disorders of the pleural space, mediastinum and chest wall Flashcards by Lindsey Dutton

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

pleural effusion

How well did you know this?

Not at all

Perfectly

that is transudative pleural effusion

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

How well did you know this?

Not at all

Perfectly

what is exudative pleural effusion

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

How well did you know this?

Not at all

Perfectly

what is Chyle

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.

How well did you know this?

Not at all

Perfectly

what are the underlying pathophysiologic mechanisms of fluid accumulation

decreased intravascular oncotic pressure
increased intravascular hydrostatic pressure
increased capillary permeability
decreased lymphatic clearance
infection (empyema)
bleeding in the pleural space (hemothorax)

How well did you know this?

Not at all

Perfectly

what are examples of transudative pleural effusions

CHF
CKD
Nephrotic syndrome
Liver disease/cirrhosis

How well did you know this?

Not at all

Perfectly

what are example of exudative pleural effusions

infection
malignancy
trauma

How well did you know this?

Not at all

Perfectly

What is the presentation of pleural effusion

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

How well did you know this?

Not at all

Perfectly

what is seen on PE with pleural effusion

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

How well did you know this?

Not at all

Perfectly

how are pleural effusions worked up

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

How well did you know this?

Not at all

Perfectly

what is both diagnostic and therapeutic for pleural effusion

thoracentesis

How well did you know this?

Not at all

Perfectly

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

CHF or malignancy

How well did you know this?

Not at all

Perfectly

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

malignancy, CHF, ascites, TB

How well did you know this?

Not at all

Perfectly

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

CHF

How well did you know this?

Not at all

Perfectly

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

esophageal rupture, pancreatic, post -CABG

How well did you know this?

Not at all

Perfectly

what are the contraindications of thoracentesis

overlying skin infection/wound
small fluid accumulation
bleeding disorders

How well did you know this?

Not at all

Perfectly

what are some potential complications of thoracentesis

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

How well did you know this?

Not at all

Perfectly

What is the standard fluid workup for pleural effusion

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

How well did you know this?

Not at all

Perfectly

What is Lights Criteria

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

How well did you know this?

Not at all

Perfectly

what is the treatment of pleural effusion

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

How well did you know this?

Not at all

Perfectly

what is a pooling of blood in the pleural space

hemothorax

How well did you know this?

Not at all

Perfectly

what is the cause of hemothorax

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

How well did you know this?

Not at all

Perfectly

what is the presentation of a hemothorax

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

what is found on PE with hemothorax

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

how do you work up a hemothorax

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

what is the treatment for hemothorax

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

who do we open up for hemothorax

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

what is the accumulation of air in the pleural space

pneumothorax

what are the classifications of pneumothorax

primary (spontaneous) secondary (spontaneous) traumatic Iatrogenic Tension

what is a primary spontaneous pneumothorax

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

what is a secondary pneumothorax

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

what is traumatic pneumothorax

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

What is iatrogenic penumothorax

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

what is a tension pneumothorax

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

what is the 'check valve' mechanism

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

what is the presentation of pneumothorax

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

what is seen on PE with pneumothorax

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

how is pneumothorax worked up

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

when can you see contralateral mediastinal shift

tension pneumothorax

who is stable with pneumothorax

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

when is plurodesis considered

recurrent, bilateral failure of chest tub or high risk

What is the mediastinum

area between the lungs

what are the symptoms of mediastinal masses

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

how do you work up a mediastinal mass

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

what is thymoma

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

what are the symptoms of thymomas

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

what is the work up for thymoma

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

what is the treatment of thymomas

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

what is air within the mediastinal space called

pneumomediastinum

what is the presentation of pneumomediastinum

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

what is the diagnostic test for pneumomediastium

CXR (AP view) CT to confirm

what is the treatment of pneumomediastinum

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

what is medistinitis

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

how do you diagnose medistinitis

CXR or chest CT

what is the treatment for medistinitis

antibiotics (clindamycin + ceftriaxone)