Empyema and Pneumothorax Lecture Powerpoint Flashcards
3 types of pneumothorax
- simple
- tension
- spontaneous
Causes of pneumothorax (4)
- penetrating trauma (stabbing)
- blunt trauma (rib fracture)
- barrotrauma (mechanical ventilation positive pressure too high ruptures visceral pleura creating pneumothorax)
- birth (compression of the infant in the birth canal)
Pneumothorax signs and symptoms (6)
- dyspnea
- cough
- shock (typically with tension pneumothorax)
- decreased breath sounds
- hyperresonance
- tracheal deviation
Tension vs simple pneumothorax differentiation
- Tracheal deviation away from side of decreased breath sounds indicates tension
- No tracheal deviation or tracheal deviation toward the side of decreased breath sounds indicates simple
Tension pneumothorax mech of action
- “one way pump” formation from the mechanism by which the pneumothorax was obtained
- With any further air entrance into space, cannot see any air exiting
- compression of mediastinal structures builds shifting mediastinal structures to the contralateral side
Pneumothorax diagnosis (2)
- chest x ray
- CT scan (in cases when not able to see due to anatomic location behind lung tissue for example)
Spontaneous pneumothorax causes (4)
- rupture of subpleural bleb, cyst, or bulla
- elderly with COPD
- tumor
- Neonates
Tension pneumothorax treatment (1)
Decompression with IV catheter (blunt so doesn’t cause sharp damage) into 2nd intercostal space midclavicular line that then remains in
Spontaneous pneumothorax treatment (5)
Depends on size, symptoms, and circumstances:
- observation
- repeated aspirations
- tube thoracostomy
- needle decompression
- thoracotomy
How to measure size of a pneumothorax
Pick a fixed point on the chest wall and measure the distance between the visceral pleura and that fixed point over time to see how it changes
Heimlich valve
1 way valve attached to a chest tube that allows for air to come out but not go back in (so upon inspiration see air hiss out of tube)
3 bottle system
Composed of a reservoir (dry trap) where the patients chest tube drains into to remove pleural fluid/exudate, water seal chamber, and vacuum control chamber that can be adjusted to a level of suctioning from the patient at approx 20mmH2O, used in a chest tube to evacuate a patient and prevent redevelopment of pneumothorax
Spontaneous pneumothorax treatment (3)
- Chemical/mechanical pleurodesis (cause inflammatory response between visceral and parietal pleura to keep them attached often using agents such as erythromycin or rubbing them to irritate the site)
- surgery (open vs thoracoscopy, first typically treated conservatively but has high risk of recurrence as more occur, bilateral requires surgerical intervention)
- Observe in asymptomatic small non expanding cases
Empyema
Infection of purulent fluid in the pleural space, an extension of pleural effusion where there is now the clear fluid has become pus
3 stages of empyema
- exudative (early)
- fibrinopurulent (white membrane)
- organizing (covers entire lung, preventing lung from expanding)
Empyema causes (3)
- pneumonic process (infection)
- mediastinal structure infection
- Abdominal space infection transmigration
Common organisms in empyema (4)
- pneumococci
- pseudomonas
- salmonella
- gram - organisms (aspiration of saliva)
Empyema diagnostic studies (3)
- detect underlying infectious process
- chest x ray
- needle aspiration
How to determine empyema vs pneumothorax (exudate vs transudate) from needle aspirated fluid?
-will likely see higher protein and lower glucose in empyema compared to pneumothorax
Empyema treatment (3)
- thoracentesis
- Open flap drainage (eloesser flap)
- empyemectomy
Eloesser flap
Rib resection drainage that involves removal of part of rib, opening of the cavity containing empyema, and exposing it to the air by wrapping the skin around to ensure it is exposed to the surface where it can heal
Empyema vs lung abscess
Empyema is a collection of purulent material in pleural space surrounding the lung, lung abscess is within the lung tissue itself held in place by the visceral pleura
Lung abscess risk factors (3)
- severe dental caries
- Alcoholism (aspiration)
- anasthesia (aspiration)
Lung abscess symptoms (4)
- sputum production
- chills and fever
- dyspnea and fatigue
- hemoptysis
Lung abscess diagnostic studies (4)
- chest x ray
- CT scan
- Transtrachial aspiration for culture (avoids cross contamination with respiratory flora)
- bronchoscopy
Common organisms in lung abscess (3)
- oral flora
- polymicrobial
- anaerobes
Lung abscess treatment options (4)
- antibiotics
- chest physiotherapy
- postural drainage
- operative management if not healing
Complications of operation on lung abscess (2)
- empyema
- bronchopleural fistula
Patients who are candidates for tube drainage for lung access
Those who are severely ill individuals and are unresponsive to conservative management
Bronchiectasis definition
Persistent abnormal dilation of bronchi beyond subsegmental level, majority are acquired and varicose type
Bronchiectasis causes (5)
- congenital (rare)
- connective tissue disorders
- kartagener’s syndrome
- cystic fibrosis
- acquired infection
Bronchiectasis signs and symptoms (6)
- persistent cough
- bad breath (fetor oris)
- hemoptysis
- repeated respiratory infection
- rales
- clubbing
Bronchiectasis diagnostic studies (4)
- Chest x ray abnormal but not diagnostic
- CT scan
- bronchoscopy
- V/Q scan
Bronchiectasis treatment conservative (3) and operative (2)
Conservative: -antibiotics -Chest physiotherapy -postural drainage Operative: -patients with continuing symptoms -conserve bilateral disease remove side with greater involvement
General pneumothorax mech of action
- air enters the potential space between the visceral and parietal pleura
- This removes the negative pressure adhering the visceral pleura from the parietal pluera
- As air continues to fill this space the chest wall fails to balloon out as compensation (because it is bony and contained)
- This results in the pressure being pushed inward, collapsing the lung and shrinking its size
Crepitance
A clinical sign characterized by crackling or grating subcutaneously often due to air deposition in these locations
Empyema necessitans
When empyema drains thru the chest wall
Most common lung abscess anatomic locations
Right (75%) posterior segment upper lobe and superior segment lower lobe
Left (25%) superior segment lower lobe
