ICL 3.5: Pleural Disease Flashcards
what is pleurisy?
inflammation of the pleural membranes
what is a pleural effusion?
abnormal accumulation of >15 ml in pleural space
what is a pneumothorax?
air in the pleural space
what is the etiology of pleurisy?
- infection: viral, bacterial or fungal
- injury – if the ribs are bruised or fractured, the pleura can become inflamed
- pulmonary embolism: a blood clot developing inside the lungs
- sickle cell anaemia: a blood disorder that usually affects people of African or Caribbean descent
- chemotherapy and radiotherapy
- uremia
what is the clinical presentation of pleurisy?
- sharp chest pain associated with
breathing; especially breathing deeply. - referral of pain to the shoulder.
- worse pain with cough, sneeze or movement – patients often go to ER due to severity and acuity of pain
- may or may not be associated with pleural effusion or neumothorax
- 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
what are the viral causes of pleurisy?
- influenza
- EBV
- CMV
- parainfluenza
what is pleuredynia? what virus causes it?
inflammation of intercostal muscles that causes pleuritic pain
epidemic pleuredynia due to Coxsackie B virus
how do you treat uncomplicated pleurisy or pleuredynia?
NSAIDs
occasionally may need corticosteroids, rarely if ever narcotics
pleuredynia = inflammation of intercostal muscles that causes pleuritic pain
what do you give to treat the inflammation and pain seen in pleurisy?
- nonsteroidal anti-inflammatory drugssuch as ibuprofento reduce pain and inflammation
- corticosteroidsto reduce inflammation if NSAIDs not effective or contraindicated
- narcoticsin low doses to treat chronic shortness of breath. Only as last resort
diagnose and treat cause of inflammation!!
a 55 year old patient with PE and infarct is admitted. the patient still has pain. the best initial treatment of pain is what?
NSAIDs
what is the Light criteria?
Light criteria (N=3)
1. pleural fluid
LDH/serum LDH ratio >0.6
- pleural fluid LDH > two‐thirds the upper limits of the laboratory’s normal serum
- 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
what is a normal pleural transudate?
Qf is negative or zero
fluid flow into capillary from interstitium
no accumulation of interstitial fluid (effusion)
Qf = (Pc + πi) - (Pi + πp)
what is an abnormal pleural transudate?
Qf positive:
fluid flow out of capillary into interstitium resulting in effusion
Qf = k [(Pc + πi) - (Pi + πp)]
what are the causes of a positive Qf?
- elevated capillary pressure (Pc) due to left ventricular hear failure
- lower capillary oncotic pressure due to (pc) hypoalbuminemia
- increased leakiness of capillaries (k) due to septic shock or vasculitis
what can cause pleural transudate?
- Increased capillary hydrostatic pressure (Pc)
ex. LV CHF, cirrhosis - decreased capillary oncotic pressure (hypoalbuminemia) (pc):
ex. malnutrition, hepatic failure, critical care/iatrogenic due to fluid resuscitation of shock - increased capillary leakage (k):
ex. septic shock, anaphylactic shock, vasculitis
what is the etiology of pleural exudates?
INFLAMMATION
1. infection: viral, bacterial
- connective tissue disease: RA, SLE
MALIGNANCY
1. metastatic
- primary mesothelioma
INJURY
1. trauma
- surgery
what are the clinical signs that someone has a pleural exudate caused by a virus?
- high lymphocyte count
2. low neutrophil count
what are the clinical signs that someone has a pleural exudate caused by a fungus?
- high lymphocyte count
- low neutrophil count
usually immunosuppressed
what are the clinical signs that someone has a pleural exudate caused by TB?
- high lymphocyte count
- low neutrophil count
- Adenosine deaminase and/or interferon gamma elevated
- Tuberculosis mycobacteria observed on slide or culture
uncommon in the US
what are the clinical signs that someone has a pleural exudate caused by bacteria?
high neutrophil count!
- para-pneumonic: non-infected
pH > 7.2, fluid not cloudy or prurulent, no growth of bacteria
- empyema: infected
infected
pH <7.2, fluid cloudy or prurluent, grow bacteria in culture
what is a malignant pleural effusion?
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
what are other causes of effusions associated with malignancy other than MPE?
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,
- pulmonary embolism/infarct: malignancy is a cause of hypercoagulability
- post-obstructive pneumonia
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
D. all of the above
how do you diagnose a pleural effusion?
- CXR
- ultrasound
- chest CT
- blood tests
what does a CXR/CT scan tell you about a pleural effusion?
- Air or fluid in the pleural space
- pockets (loculation) of fluid or air due to proteinaceous septae
- disease in the lung or pleura; such as pneumonia, abcess, pulmonary embolism, a fractured rib, or a lung tumor
what does a ultrasound scan tell you about a pleural effusion?
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
why would you do an ultrasound guided thoracentesis of a pleural effusion?
to test for:
- transudate or exudate via light criteria
- cell count: lymphocytes, neutrophils
- gram stain and culture
- cytopathology for cancer
- glucose, triglycerides
- other specific tests: for TB (ADA, interferon gamma), pancreatitis (amylase, lipase)
- biopsy to retrieve a sample of the pleura if concern for TB or malignancy and effusion is negative
how do to treat pleural effusion?
- treat underlying condition
- thoracentesis
- chest tube to drain fluid from the pleural space
- indwelling pleural catheter (IPC) for drainage of pleural fluid a few times a week (Pleurex)
- Heimlich valve
- injection of fibrinolytic and DNAse
- pleurodesis
- surgery
when would you use a chest tube?
a chest tube drains fluid from the pleural space
typically used for exudates, most commonly empyema or malignant effusion
what is a Heimlich valve?
one-way valve attached to a chest tube or indwelling pleural catheter (IPC) that prevents fluid and air from getting into chest
when would you give someone fibrinolytic and DNAse?
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
what is pleurodesis?
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
when would you do surgery to treat a pleural effusion?
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
what are the most common causes of pleural effusion seen in an outpatient clinic?
- previously diagnosed CHF transudate
treat with medical management to improve CHF compensation
- previously diagnosed malignant pleural effusion (MPE)
treatment of cancer with chemotherapy
place indwelling pleural catheter drainage (e.g. Pleurx)
what are the most common causes of pleural effusion seen in the ER and ICU?
- new or decompensated CHF
- pneumonia; parapneumonia or empyema
- new MPE
- pulmonary infarct
- systemic inflammatory response from septic shock
what is the pathophysiology of a pneumothorax?
when a connection develops between:
- the alveoli and pleural space(e.g., a lung bleb that pops) = ronchopleural fistula
- between the chest wall and pleural space (e.g. a knife wound)
the connection may be limited or persistent
what is a persistent connection pneumothorax?
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
what is a primary spontaneous pneumothorax?
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
what is a secondary spontaneous pneumothorax?
caused by underlying lung disease like:
- COPD (e.g. ruptured bulla)
- tuberculosis
what is a traumatic pneumothorax?
- trauma like due to rib fractures or penetrating injury
most common in ER
- Iiatrogenic
- needle insertion for central line placement
- needle insertion for transthoracic lung biopsy
- mechanical ventilation; high positive airway pressures
most common in hospitalized patient
how do you treat a pneumothorax?
- small < 3 cm at apex and stable
discharge with NSAID for pain and obtain follow-up CXR
- 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 - unstable
- needle thoracostomy
- chest tube
how do you prevent the recurrence of a spontaneous pneumothorax?
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
- behaviour modification
- quitting smoking cigarettes or do not start
- quit inhalation of recreational drugs
- deep inhalation and breath hold increases risk
how do you treat recurrent pneumothorax?
surgical intervention with pleuredesis to obliterate pleural space after:
- second recurrence of primary spontaneous pneumothorax
- first recurrence of secondary spontaneous pneumothorax
what is a tension pneumothorax? what are the consequences of having one?
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
what are the clinical PE findings of a pneumothorax?
- decreased tactile fremitus
- chest expansion on affected side
- tracheal deviation away from affected side
- hyperressoance
- decreased breath sounds
- decreased vocal resonance
how do you treat a tension pneumothorax?
insert large bore needle into second intercostal space on affected side
after resolution of tension pneumothorax convert to small bore chest tube
