lecture 59 - Pleural Disease

Question 1

what are the two layers of the pleural ?

which has no somatic innervation?

Answer 1

Parietal (serosal) and Visceral

Visceral has no somatic innervation

Question 2

What is a pleural effusion ?

what is a pneumothorax?

Answer 2

Abn accumulation of fluid into the pleural space

Abnormal accumulation of air into the pleural space

Question 3

What are tools for dx of Pleural effusion?

Answer 3

H&P

CT / CXR findings

Pleural fluid analysis

Physical exam

Question 4

what are physical exams findings with an effusion

Answer 4

Decreased movement with inspiration of ipsilateral hemithorax
Dull or flat Ipsilateral percussion
Contralateral tracheal shift with large effusions
Decreased breath sounds
Occasional pleural rub
Decreased fremitus

Question 5

what is seen on imaging?

Answer 5

CXR - meniscus opacity

CT – densities indicating fluid in dependent fashion

Question 6

how are effusions classified?

what is Light’s Criteria ?

Answer 6

transudate vs exudate

Total Protein – -Pleural fluid and compare to serum
< .6 indicates transudate

LDH Fluid compared to upper normal limit of serum
- Pleural fluid LDH < 2/3 upper limit of normal of serum indicates a transudate

NEED ALL THREE TO BE TRANSUDATIVE
“HIGH” value of ANY OF THREE VALUES = EXUDATIVE

Question 7

what are the etiologies of a transudative effusion?

Answer 7

Prototype – CHF
Cirrohosis
Renal failure

Question 8

Treatment of transudative effusion ?

Answer 8

Diuretics to decrease Filtration Pressure (Pc) – in CHF
Increase oncotic pressure in settings of low albumin

Thoracentesis – as a therapy

Question 9

Etiologies of exudative effusion ?

Answer 9

Connective tissue disease
				Pulmonary embolism 
				TB
				Malignancy 
				Parapneumonic effusion (or empyema)

Question 10

Treatment of exudative effusion caused by:
- connective tissue disease

• pulmonary embolism
• TB

Answer 10

Connective tissue Disease — anti-inflammatory drugs (steroids), for rheumatic disease which cause inflammation

Pulmonary embolism – Treat the embolism (anticoagulaiton)

TB – treat medically; abx

Question 11

what is the primary malignancy of the pleura called? what causes it? how do you treat it?

Answer 11

Mesothelioma
Asbestos
Chemo/surgery

Question 12

How do you treat vs manage metastatic disease to the pleura ?

Answer 12

Treatment of the disease – Systemic Chemotherapy

Management / Symptomatic /Palliative –
Chest tube
Pleurodesis – chemical or mechanical fusion of the visceral and parietal pleura
indwelling pleural catheter – another form drainage

Question 13

what is a parapneumonic effusion ?

what are the classificaitons?

Answer 13

parapneumonic effusion – an effusion which occurs in the setting of a PNA

May be Infectious: aka empyema

May be sterile

Question 14

How do you treat a sterile parapneumonic effusion ?

How do you treat an empyema (infectious paraneumonic effusion)?

Answer 14

Sterile – Give abx for the PNA

Empyema – Chest tube drainage; surgical intervention

Question 15

What is a Pneumothorax

Answer 15

What is it? Abnormal accumulation of air into the pleural space leading to uncoupling of the chest wall and the lung

Question 16

what are the two ways in which pneumothroax can occur ?

Answer 16

Abn communication between Lung and Pleural space (More common in non-trauma)

Abn communication between Atmosphere and pleural space (trauma, stabbin

Question 17

Symptoms of a pneumo thorax

Answer 17

Symptoms – Usually have Chest Pain, pleuritic pain (air is an irritant to the pleura)

Usually sudden onset

Question 18

What is seen on imaging for a pneumothroax

Answer 18

air in the pleural space

Question 19

Physical exam findings for pneumothroax

Answer 19

Decreased BS
Hyperresonant
Chest wall on that side appears large, but decreased movement
Contralateral tracheal/mediastinal shift

Question 20

what helps determine the treatment of the patinet with pneumothorax ?

Answer 20

Their clinical condition; the radiograph severity

There may not be a correlation between size and discomfort

Question 21

Treatment for a pneumo thorax

Answer 21

Observation -

100% O2

Aspiration

Chest tube with suction

Surgical intervention

Question 22

what is the rationale for providing patient with 100% O2 ?

Answer 22

Usually for a small Pneumothorax
Air is 21% oxygen and 80% nitrogen
Have patient breathe in 100% O2
Eventually no more nitrogen in the blood or lung, but still in the pleural space
Therefore the nitrogen will dissipate (due to concentration gradient) into the blood stream and help reduce the pneumothorax

Question 23

What is a tension penumo thorax

Answer 23

Cardiovascular Compromise due to continuing accumulation of air into the pleural space which cannot escape (1 way valve)
- Pressure builds, such that it exceeds the Right Atrial Pressure and then start to have CV compromise

Question 24

what is the treatment for a tension pneumo thorax

Answer 24

Treatment – Must Urgently decompress –

		Stick needle into the patient -- still left with  pneumothorax, but have relieved the tension 

		Let air out 
		Then put In chest tube