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Pulmonary Week 3 > ICL 3.5: Pleural Disease > Flashcards

ICL 3.5: Pleural Disease Flashcards

1
Q

what is pleurisy?

A

inflammation of the pleural membranes

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2
Q

what is a pleural effusion?

A

abnormal accumulation of >15 ml in pleural space

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3
Q

what is a pneumothorax?

A

air in the pleural space

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4
Q

what is the etiology of pleurisy?

A
  1. infection: viral, bacterial or fungal
  2. injury – if the ribs are bruised or fractured, the pleura can become inflamed
  3. pulmonary embolism: a blood clot developing inside the lungs
  4. sickle cell anaemia: a blood disorder that usually affects people of African or Caribbean descent
  5. chemotherapy and radiotherapy
  6. uremia
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5
Q

what is the clinical presentation of pleurisy?

A
  1. sharp chest pain associated with
    breathing; especially breathing deeply.
  2. referral of pain to the shoulder.
  3. worse pain with cough, sneeze or movement – patients often go to ER due to severity and acuity of pain
  4. may or may not be associated with pleural effusion or neumothorax
  5. pleurisy accompanied by effusion or pneumothorax is uncommon with viral infection and may present in outpatient clinic or ER only but it is common with other causes and frequently admitted to hospital
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6
Q

what are the viral causes of pleurisy?

A
  1. influenza
  2. EBV
  3. CMV
  4. parainfluenza
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7
Q

what is pleuredynia? what virus causes it?

A

inflammation of intercostal muscles that causes pleuritic pain

epidemic pleuredynia due to Coxsackie B virus

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8
Q

how do you treat uncomplicated pleurisy or pleuredynia?

A

NSAIDs

occasionally may need corticosteroids, rarely if ever narcotics

pleuredynia = inflammation of intercostal muscles that causes pleuritic pain

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9
Q

what do you give to treat the inflammation and pain seen in pleurisy?

A
  1. nonsteroidal anti-inflammatory drugssuch as ibuprofento reduce pain and inflammation
  2. corticosteroidsto reduce inflammation if NSAIDs not effective or contraindicated
  3. narcoticsin low doses to treat chronic shortness of breath. Only as last resort

diagnose and treat cause of inflammation!!

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10
Q

a 55 year old patient with PE and infarct is admitted. the patient still has pain. the best initial treatment of pain is what?

A

NSAIDs

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11
Q

what is the Light criteria?

A

Light criteria (N=3)
1. pleural fluid
LDH/serum LDH ratio >0.6

  1. pleural fluid LDH > two‐thirds the upper limits of the laboratory’s normal serum
  2. pleural fluid protein/serum protein ratio >0.5
    mnemonic: LDH ratio (0.6) is larger than protein ratio 0.5

it’s a transudate if no light criteria are present

it’s an exudate if even 1 of 3 light criteria is present

pleural fluid is called a transudate if if it permeates (transudes) into the pleural cavity through the walls of intact pulmonary vessels –> it’s an exudate if it escapes (exudes) into the pleural cavity through lesions in blood and lymph vessels, e.g., as caused by inflammation and tumors

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12
Q

what is a normal pleural transudate?

A

Qf is negative or zero

fluid flow into capillary from interstitium

no accumulation of interstitial fluid (effusion)

Qf = (Pc + πi) - (Pi + πp)

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13
Q

what is an abnormal pleural transudate?

A

Qf positive:

fluid flow out of capillary into interstitium resulting in effusion

Qf = k [(Pc + πi) - (Pi + πp)]

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14
Q

what are the causes of a positive Qf?

A
  1. elevated capillary pressure (Pc) due to left ventricular hear failure
  2. lower capillary oncotic pressure due to (pc) hypoalbuminemia
  3. increased leakiness of capillaries (k) due to septic shock or vasculitis
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15
Q

what can cause pleural transudate?

A
  1. Increased capillary hydrostatic pressure (Pc)
    ex. LV CHF, cirrhosis
  2. decreased capillary oncotic pressure (hypoalbuminemia) (pc):
    ex. malnutrition, hepatic failure, critical care/iatrogenic due to fluid resuscitation of shock
  3. increased capillary leakage (k):
    ex. septic shock, anaphylactic shock, vasculitis
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16
Q

what is the etiology of pleural exudates?

A

INFLAMMATION
1. infection: viral, bacterial

  1. connective tissue disease: RA, SLE

MALIGNANCY
1. metastatic

  1. primary mesothelioma

INJURY
1. trauma

  1. surgery
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17
Q

what are the clinical signs that someone has a pleural exudate caused by a virus?

A
  1. high lymphocyte count

2. low neutrophil count

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18
Q

what are the clinical signs that someone has a pleural exudate caused by a fungus?

A
  1. high lymphocyte count
  2. low neutrophil count

usually immunosuppressed

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19
Q

what are the clinical signs that someone has a pleural exudate caused by TB?

A
  1. high lymphocyte count
  2. low neutrophil count
  3. Adenosine deaminase and/or interferon gamma elevated
  4. Tuberculosis mycobacteria observed on slide or culture

uncommon in the US

20
Q

what are the clinical signs that someone has a pleural exudate caused by bacteria?

A

high neutrophil count!

  1. para-pneumonic: non-infected

pH > 7.2, fluid not cloudy or prurulent, no growth of bacteria

  1. empyema: infected

infected
pH <7.2, fluid cloudy or prurluent, grow bacteria in culture

21
Q

what is a malignant pleural effusion?

A

MPE is an exudate associated with malignant cell invasion of the pleural space

cancer cells secrete fluid into pleural space and they block draining lymphatics

malignancies most commonly associated with MPE are lung, breast, and lymphoma

MPE commonly loculated, not free-flowing = confined to one or more fixed spaces caused by proteinaceous membranes

22
Q

what are other causes of effusions associated with malignancy other than MPE?

A

transudate: may occur due to collapse of lung from obstruction, resulting in decreased extracapillary pressure (i.e., interstitial)

exudate may occur from:
1. hemorrhage from tumor to cause hemothorax,

  1. pulmonary embolism/infarct: malignancy is a cause of hypercoagulability
  2. post-obstructive pneumonia
23
Q

in the presence of large lung cancer a pleural effusion could be caused by:

A. hemorrhagic exudate

B. exudate associated with post-obstructive pneumonia and parapneumonic non-malignant exudate

C. transudate due to collapsed lung

D. all of the above

A

D. all of the above

24
Q

how do you diagnose a pleural effusion?

A
  1. CXR
  2. ultrasound
  3. chest CT
  4. blood tests
25
Q

what does a CXR/CT scan tell you about a pleural effusion?

A
  1. Air or fluid in the pleural space
  2. pockets (loculation) of fluid or air due to proteinaceous septae
  3. disease in the lung or pleura; such as pneumonia, abcess, pulmonary embolism, a fractured rib, or a lung tumor
26
Q

what does a ultrasound scan tell you about a pleural effusion?

A

you can look for fluid, air, or other abnormal findings in your chest to avoid lung tissue and potential pneumothorax

it’s also used to to guide thoracentesis so as to avoid lung tissue fixed close to pleura due to loculations

27
Q

why would you do an ultrasound guided thoracentesis of a pleural effusion?

A

to test for:

  1. transudate or exudate via light criteria
  2. cell count: lymphocytes, neutrophils
  3. gram stain and culture
  4. cytopathology for cancer
  5. glucose, triglycerides
  6. other specific tests: for TB (ADA, interferon gamma), pancreatitis (amylase, lipase)
  7. biopsy to retrieve a sample of the pleura if concern for TB or malignancy and effusion is negative
28
Q

how do to treat pleural effusion?

A
  1. treat underlying condition
  2. thoracentesis
  3. chest tube to drain fluid from the pleural space
  4. indwelling pleural catheter (IPC) for drainage of pleural fluid a few times a week (Pleurex)
  5. Heimlich valve
  6. injection of fibrinolytic and DNAse
  7. pleurodesis
  8. surgery
29
Q

when would you use a chest tube?

A

a chest tube drains fluid from the pleural space

typically used for exudates, most commonly empyema or malignant effusion

30
Q

what is a Heimlich valve?

A

one-way valve attached to a chest tube or indwelling pleural catheter (IPC) that prevents fluid and air from getting into chest

31
Q

when would you give someone fibrinolytic and DNAse?

A

when treating a pleural effusion, specifically medical management of empyema!!

administering these into the pleural space will break up the empyema = a collection of pus in the pleural cavity

32
Q

what is pleurodesis?

A

it closes up the pleural space by causing inflammatory reaction that cause two sides of the pleura stick together

then you drain all of the fluid out of chest through a chest tube, then push doxycycline or talc through the chest tube into the pleural space

33
Q

when would you do surgery to treat a pleural effusion?

A

surgical management of empyema

you can surgically remove proteinaceous septae, remove pockets of fluid, puss, blood and, decortication to enable full expansion of lung

medical management of empyema is giving fibrinolytics or DNAse

34
Q

what are the most common causes of pleural effusion seen in an outpatient clinic?

A
  1. previously diagnosed CHF transudate

treat with medical management to improve CHF compensation

  1. previously diagnosed malignant pleural effusion (MPE)

treatment of cancer with chemotherapy

place indwelling pleural catheter drainage (e.g. Pleurx)

35
Q

what are the most common causes of pleural effusion seen in the ER and ICU?

A
  1. new or decompensated CHF
  2. pneumonia; parapneumonia or empyema
  3. new MPE
  4. pulmonary infarct
  5. systemic inflammatory response from septic shock
36
Q

what is the pathophysiology of a pneumothorax?

A

when a connection develops between:

  1. the alveoli and pleural space(e.g., a lung bleb that pops) = ronchopleural fistula
  2. between the chest wall and pleural space (e.g. a knife wound)

the connection may be limited or persistent

37
Q

what is a persistent connection pneumothorax?

A

ex. bronchopleural fistula from iatrogenic tear in lung during needle biopsy

if persistent, it may be largely in one direction, leading to air-trapping and tension pneumothorax

38
Q

what is a primary spontaneous pneumothorax?

A

no apparent trauma or obvious cause.

the most likely cause of a primary pneumothorax is rupture of an apical bleb

increased risk for tall, slender, young men who smoke cigarettes and/or inhale recreational drugs

associated with Marfan syndrome and homocysteinuria

39
Q

what is a secondary spontaneous pneumothorax?

A

caused by underlying lung disease like:

  1. COPD (e.g. ruptured bulla)
  2. tuberculosis
40
Q

what is a traumatic pneumothorax?

A
  1. trauma like due to rib fractures or penetrating injury

most common in ER

  1. Iiatrogenic
    - needle insertion for central line placement
  • needle insertion for transthoracic lung biopsy
  • mechanical ventilation; high positive airway pressures

most common in hospitalized patient

41
Q

how do you treat a pneumothorax?

A
  1. small < 3 cm at apex and stable

discharge with NSAID for pain and obtain follow-up CXR

  1. large >3 cm at apex
    - pleural aspiration with catheter
    - admit for observation
    - supplemental oxygen will help N2 in the pleural space to diffuse out; not that effective
    - if not resolved, chest tube
  2. unstable
    - needle thoracostomy
    - chest tube
42
Q

how do you prevent the recurrence of a spontaneous pneumothorax?

A

after a spontaneous pneumothorax, there is a significant risk of having another spontaneous pneumothorax

people who have underlying lung disease are more likely to have another spontaneous pneumothorax

  1. behaviour modification
  2. quitting smoking cigarettes or do not start
  3. quit inhalation of recreational drugs
  4. deep inhalation and breath hold increases risk
43
Q

how do you treat recurrent pneumothorax?

A

surgical intervention with pleuredesis to obliterate pleural space after:

  1. second recurrence of primary spontaneous pneumothorax
  2. first recurrence of secondary spontaneous pneumothorax
44
Q

what is a tension pneumothorax? what are the consequences of having one?

A

air flows into pleural space but can’t get out (one-way valve)

you end up with increasing intrathoracic pressure which prevents venous return to heart, prevents effective breathing

it can be caused by traumatic penetrating, or iatrogenic injuries

most are caused by bronchopulmonary fistulas from a secondary spontaneous cause

ideally, you want to diagnose and treat based on physical exam, without need for CXR because any delay may lead to cardiac arrest due to intrathoracic pressures preventing venous return

45
Q

what are the clinical PE findings of a pneumothorax?

A
  1. decreased tactile fremitus
  2. chest expansion on affected side
  3. tracheal deviation away from affected side
  4. hyperressoance
  5. decreased breath sounds
  6. decreased vocal resonance
46
Q

how do you treat a tension pneumothorax?

A

insert large bore needle into second intercostal space on affected side

after resolution of tension pneumothorax convert to small bore chest tube

Pulmonary Week 3 (8 decks)

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