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F2 E3 Shea > Pleural Disease 1 > Flashcards

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

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2
Q

Think of pleuritis as both ____ and ____.

A
  • Symptom
  • Disease
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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
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4
Q

What is the main cause of pleuritis?

A

Viral etiology

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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
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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!*
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7
Q

Treatment for pleuritis? (2)

A
  • NSAIDS (Naproxen)
  • Steroids (Prednisone) w/ taper
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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)
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9
Q

Is pleuritis more common in patients w/ Lupus (SLE) or Rheumatoid Arthritis?

A

SLE

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10
Q
  • 3 common signs of Rheumatoid Pleuritis
  • Tx?
A
  • Pleuritic CP
  • Fever
  • +/- dyspnea
  • Tx: NSAIDS (Naproxen)
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11
Q

What is the most common manifestation of pleural disease?

A

Pleural Effusion

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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
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13
Q
  • The pleural cavity is maintained by a balance of _____ and _____ pressures in the pleural capillaries.
  • And persistent lymphatic drainage.
A
  • Hydrostatic
  • Oncotic
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14
Q

What 8 mechanisms can cause a Pleural Effusion?

(MACH PICH)

A
  1. Malignancy
  2. Atelectasis
  3. Chylothorax
  4. Hepatic Hydrothorax
  5. PNA
  6. Inflammation
  7. CHF
  8. Hypo-albuminemia
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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)
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16
Q

What are the 2 types of pleural effusions?

A
  • Transudative
  • Exudative
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17
Q

3 common sxs of pleural effusion

A
  • Dyspnea
  • Cough
  • Pleuritic CP
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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)
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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
Q

When performing a thoracentesis, if the fluid is milky white what is this type?

Green / smelly?

A
  • Milky: Chylothorax
  • Green/Smelly: Empyema/Purulent
26
Q

1 reason for transudative effusion***

(ON EXAM)

A

Heart Failure

27
Q

Light’s Criteria is used to differentiate ____ vs _____.

A
  • Transudate
  • Exudate
28
Q

To be considered exudative effusion, one of what 3 things needs to be present?

A
  • 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
Q

Which type of effusion?

  • Results from systemic imbalances in hydrostatic and oncotic forces
A

Transudative Effusion

30
Q

Which type of effusion?

  • Local factors influence accumulation of pleural fluid are altered
  • Increased pleural capillary permeability leads to elevated protein/cellular content
A

Exudative Effusion

31
Q

3 most common causes of Exudative Effusions**

(ON EXAM)

A
  • Malignancy
  • Infectious
  • Pulmonary Embolus
32
Q

2 “additional fluid testing” that are most helpful/definitely should get

A
  • Pleural fluid culture
  • Pleural fluid cytology (to see if malignancy and is less invasive than biopsy)
33
Q

How would you treat “end stage malignancy” / “malignant pleural effusion?” (3)

A
  • 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
Q

Occurs w/o a precipitating event in a person w/o known lung disease

A

Primary Spontaneous Pneumothorax (PSP)

35
Q

Occurs as complication of an underlying lung disease

A

Secondary Spontaneous Pneumothorax (SSP)

36
Q
  • Occurs due to penetrating / blunt trauma
  • Iatrogenic (thoracentesis, biopsy, catheter placement)
A

Traumatic Pneumothorax

37
Q
  • Young healthy male who smokes
    • also due to familial or Marfans

(ON EXAM)

A

Primary Spontaneous Pneumothorax (PSP)

38
Q

Describe the presentation of a person w/ Spontaneous Pneumothorax.

(age/sex/sxs/pain)

A
  • Tall, thin, young men
  • Age 20-40
  • Dyspnea & Pleuritic CP
  • Unilateral sharp pain
  • Cough (sometimes = 10%)
39
Q

Physical exam findings of Spontaneous Pneumothorax

(2 special exam findings)

(Possibly on exam…)

A
  • 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
Q

What are the two 1st line diagnostic testing for Spontaneous Pneumothorax?

A
  • Chest x -ray (lateral decubitus is most sensitive)
  • CT chest
41
Q
  • 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?
A

Absence of “sliding lung sign”

42
Q

Tx of spontaneous pneumothorax

A
  • High flow oxygen (100% oxygen administration)
    • Reduces partial pressure of nitrogen in pleural capillaries
43
Q

Tx for spontaneous pneumos

  • Small?
  • Large?
  • Recurrent PSP?
  • Unstable pts?
A
  • Small: observe if stable / first PSP
  • Large: needle aspiration
  • Recurrent PSP: Chest tube insertion
  • Unstable*: Chest tube insertion (ALWAYS)**
44
Q

Additional (super important) tx of Spontaneous Pneumothorax

(ON EXAM)

A

Smoking Cessation

45
Q

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?
A
  • 2nd
  • Until resistance met / Pt starts coughing
  • Immediately after procedure / 4 to 24 hrs after
46
Q

What procedure would you do for pneumothorax if:

  • no response to needle asp
  • SSP
  • Recurrence
  • Hemothorax
A

Chest Tube (connected to water seal device)

47
Q

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
A

Video Assisted ThoracoScopy (VATS) / Pleurodesis

F2 E3 Shea (16 decks)

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