pleural disease Flashcards
pleural effusion
-5–15 mL of fluid is normal in pleural space
-Pleural effusion:
-Abnormal accumulation of fluid in the pleural space
pleural pn: 4 pathophysiologic processes
-1. Transudates:
-Increased fluid in the setting of NORMAL capillaries due to INCREASED hydrostatic or DECREASED oncotic pressures
-fluid overload
-2. Exudates:
-Increased fluid due to ABNORMAL capillary permeability
-DECREASED lymphatic clearance of fluid from pleural space
-Empyema: INFECTION in pleural space, pus
-Hemothorax: BLEEDING into pleural space
transudate causes
-CHF (>90%) -> bilateral*
-Cirrhosis w/ascites- low protein
-Nephrotic Syndrome- low protein
-Peritoneal Dialysis
-Acute atelectasis
-Constrictive pericarditis
-PE
-Superior vena cava obs
exudate causes
-infection or cancer
-Pn*
-Ca*
-PE
-Bacterial, viral, fungal, parasitic
-Post MI
-Chronic atelectasis
-Asbestos
-Sarcoid-rare
signs and symptoms
-Dyspnea, cough, or chest pain- Small less symptomatic
-Physical findings:
-Small: none
-Larger: dullness to percussion, diminished or absent breath sounds over effusion, increase tactile fremitus
-Massive: may have contralateral shift of trachea and bulging of the intercostal spaces
labs
-Diagnostic Thoracentesis: gold standard
-Indications: new pleural effusion and no clinically apparent cause
-1. Visualization of fluid
-2. Send to lab:
-Cell count and cell differential, pH, protein, LDH, glucose -> determines Transudate vs exudate
-Additional tests in selected patients: amylase, cholesterol, triglycerides, N-terminal pro-brain natriuretic peptide (NT-proBNP), creatinine, adenosine deaminase (ADA), gram and acid-fast bacillus (AFB) stain, bacterial and AFB culture, and cytology
pleural fluid analysis
hemorrhagic
mixture of blood and pleural fluid
10,000 rbc/ml to create blood-tinged fluid (dont need to know numbers)
-blood tinged
hemothorax
-gross blood in pleural space
-100,000 rbc /ml create grossly bloody pleural fluid
-Defined as a ratio of pleural fluid hematocrit to peripheral blood hematocrit > 0.5
-gross appearance:
-straw colored
-blood stained
-purulent
-chylous
exudate lights criteria rule***
-Effusion that has ONE OR MORE of the following is exudate:
-Pleural fluid protein/serum protein ratio > 0.5, or
-Pleural fluid LDH/serum LDH ratio > 0.6, or
-Pleural fluid LDH greater than two-thirds the upper limits of the laboratory’s normal serum LDH
transudates
-Transudates have NONE of mentioned exudate features/criteria
-Occur in setting of normal capillary integrity and suggest ABSENCE of local pleural disease
-Distinguishing laboratory findings include:
-Glucose=serum glucose -> normal (low in exudate bc its using the energy)
-pH between 7.40 -7.55 (nl 7.6)
-< 1,000 wbc/mcL with a predominance of mononuclear cells
other features of pleural fluid
-Pleural fluid pH is useful in the assessment of parapneumonic effusions
-A pH below 7.30 -> drain
-Elevated pleural amylase:
-Pancreatitis, pancreatic pseudocyst
-Adenocarcinoma of pancreas
-Esophageal rupture
-Cytology
imaging
-Standard upright CXR:
-75–200 mL to be visible in costophrenic angle
-May become loculated by pleural adhesions:
-Round/oval fluid collections in fissures resembling intraparenchymal masses (pseudotumors)
-Chest CT scans: May identify as little as 15 mL of fluid
transudative treatment
-Transudative pleural effusions:
-Treat underlying condition - will just fill again if not
-Therapeutic thoracentesis for significant dyspnea
-Often transient effect:
-Repeat again and reassess dx
-Refractory:
-Pleurodesis- irritant into the space- obliterates the space so no fluid can fill
-Indwelling pleural catheter- drain at home
exudate treatment
-Malignant Pleural Effusion:
-Most common: lung and breast cancer
-Variety of Mechanisms
-Local treatment:
-Drainage: repeated thoracentesis or chest tube
-Long-term if needed:
-Pleurodesis
-Indwelling pleural catheter (eg, Pleurex) for home drainage
parapneumonic pleural effusion
-Exudates accompany approximately 40% of bacterial pneumonias.
-Divided into 3 categories:
-Simple or uncomplicated
-Complicated
-Empyema
uncomplicated parapneumonic effusions
-Free-flowing sterile exudates of modest size that resolve quickly with antibiotic treatment of pneumonia
-Do not need drainage
empyema
-Gross infection of pleural space indicated by positive Gram stain or culture
-Empyema should always be drained + antibiotics
complicated parapneumonic effusions
-Difficult management decisions
-Larger than simple parapneumonic effusions and show more evidence of inflammatory stimuli
-> Low glucose level, low pH, or evidence of loculation
-Tube thoracostomy if glu is < 60 mg/dL or pH is < 7.3
-clinical decision based on provider
empyema or complicated parapneumonic effusions drainage complications
-frequently complicated by loculation
-Intrapleural injection of fibrinolytic agents:
-Streptokinase, 250,000 units
-Urokinase, 100,000 units
-break up the loculation
hemothorax tx
-Small-volume hemothorax that is stable or improving on cxr may be managed by close observation
-In all other cases: immediate insertion of a large-bore thoracostomy tube
-Controls hemorrhage
-Removes clot
-Treats complications
-drained
pneumothorax
-Classified as spontaneous (primary or secondary) or traumatic
-Non-Traumatic Spontaneous pneumothorax:
-Primary: Occurs in absence of underlying lung disease
-Secondary: Complication of preexisting pulmonary disease (COPD bulla)
-Traumatic pneumothorax:
-Results from penetrating or blunt trauma
-Includes iatrogenic
primary pneumothorax causes
-tall, thin boys -> blebs
-drug use
-increased transpilmonary pressure -> valsava maneuver, diving, military, flying
secondary pneumothorax causes
-cystic fibrosis
-COPD
-asthma
-TB- infection
-PCP
-necrotizing pneumonia
-congenital
-sarcoidosis
-interstitial lung disease
-connective tissue inflammatory disease- marfan, ehlers-danlos
tension pneumothorax
-A check-valve mechanism allows air to enter the pleural space on inspiration and prevents egress of air on expiration
-can breath in, but not out -> pressure builds
pneumothorax signs and symptoms
-Sudden onset of dyspnea and pleuritic cp
-Chest pain: minimal to severe on affected side
-May present with life-threatening respiratory failure
-Small pneumothorax (<15% of a hemithorax): Mild tachycardia
-Large pneumothorax:
-Diminished breath sounds
-Decreased tactile fremitus, hyperresonance
-Decreased movement of chest on affected side
-Tension pneumothorax:
-Marked tachycardia, hypotension, labored breathing and mediastinal or tracheal shift
pneumothorax labs
-Arterial blood gas analysis: Reveals hypoxemia and acute respiratory alkalosis (hyperventilation)
-EKG- Left-sided primary pneumothorax may produce QRS, axis and precordial T wave changes misinterpreted as acute myocardial infarction
pneumothorax imaging
-CXR:
-Demonstration of a visceral pleural line is diagnostic
-In supine patients, abnormally radiolucent costophrenic sulcus (the “deep sulcus” sign)
-Tension pneumothorax:
-Large amount of air in the affected hemithorax and contralateral shift of the mediastinum
-ultrasound:
-no lung sliding
pneumothorax diff dx
-Emphysematous bleb
-Myocardial infarction
-Pulmonary embolization
-Pneumonia
pneumothorax complications
-Tension pneomothorax: life threatening
-Pneumomediastinum
-Subcutaneous emphysema
pneumothorax tx
-Treatment: severity and underlying disease
-Spontaneous primary pneumothorax:
-Small (< 15% of a hemithorax) in reliable stable patient:
-Observation alone may be appropriate
-Many resolve spontaneously
-Supplemental oxygen therapy
spontaneous primary pneumothorax tx
-Spontaneous primary pneumothoraces that are large or progressive:
-Needle decompression with a small-bore catheter
-Small-bore chest tube
-Treated symptomatically for cough and chest pain
-Serial chest radiographs every 24 hours
secondary pneumothorax, large pneumothorax, tension pneumothorax, severe symptoms or those who have a pneumothorax on mechanical ventilation TREATMENT
needle decompression and large chest tube
thoracoscopy or open thoracotomy
-Recurrences
-Bilateral pneumothorax
-Failure of tube thoracostomy for the first episode (failure of lung to reexpand or persistent air leak)
-Surgery permits resection of blebs responsible for the pneumothorax and pleurodesis
pneumothorax prognosis
-Recurrence:
-30% with spontaneous pneumothorax
-50% Smokers
-Avoid:
-High altitudes
-Flying in unpressurized aircrafts
-Scuba diving
