Pleural disease Flashcards
1) Define pleural effusion
2) Define pneumothorax
1) Abnormal collection of fluid in pleural space
2) Abnormal collection of air in the pleural space
Abnormal accumulation of fluid in the pleural space may be visible where?
At the costophrenic angles
What are the 2 types of pleural effusion?
1) Transudate
2) Exudate
1) What is the mechanism by the release of transudate?
2) What is the #1 cause?
3) What are other causes?
1) imbalance in hydrostatic & oncotic pressure
2) HF
3) -Cirrhosis (hepatic)
-Nephrotic syndrome (low serum albumin, proteinuria (3+ grams), massive peripheral edema (3rd spacing), hyperlipidemia)
-PE
1) What is the mechanism behind the release of exudate?
2) What are some causes of this?
1) Increased capillary permeability, decreased lymphatic drainage
2) Infection/inflammation
-Malignancy
-PE
-Chylothorax/hemothorax
Give the OLDCARTS for pleural effusion
Onset: chronic to acute accumulation of fluid – PE, ACS with HF, slowly progressive HF, malignancy
Duration: effusion may be chronic or acute, usually persistent
Timing: associated with insult – ACS, pneumonia, PE, malignancy
Location: pleural space. May see JVD, HJR, change in heart sounds
Character: dyspnea, coughing usually non-productive, pleuritic chest pain
Alleviating: sitting upright, rest
Aggravating: inspiration may worsen CP, lying supine more dyspnea, activity (increased respiratory rate) DOE
Radiation: usually unilateral but may occur bilaterally
Associated Symptoms: medical conditions – HF, hepatic, malignancy, nephrotic syndrome, pneumonia, PE - asities, dependent pitting edema, calf pain
Pleural effusion exam findings:
1) What will you observe?
2) What are the VS?
3) What will you see on a respiratory exam?
1) Inapparent to respiratory distress, anxious, labored breathing
2) Variable: normal to febrile, tachycardic, tachypneic, SpO2 may be low depending on acuteness and extent of pleural involvement and lung parenchymal involvement
3) Over effusion, you’ll hear:
-Decreased or absent BS
-Decreased tactile fremitus
-Dullness to percussion
1) What are 3 types of imaging for pleural effusion? What can they do?
2) What is needed next? Why?
1) CXR, US, CT; confirm/diagnose pleural effusion but not characterization
2) Needle thoracentesis to get sample for lab analysis; characterizes as transudate or exudate to narrow DDX
Where do you put the needle for thoracentesis, above or below the rib?
this will be on the final, “just because”
Above
List the Light criteria for transudate pleural effusion:
1) Pleural:serum protein ratio
2) Pleural:serum LDH ratio
3) Pleural fluid LDH
4) Primary causes
need to know
1) 0.5 or less
2) 0.6 or less
3) <2/3 upper limit of normal serum LDH (may vary w each lab)
4) HF, cirrhosis, nephrotic syndrome, PE
For each of the following pleural effusion fluid appearances/ odor, incl. what fluid study is needed and what differential.
1) Bloody: Hematocrit and RBC count
-Malignancy, trauma, PE, hemothorax
2) Cloudy: Triglycerides
-Chylothorax
3) Putrid odor: Gram stain and culture
-Anaerobic infection
Pleural effusions:
1) What size is often asymptomatic?
2) What will be the HPI?
3) What are typically symptomatic?
4) What are the exam findings? (incl. percussion and auscultation)
1) Small pleural effusions: < 2 ICS (<300ml)
2) (depending on underlying etiology): Dyspnea, +/- fever, malaise, and weight loss, chest pain, cough, hemoptysis and dull pain
3) Pleural effusions > 300ml
4) Tachypnea, hypoxia, tachycardia
-Percussion: decreased tactile fremitus, dullness to percussion
-Auscultation: decreased breath sounds
Pleural effusion exam findings:
1) + Ascites (peritoneal cavity fluid) suggests?
2) Define Meigs syndrome
3) + Unilateral lower leg swelling means you should consider?
1) Hepatic hydrothorax, ovarian cancer, Meigs syndrome
2) Triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. Ovarian fibromas constitute majority of the benign tumors seen inMeigs syndrome.
3) DVT with Pulmonary Emboli
Pleural effusion: what imaging?
Upright CXR – blunting of posterior CP angle, ~ 75 ml of pleural fluid
Left and right decubital films
US – more sensitive, bedside evaluation (POCUS)
5-50 ml of pleural fluid
IDs loculated effusions
Site for thoracentesis, pleural bx or pleural drainage
Pleural effusion: imaging
1) When should chest CT w contrast be done?
2) What should you do if you suspect PE?
1) Pts with undiagnosed pleural effusions
2) CT pulmonary angiography
How do you Tx symptomatic pleural effusion?
-Therapeutic thoracentesis
-Chest tube thoracostomy if massive, hemothorax, empyema
(Limit 1000 – 1500 ml in single procedure)
What is pleural effusion Tx based on??
Sx
Thoracentesis:
1) What are the indications?
2) What is the general technique?
1) Lab sample to characterize effusion/DDX OR for treatment
2) Locate with interface of pleural effusion with percussion or POCUS
-At least 1-2 ICS below fluid line but above 9th rib to avoid intra-abdominal injury
-Posterior approach, ~ 5-10 cm lateral of midline (scapular line)
Tx underlying cause of pleural effusion:
1) What meds can be used for CHF?
2) When are abx appropriate?
3) When are Steroids/NSAIDs/DMARD needed?
4) What may be managed with repeat thoracentesis or pleurodesis?
1) Diuretics
2) Parapneumonic effusions
3) Rheumatoid conditions/inflammation
4) Symptomatic non-malignant effusions refractory to Tx
What are the 2 causes of spontaneous pneumothorax? Describe each
1) Primary: spontaneous rupture of apical bleb
-Tall thin healthy young males
-30% recur within 2 years
2) Secondary: to underlying pulmonary disease
-asthma/copd/CF/ILD
Describe each of the following pneumothorax etiologies:
1) Traumatic PTX (rib fracture, CPR)
2) Iatrogenic PTX
3) Tension PTX
1) From blunt (rib fracture, CPR) or penetrating trauma – bullet, knife, etc.
2) Over pressure from ventilator, surgical procedure (central line in subclavian)
3) Often result of trauma creating a 1-way valve sucking air into pleural space during inspiration, air becomes trapped and pleural pressure continues to rise and displace mediastinum
Describe simple or non-tension pneumothorax
(spontaneous primary or secondary, traumatic, or iatrogenic)
1) Air enters the pleural space
2) Results in partial or total lung collapse
3) Mediastinal structures may shift into the “empty” space created by the collapsed lung (shifts toward the PTX)
Describe tension pneumothoraxes
1) Air enters the pleural space during inspiration; results in progressive lung collapse
2) Pleural air is trapped via 1-way valve and accumulates with each inspiration, resulting in increasing pleural pressure, & progressive collapse of affected lung
3) If continues, will totally collapse the involved lung and continue to push on the mediastinum … shift the mediastinum away from affected side … and may affect cardiovascular output and opposite lung until cardiopulmonary collapse – emergent situation
Pneumothorax: List the HPI/ros using OLDCARTS
Onset: insidious, most often acute, may be related to trauma
Duration: usually persistent if symptomatic
Timing: spontaneous or associated with trauma
Location: typically, unilateral, potentially bilateral
Character: asymptomatic to sharp pleuritic chest pain at onset followed by dyspnea, cough, and variable impaired ventilation
Alleviated: rest
Aggravated: inspiration (negative intrathoracic pressure pulls more air into pleural space)
Radiation: if tension pneumothorax may push mediastinum to contralateral side. If large pneumothorax, collapse may pull mediastinum to ipsilateral side; either may impair respiration
Assoc. Sx: depends on etiology - trauma, idiopathic, underlying lung disease (COPD, asthma, CF, bronchiectasis, PE, etc.) – usually acute and progressive dyspnea, hypoxia, impaired cardiac output, mental status changes…. Cardiopulmonary collapse
Pneumothorax: List and describe the 3 types of imaging that can be done to confirm it
1) CXR (full expiration is best if patient stable and able) - reveals air in pleural space, collapsed lung, lack of vascular markings
-Inexpensive, available
-Lower sensitivity
2) POCUS: Equipment and training, high sensitivity
-Bedside for unstable patients and assist with treatment
3) CT: Gold standard, takes longer, availability
Describe the 2 types of mediastinal shift in pneumothorax
1) Tension – away from affected side, progressive
2) Simple – toward affected side if large
Pneumothorax treatment: Describe asymptomatic pts and what to do for them
Usually small, < 15% of hemithorax
Often resolve spontaneously
Monitor with serial imaging
Pneumothorax treatment: Describe symptomatic pts and what to do for them
1) May be emergent; usually larger, 15% +
2) Oxygen ; chest tube placement
3) Needle thoracentesis if emergent (tension) and or hemodynamically unstable
-[2nd ICS (above rib), mid clavicular line followed by chest tube]
4) Monitor with serial imaging
