tachycardia
if large - decreased breath sounds, tactile fremitus, hyper-resonance to percussion
if tension: severe tachycardia, hypotension, reduced chest movement, JVD, respiratory distress

38
Q

how is pneumothorax worked up

A

hypoxia (pulse ox)
chest x-ray is the first line
if tension pneumo - immediate treatment, no imaging

39
Q

when can you see contralateral mediastinal shift

A

tension pneumothorax

40
Q

who is stable with pneumothorax

A

RR <24 AND normal BP AND SpO2 >90% AND HR 60-120 AND able to speak in sentences

41
Q

when is plurodesis considered

A

recurrent, bilateral failure of chest tub or high risk

42
Q

What is the mediastinum

A

area between the lungs

43
Q

what are the symptoms of mediastinal masses

A

obstructive respiratory sympms
stridor
recurrent bronchitis or PNA
chest pain, weight loss, dysphagia

44
Q

how do you work up a mediastinal mass

A

many found incidentally on CXR
Chest CT = test of choice
Biopsy for definitive diagnosis

45
Q

what is thymoma

A

tumor arising from thymus
#1 anterior mediastinal tumor
associated with autoimmune paraneoplastic syndrome - M. gravis

46
Q

what are the symptoms of thymomas

A

often asymptomatic
1/3 with autoimmune symptoms
cough, dyspnea, chest pain, hoarseness
phrenic n palsy
SVC syndrome

47
Q

what is the work up for thymoma

A

often indentified on CXR
CT, MRI, PET for further eval and staging
biopsy for definitive diagnosis

48
Q

what is the treatment of thymomas

A

surgical resection
+/- chemo and radiation if more severe
systemic chemo for advanced diseases

49
Q

what is air within the mediastinal space called

A

pneumomediastinum

50
Q

what is the presentation of pneumomediastinum

A

sudden, severe, retrosternal CP
chest pain radiating to neck/back
chest pain radiating to neck and back
cough
dyspnea
increased work of breathing
voice changes

51
Q

what is the diagnostic test for pneumomediastium

A

CXR (AP view)
CT to confirm

52
Q

what is the treatment of pneumomediastinum

A

most resolve on their own - air resorbs
treat underlying disorders
symptomatic treatment
rarely, if tamponading other structures - decompression

53
Q

what is medistinitis

A

inflammation of the mediastinal space
most common secondary to infection
present with sudden or insidious onset severe CP, dyspnea and fever

54
Q

how do you diagnose medistinitis

A

CXR or chest CT

55
Q

what is the treatment for medistinitis

A

antibiotics (clindamycin + ceftriaxone)

Clin Med2: Pulmonology (13 decks)

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