Pleura Disease Flashcards
Define PTX
Accumulation of air in the pleural space
Define a tension PTX
A one way valve is developed in the tissue that allows air to enter the pleural space on expiration and not escape.
How is PTX diagnosed
Imaging
How is a PTX diagnosed in a urgent situation
Ultrasound
How is a PTX discovered when it is hard to locate
CT scan
What effects can PTX have on the thoracic cavity
Mass effect on the lungs
Air trapping can crush the heart
Unilateral chest expansion
Describe sucking chest wound
As the patient inhales the air enters pleural space and enters subcutaneous on exhalation
How does puncture to the visceral pleura effect ventilation
Air leaves lung itself and enters pleura and crushes remaining lung on exhalation
What does eFAST stand for
(Extended) Focused Assessment with Sonography for Trauma
What is FAST vs eFAST
FAST: a standard tool of trauma assessment
“E” includes inspection of plural space
Classic site for needle decomposition of tension PTX
Second intercostal space
Trace to midclavicular line
Insert needle superior to rib
Alternate way to locate classic site for decompression
Locate sternal angle
Trace to intercostal space
Insert needle
What gauge does EMS use
14
3.25 inches
What gauge does the hospital use
14
4.5 cm (1.77 inches)
When do you use alternate insertion sites for decomposition
When the chest wall is >5cm or 2 inches
What is the alternate site for decomposition/ finger thoracostomy
4th or 5th intercostal space at the anterior axillary line
Difference between PTX and HTX presentation
HTX:
Chest trauma
Dullness
Tachycardia
Hypotension
Crackles
PTX:
Hyperresonance
Consequences of HTX
Crushing of lungs and heart
Restrictive lung condition
Compromises O2 delivery
Hypovolemic/hemorrhagic shock
What is the minimum amount of blood seen on a CXR
Greater or equal to 200-300 mL
(Upright position is better)
What classifies as acute HTX
300-500mL
(28-32 Fr chest tube)
Where are chest tubes inserted
4th or 5th intercostal space in mid-axillary or anterior axillary line
What HTX indicates a massive transfusion
> 1500mL
What is the risk of >1500mL HTX
Difficulty breathing with shock
Need blood products (saline is not efficient)
Why can’t saline help with massive HTX
Doesn’t have oxygen carrying capacity or clotting factors
What fluid can be an effusion
Transudate
Blood
Pus (empyema)
Chyle
Cholesterol
Tube feed
What organs failing can cause a pleural effusion
Lungs
Heart
Liver
Kidneys
Bodies in ability to beat cancer
What is a parapneumonic effusion
Caused by the lungs
Associated with bacterial pneumonia
Two types:
Simple and complicated
Explain a simple parapneumonic effusion
Transudative due to increase in fluid in the pneumonia leaking into the pleura space
Explain a complicated parapneumonic effusion
Fluid from inflammation enters the pleura space with bacteria
Can have pus (empyema)
What are the two ways lung failure can cause pleura effusion
Pulmonary embolism:
Increased hydrostatic pressure causing R. Heart failure pushing fluid into parietal than pleura
Parapneumonic
The ways the heart can cause heart failure
(Increased hydrostatic pressure)
Left side heart failure
Cor pulmonale
How does the liver cause pleural effusion
Cirrhotic liver fails:
Doesn’t make albumin leading to transudate
How does kidney failure cause pleural effusion
Nephrotic Syndrome:
Rather than retaining protein it allows it to be peed out.
How does the gastrointestinal system cause a pleural effusion
Failure of lymphatic system can allow chyle to be pushed past diaphragm and enter space.
How does cancer cause a pleural effusion
Non-malignant:
Lymphatic vessels are blocked
Malignant:
Spreads to the pleural space
Why do you need diagnostic test after confirmation of pleural effusion
Usually indicates another disease
Early signs and symptoms of pleural effusion
Dyspnea
Pleuritic chest pain
Cough
What is pleurisy
An intense inflammation of the pleural surface
What classifies as a moderate pleural effusion
.05-1.5L
What classifies as a large pleural effusion
> 1.5L
What feeling accompanies moderate to large pleural effusions
Chest pressure or feeling of fullness
When might you feel Dyspnea with a small pleural effusion
Only if a significant pleurisy is present.
Define a loculated pleural effusion
Trapped in one place and doesn’t follow gravity
Is pale yellow (straw) effusion transudate or exudate
Transudate, some exudate
What does red effusion indicate
Malignancy, trauma
What does white (milky) effusion indicate
Chylothorax or cholesterol
What does brown effusion indicate
Old blood
What does black effusion indicate
Malignancy, aspergilis niger
What are the two rules to confirm exudative nature of pleural effusion
Distinguish transudate from exudate
Discover source of the exudative pleura effusion
What are the two test to distinguish exudative from Transudative
Light criteria
Three test rule
What protein to serum ratio is positive in the light criteria
> 0.5
What pleural fluid lactate dehydrogenase to serum ratio is positive for the light criteria
> 0.6
What pleural fluid LDH is positive for light criteria
> 2/3 upper limit of laboratory’s normal serum
How many positive for the light criteria do you need to be exudative
All three
What distinguishes three-test from light criteria
Three-test doesn’t need serum
What’s the principal of pleural effusion management
Treat the underline pathology
If there is empyema rid pus
What does self limiting mean
Only exist as lung as the underline pathology is present
What are the two indications for thoracentesis
Diagnostic purposes
Therapeutic purposes
What is the maximum amount that can be extracted from a thoracentesis
1.5L
Greater amount is associated with reexpansion pulmonary edema
How to position conscious patient for a thoracentesis
Sit up leaning forward
How do you position a unconscious patient for a thoracentesis
On the infected side
How to position for a HTX
Sit up right
How to position for a pleural effusion
Lay down
Steps for a pleural thoracentesis
Clean with antiseptic
Anesthetize with lidocaine
Administer until the pleural space is reached
Use needle to draw out at least 100 mL for or 1.5L for relief
When do you uses chest tube for a pleural effusion
Temporary measure for management
Define pleurodesis
Obliteration of the pleural space
Who gets a pleurodesis
Those who have recurrent pleural disease
What are the three sclerosants used during pleurodesis
Talc
Doxycycline
Bleomycin
What are the standards of talc
Graded for particle size and cleaned of asbestos
Slurry of particles is injected into pleural space
When would you use a tunneled pleural catheter
When the patient has a symptomatic malignant effusion
Drains as fluid collects
What are the two types of spontaneous pneumothorax
Primary
Secondary
What is a primary pneumothorax
A pneumothorax that has no external cause
(Sometimes associated with drugs and increased transpulmonary pressure)
What is a secondary pneumothorax
Casual link to other pathology
What is a bulla
A airspace > 1cm associated with emphysema
What can cause a iatrogenic PTX
Biopsy
Central venous catheter
Mechanical Ventilation
Pacemaker insertion
Tracheostomy
Describe a deep sulcus sign
Air pocket at the costophrenic angle when a patient is supine
(At the highest point)
What does the visceral pleura look like with a pneumothorax
A white outline
How long can it take for a pneumothorax to be absorbed
Up to 30 days
