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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
How is a traumatic pneumothorax treated?
chest drain
26
What might a primary spontaneous pneumothorax be caused by?
Apical bleb | More common in smokers (especially cannabis smoking)
27
Which people are apical blebs common in?
smokers, cannabis smoking
28
What are the features that would be common in a patient with a primary spontaneous pneumothorax?
short of breath | by the time you see them in A&E, they've got normal oxygen saturations, don't short of breath anymore
29
How do you treat a patient with a primary spontaneous pneumothorax in A&E who is systematically improving?
send them home see the in a Clinic in two weeks or less to check that the pneumothorax is resolving
30
How do you treat a patient with a primary spontaneous pneumothorax is hypoxic or is breathless?
first line - aspiration | may need a chest drain
31
When is aspirating done?
as a first alternative to a chest drain
32
What might suggest a secondary pneumothorax?
if the patient has a known background of a lung disease | have previously been mechanically ventilated due to a lung condition
33
What conditions suggest a secondary pneumothorax?
COPD bronchiectasis ILD etc
34
How do you treat a patient with a secondary pneumothorax and why?
mostly will need a drain | bc tension is more common
35
Why is the measurement for a large iatrogenic pneumothorax set at more than 2cm?
bc this dimension is about a 50% reduction of the lungs when they collapse
36
Why is the location of where a pneumothorax is measured from significant?
the Americans do it differently - they measure from the apex up instead
37
What happens after a patient has been seen for having a primary pneumothorax?
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
38
What are the recurrence rates for a primary pneumothorax?
54% recurrence in the first 4 years | 20-30% recurrence in first 2 years
39
What happens after a patient has been seen for having a recurrent primary pneumothorax?
they will be referred to surgeons to have a surgical / medical thoracoscopy and pleurodesis
40
What happens after a patient has been seen for having a secondary pneumothorax?
immediately attempt a pleurodesis after the first episode | bc the recurrence rate is high
41
What is the advice regarding normal swimming and diving for pneumothorax patients?
as long as it is less than 10 ft depth. it is fine
42
What is the advice regarding air travel for pneumothorax patients?
officially allowed one week after full re-expansion of the lung but should be longer
43
Pneumothorax patients with which professions will have to change jobs?
coast guard naval officer air force
44
What will happen to a pneumothorax patient who is a pilot?
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
What is the advice regarding high altitude sports and travel for pneumothorax patients?
should be done with caution | should be discouraged
46
What three factors are in a delicate balance to maintain the small volume of lubricating fluid in the pleura?
hydrostatic pressure oncotic pressure lymphatic drainage
47
What happens if any of the mechanisms keeping the volume of pleural lubricating fluid in check is disturbed?
may lead to pathology | may cause a pleural effusion
48
What are the clinical features of pleural effusion?
SOB, cough pleuritic chest pain reduced breath sound “Dull” to percussion on examination
49
What are the causes of pleural effusion?
altered permeability of the pleural membranes reduced oncotic pressure increased capillary hydrostatic pressure decreased lymphatic drainage or blockage increased peritoneal fluid
50
What conditions might cause altered permeability of the pleural membranes?
inflammation infection cancer
51
What conditions might cause reduced oncotic pressure?
renal disease | liver cirrhosis
52
What is reduced oncotic pressure caused by?
low levels of albumin
53
What condition could cause increased capillary hydrostatic pressure?
heart failure
54
What conditions could cause decreased lymphatic drainage or blockage?
malignancy | trauma
55
What conditions could cause increased peritoneal fluid?
liver cirrhosis | peritoneal dialysis
56
What are the three most common conditions that cause pleural effusion?
heart failure pneumonia malignancy
57
What types of infection could cause pleural effusion?
Bacterial - common Tuberculous - common Fungal Viral
58
What are the benign causes pleural effusion?
High oncotic pressure Low protein state Autoimmune disease Reactive
59
What are the malignant causes pleural effusion?
1o malignant pleural effusion (mesothelioma) | 2o malignant pleural effusion (more common)
60
Where is the cancer causing a secondary malignant tumour in the pleura most likely to originate from?
lung cancer | breast cancer
61
What conditions could cause a low protein state?
nephrotic syndrome protein losing enteropathy chronic liver disease
62
What conditions are examples of a autoimmune diseases?
Rheumatoid arthritis | SLE
63
Where is the cancer causing a secondary malignant tumour in the pleura less likely to originate from?
Gyneacological heamotological renal GI tract
64
What are the statistics for pneumonias and co-morbidities? (don't need to know the numbers)
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
What are the risk factors for having a pleural infection?
Diabetes Immunosuppression (steroids) Alcohol, IVDU Poor oral hygiene and aspiration (anaerobic) Iatrogenic e.g. previous pleural procedure Trauma Recent hospitalization
66
What are the systemic features of an infection in pleural effusion?
fever | raised CRP/WCC suggest pleural infection
67
What are the predictors of the worse outcome for patients with a pleural infection?
pH <7.2 High LDH Low glucose (<2/3rd of serum glucose) Positive culture Loculations (seen on ultrasound or CT)
68
What is done to find out more information about a pleural infection?
CXR | pleural fluid sample (after the patient has been on antibiotics, to see if there's pus in the pleura)
69
Why are loculations barriers for using a drain on a pleural effusion?
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
Are antibiotics effective at treating infections in the pleural space?
no, they are notoriously bad at getting into the pleural space bad pleural penetration
71
What are the features of an uncomplicated parapneumonic effusion?
occurs earlier on in the infection the patient might be clinically well there are no loculations
72
What is the cause of a complicated parapneumonic effusion?
Bacterial invasion into the pleural space | Fibrin deposition may form locules / septations
73
What is the cause of an Empyema?
pus within the pleural cavity with the thickening of the pleural surface
74
What are the three types of parapneumonic effusions?
Uncomplicated Complicated Empyema
75
How is an uncomplicated parapneumonic effusion treated?
will be resolved on treatment of the underlying pneumonia may not need to be drained may sort itself out
76
How is a complicated parapneumonic effusion treated?
Patient will likely need a drain
77
How effective is a chest drain when treating an empyema?
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
Is malignant effusion likely to happen again in a patient?
yes - it has a high recurrence rate
79
What is the median life expectancy for malignant effusion?
6 months
80
What is the most common type of malignant effusion?
unilateral
81
What symptoms does a malignant effusion usually present with?
breathlessness cough hypoxia mostly are hemorrhagic
82
What are the different management treatments available for a malignant pleural effusion?
Aspiration with a >90% recurrence rate Chest drain +/- pleurodesis – 60-70% success Indwelling pleural catheter Thoracoscopic drainage + pleurodesis
83
What are the four advantages of effusion drainage via an indwelling pleural catheter?
Avoids patient admission to hospital. Suitable for long term drainage Improves quality of life 50% spontaneous pleurodesis
84
Why is a talc pleurodesis used?
to prevent recurrence in patients with COPD who are too ill to have a general anaesthetic
85
When is a talc pleurodesis used?
for a malignant pleural effusion with no sign of infection
86
What is talc pleurodesis made up of?
medicated talc that creates a talc ‘slurry’ (a bit like glue) to stick the pleura together
87
What is the success rate of a talc pleurodesis?
about 70%
88
What are the two conditions of the lungs for a talc pleurodesis to be performed?
the lung needs to be reinflated for a talc pleurodesis to work the lungs output needs to be <200ml/24hr
89
Why is a haemothorax not a bloody effusion?
bc the HCT >50%
90
What are the causes of a haemothorax?
Traumatic Iatrogenic Aortic dissection
91
How is a haemothorax treated?
resuscitate urgent drainage (“surgical” drain) Consider VATS
92
What is the difference between a primary spontaneous pneumothorax and a secondary one?
primary - SP in a person without an underlying lung disease | 2o - SP with an underlying lung disease
93
What does a talc pleurodesis involve?
sterile talc mixed with saline is inserted via a tube IOT | cause irritation to the lung lining
94
What is the aim of talc pleurodesis?
to prevent fluid building up in the lining of the lung

M103 T4 (19 decks)

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