Pleural and Chest Wall Disorders Flashcards
Inflammation of the pleura causes loss of lubricant between them,
inspiration causes the friction rub when the pleura rub together
Pleuritis
What are some signs/symptoms of pleuritis?
Pain is localized, sharp, fleeting and made worse by coughing, sneezing, deep breath, or movement
Sharp pain like stabbing sensation – patient will be able to point out
exactly where it is felt
May hear a friction rub on inspiration
What is contraindicationed in a rib fracture?
Constrictive brace is contraindicated
Abnormal accumulation of fluid in pleural space
Pleural Effusion
What are the two categories of pleural effusions?
transudative and exudative
The most common cause of pleural effusion is what?
congestive heart failure
What is the pathophysiology of pleural effusions?
Fluid enters the space through capillaries and exits through lymphatics in the visceral and parietal pleura
Pleural effusions occur when there is an excess formation of pleural fluid, decreased fluid removal, or both
What is the difference between transudative and exudative pleural effusions?
Exudative: Increased production of fluid due to abnormal capillary permeability or decreased lymphatic clearance (Capillaries are damaged)
Transudative: Increased production of fluid in the setting of normal capillaries
What are the most common causes of exudative pleural effusions?
Bacterial pneumonia
Cancer (decreased lymphatic drainage)
What are the subtypes of exudative pleural effusions?
Empyema
Hemothorax
Chylothorax
infection in pleural space (abscess in the pleural space)
Empyema
bleeding in pleural space (gross blood from trauma)
Hemothorax
lymphatic fluid in pleural space (cholesterol complex accumulation, appears white)
Associated with lymphoma and thoracic surgery
Chylothorax
Exudative pleural effusions criteria: one or more of the following
Note: transudates have NONE of these features
Pleural fluid protein to serum protein ratio >0.5
Pleural fluid LDH to serum LDH ratio >0.6 and pleural fluid LDH greater than two thirds the upper limit of normal serum LDH
LDH = lactose dehydrogenase
Transudates differentiated from exudates by what criteria?
Light’s Criteria
Looks at LDH and protein (compare to serum)
What are the most common causes of transudative pleural effusions?
Congestive heart failure – one of the most common causes
Hypoproteinemia (Nephrotic syndrome)
Cirrhosis
Pulmonary embolism
What is the gold standard treatment for pleural effusions?
Thoracentesis
If the protein is <3gm%, which type of pleural effusion do you have?
Transudate
If the protein is >/= 3gm%, which type of pleural effusion do you have?
Exudate
Which two types of cancer commonly have malignant pleural effusions?
Lung cancer
breast cancer
Accumulation of air in the pleural space
Pneumothorax
What are the types of pneumothorax?
Primary spontaneous pneumothorax
Secondary spontaneous pneumothorax
Tension pneumothorax
Type of pneumothorax that occurs in the absence of underlying disease?
Primary spontaneous pneumothorax
Type of pneumothorax that occurs in the presence of underlying disease?
Secondary spontaneous pneumothorax
What is the most common disease that can result in a secondary spontaneous pneumothorax?
COPD
What is the classic patient demographic that you may see a primary spontaneous pneumothorax?
tall, thin males
men between the ages of 18-40
smoking increases risk 20x
Positive pressure in the pleural space throughout the respiratory cycle
Tension pneumothorax
Spontaneous Pneumothorax is common in patients with which disorder?
Marfan’s Syndrome
If you have severe tachycardia, hypotension, and mediastinal or
tracheal shift, which type of pneumothorax should you suspect?
tension pneumothorax
What therapy may hasten the resolution of pneumothorax?
Oxygen
What imaging is diagnostic? What is the exception?
CXR
Exception: tension pneumothorax
What are some complications of a pneumothorax?
Subcutaneous emphysema
Pneumomediastinum
death
Tension pneumothorax will result in what?
acute respiratory failure and potentially death
What are the two common etiologies of a tension pneumothorax?
Traumatic
Barotrauma (i.e. mechanical ventilation)
What is the most common cause of a tension pneumothorax?
trauma
In a tension pneumothorax, you’d see a tracheal +/or mediastinal shift
toward which side?
the unaffected side
(contralateral hemithorax)
If a tension pneumothorax is suspected, a large-bore needle should be inserted immediately in the affected side for decompression at which site?
second intercostal space in midclavicular line
A primary tumor predominately of pleural surface lining, arising from the mesothelial cells that line the pleural cavities or peritoneum
known as the only pleural cancer
“pleural-based mass”
Mesothelioma
Malignant pleural mesotheliomas are commonly associated with what exposure?
asbestos exposure
In mesothelioma, what percentage of patients will you expect to see extra-thoracic spread?
> 90% of patients
In mesothelioma, what percentage of cases are diffuse (malignant) v localized (benign)?
75% are diffuse (malignant)
25% are localized (benign)
What is the most common first sign of mesothelioma we’ll come across?
Pleural effusions
In mesothelioma, what is the median survival rate in localized disease?
16 months in localized disease
In mesothelioma, what is the median survival rate in extensive disease?
4 months in extensive disease
What diagnosis should you consider if you see the following clinical presentation:
Insidious onset of SOB
Non-pleuritic chest pain
Weight loss
mesothelioma
