Pleural Disease 1 Flashcards
Inflammation or Irritation of the pleura. The two layers rub together –> producing pain w/ inhalation and exhalation
Pleuritis / Pleurisy
Think of pleuritis as both ____ and ____.
- Symptom
- Disease
Pleuritic pain can be hard to distinguish from other types of CPs. So, what must we do?**
Keep WIDE differential diagnosis.
- cardiac
- esophageal
- pulmonary
- musculoskeletal
What is the main cause of pleuritis?
Viral etiology
- Character of pleuritic pain?
- PE of pleuritis?
- Sharp CP, aggravated by breathing, coughing, sneezing (may radiate to shoulders/back)
- Pleural friction rub (may be transient), *sounds like wet rubber
How do you work up pleuritis?
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!*
Treatment for pleuritis? (2)
- NSAIDS (Naproxen)
- Steroids (Prednisone) w/ taper
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??
- Lupus (SLE)
- Must r/o infection w/ serologic testing
- Tx w/ NSAIDS (Naproxen)
Is pleuritis more common in patients w/ Lupus (SLE) or Rheumatoid Arthritis?
SLE
- 3 common signs of Rheumatoid Pleuritis
- Tx?
- Pleuritic CP
- Fever
- +/- dyspnea
- Tx: NSAIDS (Naproxen)
What is the most common manifestation of pleural disease?
Pleural Effusion
Abnormal fluid collection in the pleural space (between parietal/visceral pleura) as a result of what 2 things?
- Excess fluid production (more than 5-15ml)
- Decreased lymphatic absorption
- The pleural cavity is maintained by a balance of _____ and _____ pressures in the pleural capillaries.
- And persistent lymphatic drainage.
- Hydrostatic
- Oncotic
What 8 mechanisms can cause a Pleural Effusion?
(MACH PICH)
- Malignancy
- Atelectasis
- Chylothorax
- Hepatic Hydrothorax
- PNA
- Inflammation
- CHF
- Hypo-albuminemia
***There are over 50 things which can cause pleural effusions. What are the top 4?***
(ON EXAM)
- CHF
- PNA
- Malignancy
- PE (pulmonary embolism)
What are the 2 types of pleural effusions?
- Transudative
- Exudative
3 common sxs of pleural effusion
- Dyspnea
- Cough
- Pleuritic CP
4 common physical exam findings of pleural effusion
- Dullness to percussion
- Decreased/Absent tactile fremitus
- Decreased breath sounds
- No voice transmission (egophony)
How do you dx Pleural Effusion?
Chest x-ray (PA and Lateral)
What are 2 x-ray findings suggestive of pleural effusion?***
(ON EXAM)
- Pleural fluid causes blunting of costophrenic angle
- Meniscus is formed laterally
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)
50 cc
Besides a chest x-ray, what are 4 other ways to dx Pleural Effusion?
- CT chest or US (these are more sensitive than x-ray)
- Thoracentesis (US guided, fluid analysis)
- Pleural Biopsy
What dx test would you order to r/o PE if suspicion is high?
CT angiogram
- Where do you insert the needle when performing a thoracentesis?
- Pt in what position?
- ABOVE the rib to avoid hitting the neurovascular bundle (VAN)
- Seated upright, leaning on table
When performing a thoracentesis, if the fluid is milky white what is this type?
Green / smelly?
- Milky: Chylothorax
- Green/Smelly: Empyema/Purulent
1 reason for transudative effusion***
(ON EXAM)
Heart Failure
Light’s Criteria is used to differentiate ____ vs _____.
- Transudate
- Exudate
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
Which type of effusion?
- Results from systemic imbalances in hydrostatic and oncotic forces
Transudative Effusion
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
3 most common causes of Exudative Effusions**
(ON EXAM)
- Malignancy
- Infectious
- Pulmonary Embolus
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)
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
Occurs w/o a precipitating event in a person w/o known lung disease
Primary Spontaneous Pneumothorax (PSP)
Occurs as complication of an underlying lung disease
Secondary Spontaneous Pneumothorax (SSP)
- Occurs due to penetrating / blunt trauma
- Iatrogenic (thoracentesis, biopsy, catheter placement)
Traumatic Pneumothorax
- Young healthy male who smokes
- also due to familial or Marfans
(ON EXAM)
Primary Spontaneous Pneumothorax (PSP)
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%)
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)
What are the two 1st line diagnostic testing for Spontaneous Pneumothorax?
- Chest x -ray (lateral decubitus is most sensitive)
- CT chest
- 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”
Tx of spontaneous pneumothorax
-
High flow oxygen (100% oxygen administration)
- Reduces partial pressure of nitrogen in pleural capillaries
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)**
Additional (super important) tx of Spontaneous Pneumothorax
(ON EXAM)
Smoking Cessation
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
What procedure would you do for pneumothorax if:
- no response to needle asp
- SSP
- Recurrence
- Hemothorax
Chest Tube (connected to water seal device)
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
