Pleural Cavity Flashcards
What type of pleura is in the fissures of the lungs?
visceral only
Inflammation of the lining of the lung (usually visceral pleura)
pleurisy
What are the classic signs of pleurisy?
worsening pain with movement and deep breath
What does pleural pain occur if the inflammation is in the visceral pleura, which does not have pain receptors
b/c it rubs the parietal pleura
what is the most common cause of pleurisy?
viral infection
what are other common causes of pleurisy?
pna, PE, pneumothorax, pericarditis,
what is the treatment for pleurisy?
treat underlying cause, and provide anti-inflammatories like NSAIDS PRN
pleura typically has about 14 cc’s of fluid in it all the time which is fed from systemic vessels. Typically this fluid is drained by the lymphatics. When this doesn’t happen appropriately, what happens?
pleural effusion
What are some causes of pleural effusion
- Interstitial pressure > Pleural pressure
- Pleural membranes leaks liquid and
protein - Inflammation and/or obstruction impair
removal (lymphatics are obstructed, diseased)
what is the most sensitive method to pick up a pleural effusion?
CT scan
Is US ever used to detect pleural effusion? Why or why not?
Yes, because it can be done bedside in real time.
You have definitively dx’ed pleural effusion. Now how can you figure out what caused it?
Thoracentesis! (drain the effusion and send to lab)
When do you do a thoracentesis?
1) diagnose cause
2) symptom relief (evacuation)
Which labs MUST be ordered for every thoracentesis?
1) cell count w/ diff 2) pH 3) glucose 4) protein 5) LDH. Other tests can be ordered based on suspicion
What type of effusion forms by leakage of liquid across an intact
capillary barrier owing to increase in
hydrostatic pressure or reduced oncotic
pressure?
Transudate effusion
What type of effusion causes leakage of of liquid and protein across
altered capillary barrier with increased
permeability.
(Think inflammation)
exudate effusion
What are the 3 most common causes of transudate pleural effusion?
CHF, nephrotic syndrome, hepatic hydrothorax
what are the 4 most common causes of exudative pleural effusion?
INFECTION, malignancy, hemothorax, chylothorax
How would you treat a transudate effusion?
Treatment of underlying systemic process
Diuresis for CHF
Hemodialysis for uremia, volume overload
Liver transplant for Hepatic Hydrothorax
Decortication for trapped lung
“Never let the sun set on______________”? Meaning, what kind of effusion cannot wait to be treated?
Parapneumonic effusion (exudative)
There are 3 stages of parapneumonic effusion, simple, complicated and empyema. Which stage(s) can be treated with abx? Which stage(s) require chest tube drainage?
simple = abx
complicated and empyema = chest tube
what is the most common cause of exudative pleural effusions in patients older than 60?
malignant pleural effusions
What are some tx options for malignant pleural effusion?
1) Repeated thoracentesis (symptomatic tx)
2) Chest tube drainage and pleurodesis.
3) Pleurodesis with or w/o Thoracoscopy. (create scarring in the pleural space to limit spread of ca)
4) Small bore chest tube – destination device (Pleurex – catheter)
5) Palliative care
What is the diagnostic criteria for hemothorax?
Pleural fluid Hct: serum hct > 0.5
What condition results from blood accumulating in the pleural cavity?
Hemothorax
What should you do to treat hemothorax?
1) chest tube drainage
2) VATS
Rupture of thoracic duct causing leakage
into pleural space
causes chylothorax
How do you treat chylothorax?
chest tube drainage, surgical ligation of the thoracic duct, medium chain triglycerides?
when looking at a pleural effusion, what is the first things you should make note of?
How thick is the pleural effusion? <10mm can simply be observed
your patient has a pleural effusion, and known CHF. When would you do a thoracentesis?
if they were also experiencing chest pain, fever, or effusion is asymmetrical
Due to visceral pleural restriction, chronic
atelectasis, or endobronchial disease.
Lung Entrapment: visceral pleural restriction due to
active inflammation/infection or malignancy
Trapped lung: visceral pleural restriction with the
development of a fibrous pleural membrane in the
absence of active inflammation/infection or
malignancy.
unexpandable lung
If the parietal or visceral pleura is breached and the pleural space exposed to postive atmospheric pressure, air enters the pleural space and the lung collapses inward towards the mediastinum. this is called a ___________
pneumothorax
If you suspect______________, immediate decompression by transthoracic insertion of a needle attached to a syringe is indicated.
Waiting for radiographic confirmation may be fatal.
tension pneumothorax
There are 3 general causes for pneumothorax. What are they?
spontaneous, traumatic (penetrating or blunt injury), iatrogenic (needle aspiration, cath placement, etc)
if your pneumothorax is < 2cm in size, what will your treatment entail?
oxygen, observation
If your patient has recurrent pneumothorax, what would you do?
VATS (video assisted thorascopic surgery) to identify air leaks
What treatment would you use for a pneumothorax > 2cm?
Aspiration by needle or by small lumen catheter (least effective, may lacerate lung).
Insertion of a small chest tube or catheter attached to a one way flutter valve.
Insertion of a chest tube attached to water seal or suction drainage.
Traditional practice is to hospitalize pt for observation of complications or to insert a chest tube for 1-3 days or both.
Your patient has a pleural effusion that is thicker than 10mm, what is the next thing you should ask yourself?
Does my patient have CHF? (because if they have CHF, the pressure in the lungs is going to be high, and these patients often have pleural effusions)
What type of pleural effusion is caused by CHF!?! (and Nephrotic syndrome and cirrhosis)
Transudate effusion
Your patient has a pleural effusion that is thicker than 10mm and he has CHF, what do you do?
Diurese and observe for improvement (if no improvement after 3 days, do a thoracentesis)
your patient has a pleural effusion that is thicker than 10mm and he does NOT have CHF, what do you do?
Thoracentesis
Ok, you’ve got the results from your thoracentesis on your pleural effusion patient. There are 2 criteria that would allow you to conclude that the pleural effusion is an exudate effusion. Either criteria will allow you to draw this conclusion, you don’t need both. What are they?
1) Is the ratio of pleural fluid protein to serum protein > 0.5?
2) Is the ratio of pleural fluid LDH to serum LDH > 0.6? (or you could say–is the LDH of the pleural fluid more than 2/3rds the normal serum level?)
You’ve done a thoracentesis for pleural effusion. If neither of these criteria are met: 1) Is the ratio of pleural fluid protein to serum protein > 0.5?
2) Is the ratio of pleural fluid LDH to serum LDH > 0.6? (or you could say–is the LDH of the pleural fluid more than 2/3rds the normal serum level?)………..what is wrong with your patient? What should you do?
Patient has a transudate effusion. Treat underlying cause (most likely CHF, renal, liver dz) and provide palliation.
Ok, your pleural effusion patient has an exudate effusion. Now what?
order additional labs to narrow down differential, make sure to include TB and PE in said differential.
visceral pleural restriction DUE TO
active INFLAMMATION/INFECTION or MALIGNANCY
Lung entrapment
visceral pleural restriction with the
development of a fibrous pleural membrane in the
ABSENCE of active INFLAMMATION/INFECTION or
MALIGNANCY
Trapped lung
In a healthy person, where does the pleural fluid come from? Where does it go?
Normal pleural fluid flows from systemic
vessels feeding both pleura–>across leaky
membranes into the pleural space–>exits
via the parietal lymphatics
So what’s really happening on a pathopysiologic level, in patient’s with a pulmonary effusion?
Inflammation and/or obstruction is impairing the removal of the pleural fluid
What type of cancer is a malignancy of the pleura
mesothelioma
What is the biggest risk factor for developing mesothelioma?
asbestos exposure
What is the prognosis for mesothelioma? What is the general disease course?
Very poor, <3 years. Tumor eventually entraps the lung and spreads to mediastinal structures. Respiratory failure typically leads to death.
Are there any treatments aside from palliative care for mesothelioma patients?
Radical pneumonectomy (removal of entire lung and both visceral and parietal pleura) OR pleurodesis (sclerosing the pleural space to prevent accumulation of pleural fluid)
