Pleural Cavity Disorders Flashcards
1
Q
Define pneumothorax
A
Accumulation of air in pleural space that leads to partial or complete collapse of lung
2
Q
How is at an increased risk of pneumothorax?
A
- Tall thin males between10-30 yr are at ↑ risk
- (+) FH
- M > F
- Smoker
3
Q
What are the causes of pneumothorax?
A
- Spontaneous-most common
- Rupture of subpleural blebs of lung
A. Blebs or bullae are thin walled balloon-like extensions of air sacs
4
Q
What is the most common cause of pneumo?
A
Spontaneous
5
Q
How are blebs and bullae differentiated?
A
- 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
6
Q
What is primary spontanous pneumo caused by?
A
Etiology unknown
7
Q
What is secondary spontaneous pneumo caused by?
A
COPD Asthma CF TB Pertussis Interstitial lung diseases
8
Q
What is traumatic pneumo caused by?
A
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
9
Q
Define tension pneumo
A
- Lung collapse forced by excessive pressure
2. Usually assoc w/ traumatic event
10
Q
What is the pathophys of an open or closed pneumo?
A
- Rupture in visceral or parietal pleura & chest wall
- Visceral & parietal pleura separate
- Lung recoils by collapsing toward hilum
11
Q
What is the pathophys of a tension pneumo?
A
- 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
12
Q
What are the sxs of a pneumo?
A
- Acute onset chest pain & dyspnea
- Unilateral chest expansion
- ↓ tactile fremitus
- Hyper-resonant lung
- ↓ or absent breath sounds in lung field
13
Q
What are the sxs of a tension pneumo?
A
- Acute onset chest pain & dyspnea
- Unilateral chest expansion
- ↓ tactile fremitus
- Hyper-resonant lung
- ↓ or absent breath sounds in lung field
- Hypotension
- ↓ cardiac output
- Tachycardia
14
Q
What is the study that diagnoses pneumo? What are the results?
A
- 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
15
Q
What is the general treatment for pneumo?
A
- 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
16
Q
How is a small pneumo treated?
A
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
17
Q
How is a moderate to large pneumo treated?
A
- O2 as above
- Chest tube insertion
- Needle aspiration (primary spontaneous pneumo)
- 1-way Heimlich valve insertion (> 48 hr → wall suction)
18
Q
How is a tension pneumo treated?
A
- Medical Emergency!
A. Insert large bore needle STAT, then chest tube placement w/continuous wall suction
19
Q
When is a one-way heimlich valve used?
A
- Used for stable ambulatory pt.
2. Used for persistent air leak after chest tube
20
Q
What is the prognosis for pneumo?
A
- Approximately 70% recover without recurrence
2. 30% of patients with spontaneous pneumothorax experience recurrence of disorder after first episode
21
Q
What is chemical pleurodesis?
A
- 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
22
Q
When is a chemical pleurodesis indicated?
A
- Repeated pneumothoraces , not good candidates for surgery
- Severe recurrent pleural effusions
23
Q
Define pleural effusion
A
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
24
Q
What is the normal pleural physiology?
A
- 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
25
What are the 4 types of pleural effusions?
Transudate
Exudate
Empyema
Hemothorax
26
Define transudate pleural effusion
Excessive hydrostatic pressure or decreased colloid osmotic pressure can cause excess fluid to pass across intact capillaries
27
What is the characteristic finding in transudate pleural effusion?
Low protein fluid
28
What are the causes of transudate pleural effusion?
1. CHF (most common)
2. Hepatic disease w/ ascites
3. Hypoalbuminemia
29
What are the characteristics of exudate pleural effusion?
1. Results from increased capillary permeability
2. May or may not have asst hydrostatic or colloid osmotic pressure changes
3. High protein fluid
30
What are the causes of exudate pleural effusion?
1. Malignancy
2. Bacterial pneumonia
3. TB
4. Asbestosis
5. Sarcoidosis
6. Collagen disease
7. SLE
31
Define Empyema
1. Infection in the pleural space
| 2. Pus in pleural space
32
What are the causes of empyema?
1. Pneumonia (70%)
2. Carcinoma
3. Lung abscess
4. Iatrogenic (20%)
A. Chest surgery
B. Thoracentesis
33
Define Hemothorax
Bleeding into the pleural space
34
What are causes of hemothorax?
Chest trauma
Malignancy
Iatrogenic
35
What are the sxs of a small PE?
1. Pleuritic pain (pleurisy)
| 2. Pleural friction rub
36
What are the sxs of a large or bilateral PE?
1. Dyspnea
2. Orthopnea (asst with CHF effusion)
3. Dullness to percussion
4. ↓ breath sounds
5. Mediastinum may be shifted away from side of effusion
37
What are the CXR results in PE?
1. Blunting of costophrenic angle
2. Loss of sharp demarcation of diaphragm and heart
3. Mediastinal shift to uninvolved side
38
What are the lateral decubitus xray results in PE?
1. Identify small effusions
| 2. Differentiate free flowing vs. loculated fluid
39
When is a CT chest indicated in PE?
Small effusions
| R/O tumor
40
What is the gold standard for diagnosing the type of fluid present in a PE?
Thoracentesis
41
How is the PE fluid analyzed?
```
Fluid analysis:
WBC & differential count
Glucose
Cytology
Gram stain/ C&S
Protein
LDH
pH
```
42
What are the characteristics of transudative fluid?
1. Color: clear
2. Consistency: thin and watery
3. pH: Alkaline
4. Glucose: normal
5. LDH: <3 gm/dl
7. Cell Count: low, no or few WBCs & RBCs
8. Bacteria: None
43
What are the characteristics of Exudative fluid?
1. Color: cloudy, white
2. Consistency: thick and creamy, contains tissue fragments
3. pH: Acid
4. Glucose: Low
5. LDH: >200 IU
6. Protein: High, >4gm/dl
7. Cell Count: High, many WBCs & RBCs
8. Bacteria: May be present
44
What is the treatment for exudate effusions?
1. Treat underlying problem
2. Pleurodesis if recurrent
3. Pneumonia
A. Thoracentesis
B. Antibiotics
45
What is the treatment for transudate effusions?
1. Thoracentesis
| 2. Treat underlying problem
46
What is the treatment for empyema effusions?
1. Thoracentesis
| 2. Antibiotics
47
What is the treatment for hemothorax effusions?
Thoracentesis
48
What is the treatment for pneumonia effusions?
1. Thoracentesis
| 2. Empiric TB protocol until Cx results
49
What is the treatment for malignant effusions?
1. Thoracentesis, prn
2. Chemo
3. Radiation Tx
4. +/- surgery
