Pleural Disease Flashcards
Where is the pleural space?
between the parietal and visceral pleura
How much fluid does the pleural space hold?
holds up to 15 mL of fluid
What kind of fluid is contained in the pleural space?
lubricating, serous pleural fluid
accumulation of excess pleural fluid
pleural effusion
What can pleural effusions be caused by? (5)
- increased pulmonary capillary hydrostatic pressure
- increased pulmonary capillary vascular permeability
- decreased osmotic pressure
- increased negative pressure in the pleural space
- lymphatic obstruction
What kind of processes can pleural effusions be caused by?
inflammatory or non-inflammatory
results in transudate/exudate being produced and the accumulation of that non-purulent exudate (effusion) in the pleural space, with various amounts of fibrin formation
inflammatory causes of pleural effusion
What type of transudate/exudate is associated with inflammatory causes of pleural effusion?
May be serous, serofibrinous, or fibrinous transudate/exudate
What are 2 common signs/symptoms of the inflammatory causes of pleural effusion?
- pleuritic pain
- pulmonary friction rub
What is pleuritic pain?
sharp, stabbing pain worsening with deep respiration
What kind of diseases are associated with inflammatory causes of pleural effusion?
Generally associated with infectious diseases, especially when they affect the peripheral aspects of the lungs
What are some examples of these infectious disease associated with inflammatory causes of pleural effusion?
- TB
- pneumonia
- lung infarcts
- lung abscess
- bronchiectasis
What are some examples inflammatory disease that can result in pleuritis and subsequent inflammatory pleural effusion?
- RA
- DLE (disseminated lupus erythematosus)
- uremia
- diffuse systemic infections,
- metastatic involvement of pleura
occurs when the effusion contains purulent fluid indicating infection in the fluid (containing WBC)
empyema
Is an empyema usually unilateral or bilateral?
usually unilateral
What is an empyema usually a result from?
Usually results from bacterial or fungal seeding of the pleural space
What is the most common way that seeding occurs?
Seeding usually occurs by contiguous spread of organisms from intrapulmonary infection
What are some other ways that seeding occurs?
may also occur via:
- the lymphatic or hematogenous routes
- through the diaphragm
What are some characteristics of empyema?
- loculations
- yellow-green, creamy pus
What is the pus in an empyema composed of?
composed of masses of neutrophils mixed with other leukocytes
What volume is an empyema usually?
often the volume is SMALL, but can accumulate in large volumes up to 500-1000mL
Is an empyema usually diffuse or localized?
localized
What frequently forms the walls of loculations?
Fibrin forms dense, tough fibrous adhesions that frequently form walls of loculations
What do the loculations attach?
attach the visceral to the parietal pleura
What signs/symptoms can loculations cause?
- pain with respiration
- restricting pulmonary expansion
manifested by blood (sanguinous) with/without inflammatory exudate accumulating in the pleural space
hemorrhagic pleural effusion
What is it called if both blood with inflammatory exudate are present in hemorrhagic pleural effusion?
serosanguinous
What are hemorrhagic pleural effusions associated with?
- hemorrhagic disorders
- some infections
- cancer within pleural cavity
What must a hemorrhagic pleural effusion be differentiated from?
hemothorax
collection of noninflammatory, straw colored serous fluid within the pleural cavities
hydrothorax
Is a hydrothorax usually bilateral or unilateral?
it can be either bilateral or unilateral
What is the most common cause of a hydrothorax? What is this accompanied by?
Most common cause is heart failure, usually accompanied by pulmonary congestion and edema
What may a hydrothorax be associated with?
May be associated with generalized edema (e.g., renal failure, hepatic cirrhosis)
occurs with bleeding into the pleural cavity
hemothorax
What are some common causes of hemothorax
- ruptured aortic aneurysm
- vascular trauma
- post-op
accumulation of milky (fat-rich) lymphatic fluid in the pleural cavity
chylothorax
What are the causes of a chylothorax?
Caused by:
- thoracic duct trauma
- obstruction or rupture of major lymphatic ducts (malignant conditions)
What are the components of evaluation of pleural effusion?
- history and PE
- thoracentesis
- CBC
What are normal values of a pleural fluid via thoracentesis? (6)
- Pleural fluid is clear
- pH 7.6-7.64
- Protein content of less than 1-2 g/dL
- Fewer than 1000 WBCs per mm3
- Glucose content ≈ plasma
- LDH less than 50% of plasma activity
What are some reasons to cause a variation from normal values of pleural fluid?
- neoplastic cells
- microbes
- RBCs
- protein
partial or total collapse of a lung due to introduction of gas (usually air) into the pleural space
pneumothorax
Is a pneumothorax only due to air?
NO - can be any gas
What happens to the pleural space when a gas enters?
there is a reduction in pleural space
What allows lung compliance to collapse
negative pressure
may occur with rupture of the lung surface, allowing gas to enter into the pleural cavity
spontaneous pneumothorax
What are some examples of conditions that can lead to a spontaneous pneumothorax?
- bullous emphysema
- asthma
- TB
- abscess
- neoplasm
probably due to rupture of small, peripheral, usually apical subpleural blebs
spontaneous idiopathic pneumothorax
What type of people does a spontaneous idiopathic pneumothorax generally occur in?
Generally occurs in relatively tall, thin, young people
usually caused by perforating injury to the chest wall, and/or to the lung where gas can enter into pleural space
traumatic pneumothorax
What does lung compression and collapse cause?
- atelectasis
- respiratory distress
What happens if the point of air entry acts as a one-way flap valve, permitting air entrance during inspiration but not permitting air escape during expiration?
it will act as a pump that progressively increases intrapleural pressure
What does a one-way flap valve permitting air entrance during inspiration but not permitting air escape during expiration that acts as a pump that progressively increases intrapleural pressure describe?
tension pneumothorax
What does a tension pneumothorax compress?
Compresses the mediastinum and the contralateral lung
What may a tension pneumothorax cause?
- tracheal deviation
- hyper-expanded chest that moves little with inspiration
- increased percussion note over affected side
If there is tracheal deviation with a tension pneumothorax, which way will it deviate?
AWAY from the affected side
________ of air in the pleural space air occurs _____ in spontaneous and traumatic pneumothorax, provided that the gas source becomes _____ (defect in lung or chest wall).
Resorption of air in the pleural space air occurs slowly in spontaneous and traumatic pneumothorax, provided that the gas source becomes sealed (defect in lung or chest wall).
How can a small pneumothorax be treated?
time and observation
What does a large pneumothorax require for treatment?
chest tube insertion (thoracostomy)
What type of pleural tumors are possible?
primary and secondary/metastatic tumors are possible
What type of pleural tumors are most common?
metastatic tumors are most common
Where do most frequent metastatic malignancies arise from?
- lung
- breast
- ovary
- other
What do most metastatic cancers result in? What does this often contain?
result in a serous or serosanguineous pleural effusion that often contains neoplastic cells
