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M103 T4 > M103 T4 L14 > Flashcards

M103 T4 L14 Flashcards

1
Q

What are the common causes for chest wall deformities?

A

Kyphoscoliosis - most common
Respiratory muscle weakness
Osteoperosis - a crumbling spine and an abnormal thoracic cage AAR

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2
Q

How was TB treated before TB medication was approved?

A

thoracoplasty - people used to have very abnormal chest wounds as a result of this

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3
Q

What was involved in thoracoplasty?

A

removing lots of ribs from the patient to collapse down an area of TB infected lung

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4
Q

How can chest wall deformities affect the patient?

A

results in an altered shape of the chest wall,
less efficient at drawing air in
some alterations of respiratory mechanics

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5
Q

What are the features that, if a patient with respiratory failure comes in with, might be caused by a chest wall deformity?

A

never smoked
not very fat
don’t do drugs
have a big curvature of the spine

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6
Q

What might cause respiratory muscle weakness?

A

after prolonged critical care
low BMI
muscle wasting diseases

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7
Q

What is the normal pressure of the pleural space?

A

-2.5 mmHg

negative / subatmospheric

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8
Q

What is the effect of the negative pressure in the pleural space?

A

keeps the lungs inflated

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9
Q

How thick is the pleura?

A

0.3-0.5 mm

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10
Q

What is contained in pleural fluid?

A

proteins
lymphocytes
macrophages
mesothelial cells

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11
Q

What is the pH of pleural fluid?

A

about pH 7.6

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12
Q

What is the effect of a air or fluid moving into the lung?

A

causes an accumulation of positive pressure within the pleural space
can lead to a partial or complete collapse of the underlying lung

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13
Q

What are two common pleural conditions?

A

Pneumothorax

Pleural effusion

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14
Q

What are four types of pleural effusions?

A

Pleural infection (empyema)
Malignant Pleural Effusion
Heart failure
Haemothorax

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15
Q

What are the presenting symptoms of a pneumothorax patient?

A

Breathless
Chest pain
Cough

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16
Q

What are features within the history of a pneumothorax patient?

A

raised respiratory rate
may have low oxygen saturations
If unwell with tension pneumothorax – may be very unwell / peri arrest

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17
Q

What symptoms are found on examination in pneumothorax patient?

A 
reduced breath sounds
increased percussion note
reduced expansion
tracheal deviation
Abnormal CXR
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18
Q

What are the four types of pneumothoraxes?

A

1o and 2o
traumatic
iatrogenic

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19
Q

What might cause an iatrogenic pneumothorax?

A

putting in a central line or a pacemaker
traumatic resuscitation
a biopsy (a bronchoscopy or radiologically guided)

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20
Q

How is a small iatrogenic pneumothorax treated?

A

given oxygen
chest x ray
if they don’t feel unwell hopefully it will sort itself out

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21
Q

What type of patient would a primary spontaneous pneumothorax be common in?

A

a healthy young tall male

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22
Q

What counts as a large iatrogenic pneumothorax?

A

when the pneumothorax measures more than 2cm from the hilum to the chest wall to the edge of the lung

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23
Q

How is a large iatrogenic pneumothorax treated?

A

chest drain

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24
Q

What might cause a traumatic pneumothorax?

A

resuscitation
a fight
a car crash

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25
Q

How is a traumatic pneumothorax treated?

A

chest drain

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26
Q

What might a primary spontaneous pneumothorax be caused by?

A

Apical bleb

More common in smokers (especially cannabis smoking)

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27
Q

Which people are apical blebs common in?

A

smokers, cannabis smoking

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28
Q

What are the features that would be common in a patient with a primary spontaneous pneumothorax?

A

short of breath

by the time you see them in A&E, they’ve got normal oxygen saturations, don’t short of breath anymore

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29
Q

How do you treat a patient with a primary spontaneous pneumothorax in A&E who is systematically improving?

A

send them home
see the in a Clinic in two weeks or less
to check that the pneumothorax is resolving

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30
Q

How do you treat a patient with a primary spontaneous pneumothorax is hypoxic or is breathless?

A

first line - aspiration

may need a chest drain

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31
Q

When is aspirating done?

A

as a first alternative to a chest drain

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32
Q

What might suggest a secondary pneumothorax?

A

if the patient has a known background of a lung disease

have previously been mechanically ventilated due to a lung condition

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33
Q

What conditions suggest a secondary pneumothorax?

A

COPD
bronchiectasis
ILD etc

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34
Q

How do you treat a patient with a secondary pneumothorax and why?

A

mostly will need a drain

bc tension is more common

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35
Q

Why is the measurement for a large iatrogenic pneumothorax set at more than 2cm?

A

bc this dimension is about a 50% reduction of the lungs when they collapse

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36
Q

Why is the location of where a pneumothorax is measured from significant?

A

the Americans do it differently - they measure from the apex up instead

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37
Q

What happens after a patient has been seen for having a primary pneumothorax?

A

they will be seen as an outpatient
wait till it’s been resolved with chest xrays
they need to be educated on the recurrence rates
they need to stop smoking

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38
Q

What are the recurrence rates for a primary pneumothorax?

A

54% recurrence in the first 4 years

20-30% recurrence in first 2 years

39
Q

What happens after a patient has been seen for having a recurrent primary pneumothorax?

A

they will be referred to surgeons to have a surgical / medical thoracoscopy and pleurodesis

40
Q

What happens after a patient has been seen for having a secondary pneumothorax?

A

immediately attempt a pleurodesis after the first episode

bc the recurrence rate is high

41
Q

What is the advice regarding normal swimming and diving for pneumothorax patients?

A

as long as it is less than 10 ft depth. it is fine

42
Q

What is the advice regarding air travel for pneumothorax patients?

A

officially allowed one week after full re-expansion of the lung but should be longer

43
Q

Pneumothorax patients with which professions will have to change jobs?

A

coast guard
naval officer
air force

44
Q

What will happen to a pneumothorax patient who is a pilot?

A

would be referred on to have a pre-emptive pleurodesis even without the recurrence
bc even the chance of recurrence would be so hard for them to do that job

45
Q

What is the advice regarding high altitude sports and travel for pneumothorax patients?

A

should be done with caution

should be discouraged

46
Q

What three factors are in a delicate balance to maintain the small volume of lubricating fluid in the pleura?

A

hydrostatic pressure
oncotic pressure
lymphatic drainage

47
Q

What happens if any of the mechanisms keeping the volume of pleural lubricating fluid in check is disturbed?

A

may lead to pathology

may cause a pleural effusion

48
Q

What are the clinical features of pleural effusion?

A

SOB, cough
pleuritic chest pain
reduced breath sound
“Dull” to percussion on examination

49
Q

What are the causes of pleural effusion?

A

altered permeability of the pleural membranes
reduced oncotic pressure
increased capillary hydrostatic pressure
decreased lymphatic drainage or blockage
increased peritoneal fluid

50
Q

What conditions might cause altered permeability of the pleural membranes?

A

inflammation
infection
cancer

51
Q

What conditions might cause reduced oncotic pressure?

A

renal disease

liver cirrhosis

52
Q

What is reduced oncotic pressure caused by?

A

low levels of albumin

53
Q

What condition could cause increased capillary hydrostatic pressure?

A

heart failure

54
Q

What conditions could cause decreased lymphatic drainage or blockage?

A

malignancy

trauma

55
Q

What conditions could cause increased peritoneal fluid?

A

liver cirrhosis

peritoneal dialysis

56
Q

What are the three most common conditions that cause pleural effusion?

A

heart failure
pneumonia
malignancy

57
Q

What types of infection could cause pleural effusion?

A

Bacterial - common
Tuberculous - common
Fungal
Viral

58
Q

What are the benign causes pleural effusion?

A

High oncotic pressure
Low protein state
Autoimmune disease
Reactive

59
Q

What are the malignant causes pleural effusion?

A

1o malignant pleural effusion (mesothelioma)

2o malignant pleural effusion (more common)

60
Q

Where is the cancer causing a secondary malignant tumour in the pleura most likely to originate from?

A

lung cancer

breast cancer

61
Q

What conditions could cause a low protein state?

A

nephrotic syndrome
protein losing enteropathy
chronic liver disease

62
Q

What conditions are examples of a autoimmune diseases?

A

Rheumatoid arthritis

SLE

63
Q

Where is the cancer causing a secondary malignant tumour in the pleura less likely to originate from?

A

Gyneacological
heamotological
renal
GI tract

64
Q

What are the statistics for pneumonias and co-morbidities? (don’t need to know the numbers)

A

50% develop an effusion - increases mortality x3
10% become infected - progress to empyema
over 30% either die or require surgery
20% have a 1 year mortality
Prolonged hospital admission

65
Q

What are the risk factors for having a pleural infection?

A

Diabetes
Immunosuppression (steroids)
Alcohol, IVDU
Poor oral hygiene and aspiration (anaerobic)
Iatrogenic e.g. previous pleural procedure
Trauma
Recent hospitalization

66
Q

What are the systemic features of an infection in pleural effusion?

A

fever

raised CRP/WCC suggest pleural infection

67
Q

What are the predictors of the worse outcome for patients with a pleural infection?

A

pH <7.2 High LDH
Low glucose (<2/3rd of serum glucose)
Positive culture
Loculations (seen on ultrasound or CT)

68
Q

What is done to find out more information about a pleural infection?

A

CXR

pleural fluid sample (after the patient has been on antibiotics, to see if there’s pus in the pleura)

69
Q

Why are loculations barriers for using a drain on a pleural effusion?

A

instead of one big collection of fluid, it’s all broken up into lots of pockets
the presence of pockets means that we’re not going to be able to drain

70
Q

Are antibiotics effective at treating infections in the pleural space?

A

no, they are notoriously bad at getting into the pleural space
bad pleural penetration

71
Q

What are the features of an uncomplicated parapneumonic effusion?

A

occurs earlier on in the infection
the patient might be clinically well
there are no loculations

72
Q

What is the cause of a complicated parapneumonic effusion?

A

Bacterial invasion into the pleural space

Fibrin deposition may form locules / septations

73
Q

What is the cause of an Empyema?

A

pus within the pleural cavity with the thickening of the pleural surface

74
Q

What are the three types of parapneumonic effusions?

A

Uncomplicated
Complicated
Empyema

75
Q

How is an uncomplicated parapneumonic effusion treated?

A

will be resolved on treatment of the underlying pneumonia
may not need to be drained
may sort itself out

76
Q

How is a complicated parapneumonic effusion treated?

A

Patient will likely need a drain

77
Q

How effective is a chest drain when treating an empyema?

A

when you try and put the chest drain and it’ll be thick and hard
very difficult
trapped lung
it’s hard for the lung to re-expand, even with drainage

78
Q

Is malignant effusion likely to happen again in a patient?

A

yes - it has a high recurrence rate

79
Q

What is the median life expectancy for malignant effusion?

A

6 months

80
Q

What is the most common type of malignant effusion?

A

unilateral

81
Q

What symptoms does a malignant effusion usually present with?

A

breathlessness
cough
hypoxia
mostly are hemorrhagic

82
Q

What are the different management treatments available for a malignant pleural effusion?

A

Aspiration with a >90% recurrence rate
Chest drain +/- pleurodesis – 60-70% success
Indwelling pleural catheter
Thoracoscopic drainage + pleurodesis

83
Q

What are the four advantages of effusion drainage via an indwelling pleural catheter?

A

Avoids patient admission to hospital.
Suitable for long term drainage
Improves quality of life
50% spontaneous pleurodesis

84
Q

Why is a talc pleurodesis used?

A

to prevent recurrence in patients with COPD who are too ill to have a general anaesthetic

85
Q

When is a talc pleurodesis used?

A

for a malignant pleural effusion with no sign of infection

86
Q

What is talc pleurodesis made up of?

A

medicated talc that creates a talc ‘slurry’ (a bit like glue) to stick the pleura together

87
Q

What is the success rate of a talc pleurodesis?

A

about 70%

88
Q

What are the two conditions of the lungs for a talc pleurodesis to be performed?

A

the lung needs to be reinflated for a talc pleurodesis to work
the lungs output needs to be <200ml/24hr

89
Q

Why is a haemothorax not a bloody effusion?

A

bc the HCT >50%

90
Q

What are the causes of a haemothorax?

A

Traumatic
Iatrogenic
Aortic dissection

91
Q

How is a haemothorax treated?

A

resuscitate
urgent drainage (“surgical” drain)
Consider VATS

92
Q

What is the difference between a primary spontaneous pneumothorax and a secondary one?

A

primary - SP in a person without an underlying lung disease

2o - SP with an underlying lung disease

93
Q

What does a talc pleurodesis involve?

A

sterile talc mixed with saline is inserted via a tube IOT

cause irritation to the lung lining

94
Q

What is the aim of talc pleurodesis?

A

to prevent fluid building up in the lining of the lung

M103 T4 (19 decks)

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