Pleural and Mediastinal

Question 1

Mesothelioma

Answer 1

• Primary tumor of the pleural surfaces
• About 75% are malignant
• Risk factor: Asbestos exposure
• S/Sx: dyspnea, nonpleuritic chest pain, fevers, weight loss, pleural effusions
• Dx: cytology and biopsy
• Tx: radiation, chemotherapy
• Prognosis: very poor, 75% die in 1-2 years

Question 2

Pleurisy

Answer 2

-Chest pain caused by pleural inflammation
-E: viral, bacterial, tuberculosis, asbestosis
-S/Sx: sharp or stabbing pain with breathing (ie; pleuritic chest pain)
Deep breathing, coughing or sneezing makes is worse.
-Lab: cultures
-Tx: analgesics and anti-inflammatory medications, antimicrobials if needed. Possibly corticosteroids.

Question 3

Pleural Effusion

Answer 3

Accumulation of fluid between the lung and thoracic wall

Transudate (thin)

• Decreased plasma oncotic pressure (decreased albumin)
• Nephrotic syndrome
• Increased hydrostatic pressure-CHF
• Cirrhosis
• Myxedema (severe hypothyroidism)

Exudate (thick)

• Malignancy
• Blood (trauma)
• Infections
• Collagen vascular disease (RA)
• Pancreatitis
• Chylothorax

Question 4

Clinical Presentation of Pleural Effusion

Answer 4

-Sx: Dyspnea, possibly fevers
-PE: friction rub, dullness to percussion in lower lung fields, decreased, possibly absent breath sounds, decreased tactile fremitus
Dx:
-CXR: white out in lower lung field with blunting of costophrenic angle, loss of sharp demarcation of the diaphragm and heart and possible mediastinal shift to the uninvolved side
-USN: localizes the effusion
-Thoracentesis: diagnostic and therapeutic

Question 5

Pleural effusion treatment

Answer 5

• Thoracentesis procedure and if reaccumulation indwelling catheter possibly
• Pleurodesis mechanical, VATS or chemical for chronic effusions
• Pleurectomy
• Decortication (removal of fibrous pleural rind)

Question 6

Empyema

Answer 6

• Accumulation of pus in the pleural space
• Usually due to bacterial pneumonia and lung abscess
• Fluid has a pH <7.2
• Tx: initial-chest tube, antibiotic therapy, will often need decortication by thoracoscopy or thoracotomy. VATS procedure.

Question 7

Chylothorax

Answer 7

-Lymph fluid accumulation in the pleural space
-E: injury to the thoracic duct by laceration or obstruction by trauma or tumor
-TB, rheumatic pleural effusion, lymphoma
-Lab: positive triglycerides, milky white fluid
-Tx: chest tube, NPO, TPN
(Eating will cause more fatty fluid deposits due to triglycerides)

Question 8

Pneumothorax

Answer 8

• Accumulation of air in the pleural space
• E: spontaneous, traumatic or iatrogenic
• Risk factors: Smoking, family history
• S/Sx: acute onset of ipsilateal chest pain with shortness of breath
• PE: Decreased breath sounds, unilateral chest expansion, hyperresonance, decreased tactile fremitus
• Dx: CXR-presence of air in the pleural space, lung expansion decreased
• Tx: chest tube possibly, high FiO2 Oxygen therapy

Question 9

Tension Pneumothorax

Answer 9

• Air in the pleural space causing a mediastinal shift to the contralateral side and impaired ventilation leading to cardiovascular compromise
• Risk factor-positive-pressure mechanical ventilation
• CXR presence of air in the pleural space with tracheal/mediastinal shift. Decreased lung expansion
• TX: Immediate; insertion of large-bore needle to decompress tension pneumothorax
• When stable; chest tube placement
• Oxygen and respiratory support

Question 10

Mediastinal Masses

Answer 10

Superior mediastinal masses
-Thymomas, thyroid tumor, teratoma, parathyroid tumor, lymphoma
Anterior/middle mediastinal masses
-Bronchgenic tumor, cyst
Posterior mediastinal masses
-Neurogenic tumor, esophageal tumor