disorders of the pleural space, mediastinum and chest wall Flashcards
what is an accumulation of fluid in between the visceral and parietal space?
pleural effusion
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)
what is exudative pleural effusion
due to inflammation -> increased capillary permeability
‘leaky capillaries’
primarily infectious agent of malignancy
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.
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)
what are examples of transudative pleural effusions
CHF
CKD
Nephrotic syndrome
Liver disease/cirrhosis
what are example of exudative pleural effusions
infection
malignancy
trauma
What is the presentation of pleural effusion
SOB
Orthopnea
PND
chest pain (Pleuritic or ‘heaviness’)
cough - usually dry
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 are pleural effusions worked up
CXR - fluid accumulates in dependent areas
US is more sensitive
+/- chest CT
thoracentesis - dx and therapeutic
what is both diagnostic and therapeutic for pleural effusion
thoracentesis
if a patient presents with bilateral pleural effusion - what are you thinking
CHF or malignancy
if a patient presents with a lot of fluid with pleural effusion what are you thinking
malignancy, CHF, ascites, TB
if a patient presents with right sided pleural effusion what are you thinking
CHF
if a patient presents with left sided pleural effusion - what are you thinking
esophageal rupture, pancreatic, post -CABG
what are the contraindications of thoracentesis
overlying skin infection/wound
small fluid accumulation
bleeding disorders
what are some potential complications of thoracentesis
pneumothorax
bleeding
empyema/infection
spleen/liver puncture
vasovagal event
SOB/Cough
re-expansion Pulmonary edema
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
What is Lights Criteria
used to determine if the effusion is transudative or exudative for pleural effusion
what is the treatment of pleural effusion
treat underlying cause
therapeutic thoracentesis
+/- chest tube
+/- surgical management
what is a pooling of blood in the pleural space
hemothorax
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
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)
