Pleural Cavity Disorders Flashcards
Define pneumothorax
Accumulation of air in pleural space that leads to partial or complete collapse of lung
How is at an increased risk of pneumothorax?
- Tall thin males between10-30 yr are at ↑ risk
- (+) FH
- M > F
- Smoker
What are the causes of pneumothorax?
- Spontaneous-most common
- Rupture of subpleural blebs of lung
A. Blebs or bullae are thin walled balloon-like extensions of air sacs
What is the most common cause of pneumo?
Spontaneous
How are blebs and bullae differentiated?
- Blebs areblister-like air pockets that form on the surface of the lung
A. 1-2 cm - Bullae are air-filled cavities within the lung tissue
A. > 2 cm
What is primary spontanous pneumo caused by?
Etiology unknown
What is secondary spontaneous pneumo caused by?
COPD Asthma CF TB Pertussis Interstitial lung diseases
What is traumatic pneumo caused by?
1. Traumatic A. Blunt chest injury B. Penetrating chest injury C. Iatrogenic -Mechanical ventilation - Puncture of lung - Needle aspiration lung Bx - Thoracentesis - Central line placement
Define tension pneumo
- Lung collapse forced by excessive pressure
2. Usually assoc w/ traumatic event
What is the pathophys of an open or closed pneumo?
- Rupture in visceral or parietal pleura & chest wall
- Visceral & parietal pleura separate
- Lung recoils by collapsing toward hilum
What is the pathophys of a tension pneumo?
- Air enters pleural space from site of pleural rupture but is unable to escape since rupture site closes on inspiration
- Increased air pressure pushes on mediastinum compresses and displaces heart and great vessels
- Decreases venous return & cardiac output, leading to hypotension
What are the sxs of a pneumo?
- Acute onset chest pain & dyspnea
- Unilateral chest expansion
- ↓ tactile fremitus
- Hyper-resonant lung
- ↓ or absent breath sounds in lung field
What are the sxs of a tension pneumo?
- Acute onset chest pain & dyspnea
- Unilateral chest expansion
- ↓ tactile fremitus
- Hyper-resonant lung
- ↓ or absent breath sounds in lung field
- Hypotension
- ↓ cardiac output
- Tachycardia
What is the study that diagnoses pneumo? What are the results?
- CXR
- Visceral pleural line is evident and diagnostic
A. may only be seen on an expiratory film - Tension pneumothorax
A. Mediastinal or tracheal shift to contralateral side
What is the general treatment for pneumo?
- Observation w/out oxygen
- Observation w/oxygen
- Simple aspiration
- Chest tube placement
A. One-way valve insertion (portable system)
B. Thoracostomy with continuous wall suction
-First-time secondary spontaneous pneumothorax (SPS) (including chronic obstructive pulmonary disease [COPD])
-Traumatic pneumothorax
How is a small pneumo treated?
1. Small (< 15%) pneumothorax A. Pt stable, may observe B. Usually resolves spontaneously C. O2 via NC @ ≥ 3L/min → 4-fold increase in the rate of pleural air absorption compared with room air alone D. Close F/U
How is a moderate to large pneumo treated?
- O2 as above
- Chest tube insertion
- Needle aspiration (primary spontaneous pneumo)
- 1-way Heimlich valve insertion (> 48 hr → wall suction)
How is a tension pneumo treated?
- Medical Emergency!
A. Insert large bore needle STAT, then chest tube placement w/continuous wall suction
When is a one-way heimlich valve used?
- Used for stable ambulatory pt.
2. Used for persistent air leak after chest tube
What is the prognosis for pneumo?
- Approximately 70% recover without recurrence
2. 30% of patients with spontaneous pneumothorax experience recurrence of disorder after first episode
What is chemical pleurodesis?
- Procedure that artificially obliterates pleural space
- Irritant (talc, minocycline, etc.) instilled inside the pleural space via chest tube to create inflammation that tacks the two pleura together permanently
- Pre-medicate for pain
When is a chemical pleurodesis indicated?
- Repeated pneumothoraces , not good candidates for surgery
- Severe recurrent pleural effusions
Define pleural effusion
Excess of fluid in pleural space
Normally this space contains a small amount of extracellular fluid that lubricates the pleural surfaces
Increased production or inadequate removal
What is the normal pleural physiology?
- Balanced osmotic and hydrostatic pressures in parietal pleural capillaries normally result in movement of fluid into pleural space
- Balanced pressures in visceral pleural capillaries promote reabsorption of this fluid
What are the 4 types of pleural effusions?
Transudate
Exudate
Empyema
Hemothorax
Define transudate pleural effusion
Excessive hydrostatic pressure or decreased colloid osmotic pressure can cause excess fluid to pass across intact capillaries
What is the characteristic finding in transudate pleural effusion?
Low protein fluid
What are the causes of transudate pleural effusion?
- CHF (most common)
- Hepatic disease w/ ascites
- Hypoalbuminemia
What are the characteristics of exudate pleural effusion?
- Results from increased capillary permeability
- May or may not have asst hydrostatic or colloid osmotic pressure changes
- High protein fluid
What are the causes of exudate pleural effusion?
- Malignancy
- Bacterial pneumonia
- TB
- Asbestosis
- Sarcoidosis
- Collagen disease
- SLE
Define Empyema
- Infection in the pleural space
2. Pus in pleural space
What are the causes of empyema?
- Pneumonia (70%)
- Carcinoma
- Lung abscess
- Iatrogenic (20%)
A. Chest surgery
B. Thoracentesis
Define Hemothorax
Bleeding into the pleural space
What are causes of hemothorax?
Chest trauma
Malignancy
Iatrogenic
What are the sxs of a small PE?
- Pleuritic pain (pleurisy)
2. Pleural friction rub
What are the sxs of a large or bilateral PE?
- Dyspnea
- Orthopnea (asst with CHF effusion)
- Dullness to percussion
- ↓ breath sounds
- Mediastinum may be shifted away from side of effusion
What are the CXR results in PE?
- Blunting of costophrenic angle
- Loss of sharp demarcation of diaphragm and heart
- Mediastinal shift to uninvolved side
What are the lateral decubitus xray results in PE?
- Identify small effusions
2. Differentiate free flowing vs. loculated fluid
When is a CT chest indicated in PE?
Small effusions
R/O tumor
What is the gold standard for diagnosing the type of fluid present in a PE?
Thoracentesis
How is the PE fluid analyzed?
Fluid analysis: WBC & differential count Glucose Cytology Gram stain/ C&S Protein LDH pH
What are the characteristics of transudative fluid?
- Color: clear
- Consistency: thin and watery
- pH: Alkaline
- Glucose: normal
- LDH: <3 gm/dl
- Cell Count: low, no or few WBCs & RBCs
- Bacteria: None
What are the characteristics of Exudative fluid?
- Color: cloudy, white
- Consistency: thick and creamy, contains tissue fragments
- pH: Acid
- Glucose: Low
- LDH: >200 IU
- Protein: High, >4gm/dl
- Cell Count: High, many WBCs & RBCs
- Bacteria: May be present
What is the treatment for exudate effusions?
- Treat underlying problem
- Pleurodesis if recurrent
- Pneumonia
A. Thoracentesis
B. Antibiotics
What is the treatment for transudate effusions?
- Thoracentesis
2. Treat underlying problem
What is the treatment for empyema effusions?
- Thoracentesis
2. Antibiotics
What is the treatment for hemothorax effusions?
Thoracentesis
What is the treatment for pneumonia effusions?
- Thoracentesis
2. Empiric TB protocol until Cx results
What is the treatment for malignant effusions?
- Thoracentesis, prn
- Chemo
- Radiation Tx
- +/- surgery
