February 16, 2016 - Pleural Diseases

Question 1

Pleura in Lungs

Answer 1

Question 2

Lymphatic Stoma

Answer 2

Little holes throughout the plura that suck fluid back into the vasculature and lymphatics.

Question 3

Measuring Size of Pneumothorax

Answer 3

Considered small if < 2cm from the chest wall.

Question 4

Oxygen and Pneumothorax

Answer 4

Oxygen is readily absorbed by the lungs. Because of this, the air inside the pleural space in a pneumothorax is almost 100% nitrogen gas. By putting patients on 100% oxygen, you make it easier for their body to resorb the nitrogen and resolve the pneumothorax.

Question 5

Where to Insert a Chest Tube

Answer 5

Anteriorly at the mid-clavicular line, 2nd intercostal space

Laterally at the mid-axillary line in the 4-6th intercostal space

Question 6

Mechanisms of Pleural Fluid Accumulation

Answer 6

Decreased fluid exit

Increase in pleural fluid production

Question 7

Decreased Pleural Fluid Exit

Answer 7

The lymphatic flow is dependent on…

1. Patency of lymphatic vessels
2. Contractility of the vessels
3. Downstream pressure in lymphatics

Question 8

Increased Production of Pleural Fluid

Answer 8

These are broken into transudates and exudates.

Transudates can arise from… 1) Increase in hydrostatic pressure (CHF), 2) Decrease in plasma osmotic pressure (hypoproteinemia), 3) entry in to the pleural space of low protein fluid not normally found there (fluids tracking up from abdomen, urine, etc.)

Exudates can arise from a vascular bed that is very leaky to proteins either pleural or pulmonary.

Question 9

Transudates

Answer 9

Can be caused by…

Increase in hydrostatic pressure

Decrease in plasma osmotic pressure

Entry of abnormal fluid with low protein into pleural space

Question 10

Exudates

Answer 10

Can be caused by…

Vascular beds that are leaky to proteins either pleural or pulmonary.

Question 11

Pleural Empyema

Answer 11

An accumulation of pus in the plueral cavity that can develop when bacteria invade the pleural space, usually in the context of a pneumonia.

There are three stages; exudative, fibrinopurulent, and organizing stage.

You want to treat and resolve before the organizing stage when there is scarring of the pleural membranes and possible inability for the lung to expand.

Question 12

Classification of Parapneumonic Effusions

Answer 12

Insigificant - <1cm on CXR

Simple - >1cm on CXR, pH > 7.2, and gram stain negative

Complex - >1cm on CXR, pH < 7.2, and gram stain positive

Empyema - >1cm on CXR, pH < 7.2, and pus

Question 13

Fibrinolytics and Pleural Infections

Answer 13

Fibrinolytics help break down the clots and walls that form in the pleural fluid and make the fluid thinner and easier to drain, as well as to help prevent scarring.

Question 14

Pleurectomy

Answer 14

Can be used to eliminate the pleural space. Lungs will stick directly to the chest wall afterwards. Usually done by inserting chemical and fusing the visceral and parietal layers together.

Balance risks against the patient’s prognosis.

Question 15

Manifestations of Asbestos-Related Lung Injury

Answer 15

Benign conditions such as pleural plaques, diffuse pleural thickening, benign asbestos pleural effusions, or rounded atelectasis.

Malignant conditions can include malignant mesothelioma (primary tumor of the pleura) as well as malignant pleural effusions.

Question 16

Malignant Mesothelioma

Answer 16

Primary tumor of the pleura.

Mean age is 60 and is much more common in males. There is a long lag-time between exposure and the onset of symptoms and disease.

Moderate chest tightness followed by progressive pain, cough, and SOB is the classic presentation.

This is uniformly fatal.