Pleural Disease 1 Flashcards
1
Q
Inflammation or Irritation of the pleura. The two layers rub together –> producing pain w/ inhalation and exhalation
A
Pleuritis / Pleurisy
2
Q
Think of pleuritis as both ____ and ____.
A
- Symptom
- Disease
3
Q
Pleuritic pain can be hard to distinguish from other types of CPs. So, what must we do?**
A
Keep WIDE differential diagnosis.
- cardiac
- esophageal
- pulmonary
- musculoskeletal
4
Q
What is the main cause of pleuritis?
A
Viral etiology
5
Q
- Character of pleuritic pain?
- PE of pleuritis?
A
- Sharp CP, aggravated by breathing, coughing, sneezing (may radiate to shoulders/back)
- Pleural friction rub (may be transient), *sounds like wet rubber
6
Q
How do you work up pleuritis?
A
The work up will depend on underlying sxs:
- CXR to r/o PNA, pleural effusion, mass
- CTA chest to r/o PE
- Serologic to r/o rheum, infection, sickle cell
- Always go back to differential dx to r/o other causes of CP!*
7
Q
Treatment for pleuritis? (2)
A
- NSAIDS (Naproxen)
- Steroids (Prednisone) w/ taper
8
Q
Which disease?
- Pleurisy can be 1st sign
- Involvement of lung, pleura, & pulm vasculature is common
- USUALLY manifests as pleuritic CP +/- pleural effusion
- EXUDATIVE effusion
- Must r/o what??
- Tx with what??
A
- Lupus (SLE)
- Must r/o infection w/ serologic testing
- Tx w/ NSAIDS (Naproxen)
9
Q
Is pleuritis more common in patients w/ Lupus (SLE) or Rheumatoid Arthritis?
A
SLE
10
Q
- 3 common signs of Rheumatoid Pleuritis
- Tx?
A
- Pleuritic CP
- Fever
- +/- dyspnea
- Tx: NSAIDS (Naproxen)
11
Q
What is the most common manifestation of pleural disease?
A
Pleural Effusion
12
Q
Abnormal fluid collection in the pleural space (between parietal/visceral pleura) as a result of what 2 things?
A
- Excess fluid production (more than 5-15ml)
- Decreased lymphatic absorption
13
Q
- The pleural cavity is maintained by a balance of _____ and _____ pressures in the pleural capillaries.
- And persistent lymphatic drainage.
A
- Hydrostatic
- Oncotic
14
Q
What 8 mechanisms can cause a Pleural Effusion?
(MACH PICH)
A
- Malignancy
- Atelectasis
- Chylothorax
- Hepatic Hydrothorax
- PNA
- Inflammation
- CHF
- Hypo-albuminemia
15
Q
***There are over 50 things which can cause pleural effusions. What are the top 4?***
(ON EXAM)
A
- CHF
- PNA
- Malignancy
- PE (pulmonary embolism)
16
Q
What are the 2 types of pleural effusions?
A
- Transudative
- Exudative
17
Q
3 common sxs of pleural effusion
A
- Dyspnea
- Cough
- Pleuritic CP
18
Q
4 common physical exam findings of pleural effusion
A
- Dullness to percussion
- Decreased/Absent tactile fremitus
- Decreased breath sounds
- No voice transmission (egophony)
19
Q
How do you dx Pleural Effusion?
A
Chest x-ray (PA and Lateral)
20
Q
What are 2 x-ray findings suggestive of pleural effusion?***
(ON EXAM)
A
- Pleural fluid causes blunting of costophrenic angle
- Meniscus is formed laterally
21
Q
A chest x-ray in LATERAL DECUBITUS view can detect as little as ___ cc of fluid.
(lateral decub is more sensitive than PA)
(ON EXAM)
A
50 cc
22
Q
Besides a chest x-ray, what are 4 other ways to dx Pleural Effusion?
A
- CT chest or US (these are more sensitive than x-ray)
- Thoracentesis (US guided, fluid analysis)
- Pleural Biopsy
23
Q
What dx test would you order to r/o PE if suspicion is high?
A
CT angiogram
24
Q
- Where do you insert the needle when performing a thoracentesis?
- Pt in what position?
A
- ABOVE the rib to avoid hitting the neurovascular bundle (VAN)
- Seated upright, leaning on table
25
When performing a thoracentesis, if the fluid is milky white what is this type?
Green / smelly?
* **Milky:** Chylothorax
* **Green/Smelly:** Empyema/Purulent
26
#1 reason for transudative effusion\*\*\*
_(ON EXAM)_
Heart Failure
27
Light's Criteria is used to differentiate ____ vs \_\_\_\_\_.
* Transudate
* Exudate
28
To be considered exudative effusion, one of _what 3 things_ needs to be present?
* Ratio of pleural fluid : serum **protein** is greater than 0.5
* Ratio of pleural fluid lactate dehydrogenase **(LDH)** : serum LDH is greater than 0.6
* Pleural fluid LDH level is greater than 2/3 of upper limit of normal for serum LDH
29
**Which type of effusion?**
* Results from systemic imbalances in hydrostatic and oncotic forces
Transudative Effusion
30
**Which type of effusion?**
* Local factors influence accumulation of pleural fluid are altered
* Increased pleural capillary permeability leads to elevated protein/cellular content
Exudative Effusion
31
3 most common causes of Exudative Effusions\*\*
_(ON EXAM)_
* Malignancy
* Infectious
* Pulmonary Embolus
32
2 "additional fluid testing" that are most helpful/definitely should get
* Pleural fluid culture
* Pleural fluid cytology (to see if malignancy and is less invasive than biopsy)
33
How would you treat "end stage malignancy" / "malignant pleural effusion?" (3)
* **PleurX catheter** (refractory effusions)
* It is a port under the skin so that pt can do their own thoracentesis at home
* **PRN thoracentesis**
* **Pleurodesis**
34
Occurs w/o a precipitating event in a person w/o known lung disease
Primary Spontaneous Pneumothorax (PSP)
35
Occurs as complication of an underlying lung disease
Secondary Spontaneous Pneumothorax (SSP)
36
* Occurs due to penetrating / blunt trauma
* Iatrogenic (thoracentesis, biopsy, catheter placement)
Traumatic Pneumothorax
37
* Young healthy male who smokes
* also due to familial or Marfans
_(ON EXAM)_
Primary Spontaneous Pneumothorax (PSP)
38
Describe the presentation of a person w/ Spontaneous Pneumothorax.
(age/sex/sxs/pain)
* Tall, thin, young men
* Age 20-40
* Dyspnea & Pleuritic CP
* Unilateral sharp pain
* Cough (sometimes = 10%)
39
Physical exam findings of Spontaneous Pneumothorax
(2 special exam findings)
_(Possibly on exam...)_
* Tachycardia
* Hypotension
* Decreased chest expansion
* Diminished breath sounds
* **Hyperresonant percussions**
* Labored breathing
* **Subcutaneous emphysema** (crunchy feeling, sounds like "snap, crackle, pop" rice crispies/pop rocks)
40
What are the two 1st line diagnostic testing for Spontaneous Pneumothorax?
* Chest x -ray (lateral decubitus is most sensitive)
* CT chest
41
* US has a sensitivity of 91% for Spontaneous Pneumothorax
* Is used when dx is needed EMERGENTLY at bedside
* What is a significant finding on US?
Absence of "sliding lung sign"
42
Tx of spontaneous pneumothorax
* **High flow oxygen** (100% oxygen administration)
* Reduces partial pressure of nitrogen in pleural capillaries
43
**Tx for spontaneous pneumos**
* Small?
* Large?
* Recurrent PSP?
* Unstable pts?
* **Small:** observe if stable / first PSP
* **Large:** needle aspiration
* **Recurrent PSP:** Chest tube insertion
* **Unstable\*:** Chest tube insertion (ALWAYS)\*\*
44
Additional (super important) tx of Spontaneous Pneumothorax
_(ON EXAM)_
Smoking Cessation
45
**Needle Aspiration**
* Needle is inserted in __ intercostal space in midclavicular line
* Catheter left in place, 3 way stopcock/large syringe attached
* Air is aspirated until when?
* Repeat CXR how many times?
* 2nd
* Until resistance met / Pt starts coughing
* Immediately after procedure / 4 to 24 hrs after
46
**What procedure would you do for pneumothorax if:**
* no response to needle asp
* SSP
* Recurrence
* Hemothorax
Chest Tube (connected to water seal device)
47
**What procedure is indicated for pneumo if:**
* Persistent air leak
* Recurrence
* Chest Tube required on 1st occurrence
* If pt is a pilot (recurrence could cause him to crash plane)
* Bleb/Bullae resection
Video Assisted ThoracoScopy (VATS) / Pleurodesis
