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Pulmonary > PATHOPHYS: Pleural Effusion > Flashcards

PATHOPHYS: Pleural Effusion Flashcards

1
Q

What is the visceral pleura?

A

covering of lung surface (bumpy mesothelial cells with tight juncitons)

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2
Q

What is the parietal pleura?

A

covering of chest wall (tight mesothelial cells with loos juncitons)

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3
Q

What is the normal volume of the pleural fluid?

A

1-20 mL

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4
Q

What is the function of pleural fluid?

A

lubrication of the pleural space

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5
Q

What is a pleural effusion?

A

accumulation of fluid between the parietal and visceral pleura depending on hydrostatic and colloid osmotic pressures

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6
Q

What circulation supplies the parietal pleura?

A 
systemic circulation (intercostal artery)
HIGH PRESSURE
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7
Q

What circulation supplies the visceral pleura?

A

pulmonary circulation

LOW PRESSURE

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8
Q

What drives movement of fluid across the pleura? In what direction?

A

Hydrostatic pressure difference promotes the movement of fluid from the parietal pleura and into the pleural space through the leaky mesothelial junctions

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9
Q

True or false: the parietal pleura absorbs fluid while the visceral pleura forms it.

A

FALSE: parietal pleura forms 100 mL/hr while visceral pleura absorbs 300 mL/hr

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10
Q

How do proteins and cells get removed from the pleural space?

A

lymphatic drainage via the PARIETAL PLEURA (stomata–> lacunae–> ducts–> lymphatics–> mediastinal lymph nodes)

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11
Q

What two types of pleural effusions are there?

A
  • exudates (protein rich)

- transudates (protein poor)

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12
Q

Name the 4 types of situations when pleural effusions occur?

A
  • Increased hydrostatic pressure
  • Decreased pleural pressure
  • Decreased oncotic pressure
  • Increased oncotic pressure (EXUDATE!!)
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13
Q

What is an example of a condition that will cause pleural effusion due to increased hydrostatic pressure?

A

Congestive heart failure (increased left sided pressure will cause the visceral pleura to FORM fluid)

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14
Q

What is an example of a condition that will cause pleural effusion due to decreased hydrostatic (pleural) pressure?

A

Atelectasis (lung collapse)–that low pressure will lead to increased fluid formation from both sides (especially parietal pleura)

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15
Q

What is an example of a condition that will cause pleural effusion due to increased oncotic pressure?

A

inflammation
infection
cancer

(these conditions decrease the oncotic pressure gradient so that there is movement of protein-rich exudate with increased COP into the pleural space from both pleuras)

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16
Q

What is an example of a condition that will cause pleural effusion due to decreased oncotic pressure?

A

Low albumin
(from malnutrition, renal loss, or decreased production that allows fluid to be released from both the visceral and parietal pleura)

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17
Q

List 2 characteristics of transudative effusion caused by CHF?

A

1) cardiomegaly

2) Bilateral effusions

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18
Q

What are the 3 major signs of pleural effusion on physical exam?

A

1) diminished or absent tactile fremitus
2) Diminished or absent breath and voice sounds
3) Dullness to percussion

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19
Q

What are the top 5 causes of pleural effusions?

A

1) CHF
2) Pneumonia
3) Malignant disease
4) Pulmonary embolism
5) Cirrhosis with ascites

20
Q

What are the top 2 causes of malignant effusions?

A

Lung cancer
breast cancer
(closest to lung and have proximity to the pleural space)

21
Q

What are the two major properties that control arrangement of fluid in the pleural space?

A

1) gravity

2) elastic recoil of the lung

22
Q

What is the major cause of sepsis without other radiographic abnormalities?

A

Tb

23
Q

What are the major causes of bilateral effusions?

A 
CHF (with cardiomegaly)
Malignancy
Cirrhosis with ascites
RA
Lupus
24
Q

What is the indication for a thoracentesis?

A

> 10 mm on lateral decubitis X-ray

25
Q

What are the criteria for a pleural fluid to be exudate?

A

Pleural/serum protein ratio of >0.5
Pleural/serum LDH ratio > 0.6
Pleural fluid LDH of > two thirds upper limit of normal serum level

26
Q

What are the 3 major things that cause a transudate?

A

CHF
Nephrotic syndrome
Cirrhosis with ascites

27
Q

Having extremely high levels of WBCs in pleural fluid (>50,000) indicates what cause?

A

ONLY parapneumonic effusions

28
Q

What will be seen in pleural fluid of empyema?

A

pus

29
Q

What tests should be run on pleural fluid of expected Tb?

A

AFB (but NOT sensitive)

ADA

30
Q

Pleural fluid caused by chylothorax will have what feature?

A

Tg >110

31
Q

Pleural fluid caused by esophageal rupture will have what features?

A

high amylase

pH of 6 or below

32
Q

How can you tell a traumatic thoracentesis from a hemothorax?

A

non-uniform color distribution during aspiration and clotting of fluid within minutes (shows it is fresh blood from piercing vessel on way to pleural cavity)

33
Q

What conditions will cause low pleural fluid glucose?

A
  • Rheumatoid pleurisy
  • Empyema
  • Malignant effusions
34
Q

What are the two most common causes of pleural fluid acidosis?

A

Esophageal rupture
empyema
rheumatoid pleurisy

35
Q

What is the most common cause of pleural fluid amylase/serum amylase to be >/= 1?

A

Acute pancreatitis

36
Q

What are the 3 most common causes of exudate effusion?

A

Cancer
Infection
CTD

37
Q

What factors are examined on a thoracentesis?

A 
color
protein
LDH
Cholesterol
WBC
38
Q

What are the most likely causes of lymphocytosis?

A

Tb (negative AFB does NOT rule out Tb)

Cancer

39
Q

What is a pneumothorax?

A

Breach in pleura leading to exposure of pleural space to positive atmospheric pressure, air enters the pleural space*, and the lung collapses inward

40
Q

What is a primary pneumothorax? What causes it?

A

Spontaneous pneumothorax with NO identifiable lung disease–mostly in tall thin young men

(we now know most of these have subpleural blebs)

41
Q

What are the symptoms of a primary pneumothorax?

A

acute onset of pleuritic chest pain and dyspnea

42
Q

What is a secondary pneumothorax?

A

Pneumothorax due to an underlying lung disease

43
Q

What is an iatrogenic pneumothorax?

A

pneumothorax due to invasive procedures like the placement of a central line or a thoracentesis

44
Q

What is a tension pneumothorax?

A

pneumothorax that occurs when a patient is on positive pressure ventilation that leads to a pleural breach and unidirectional air flow into the pleural space–> circulatory collapse–> impaired venous return

45
Q

What are the clinical signs of a pneumothorax?

A

Hypotension

Hypoxemia

46
Q

What does a chest X-ray of a tension pneumothorax look like?

A
  • Collapsed lung
  • Contr. mediastinal shift
  • depression of diaphragm
47
Q

How do you treat a tension pneumothorax?

A

emergent decompression with a large bore needle (followed by chest tube)

Pulmonary (34 decks)

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