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foundations pulm exam > pleural disease > Flashcards

pleural disease Flashcards

1
Q

define pleuritis

A

inflammation or irritation of the pleura

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2
Q

pleuritis is both a ____ and ____

A

symptom and disease

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3
Q

keep a wide ddx for pleuritis, what would be in the ddx?

A 
MI
aortic dissection
HF
pericarditis
malignancy
PNA
asthma/COPD
esophagitis
esophageal rupture
costochondritis
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4
Q

what is the main cause of pleuritis?

A

viral

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5
Q

what is the clinical presentation of pleuritis?

A

SHARP chest pain aggravated by breathing, coughing and sneezing
may radiate to the shoulders and back
fever, chills, cough, SOB, pharygnitis, weight loss, arthralgias, rash

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6
Q

what may you see on physical exam with pleuritis?

A

pleural friction rub (sounds like scratching Velcro)

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7
Q

how to diagnose pleuritis?

A

clincial dx
can do:
CXR - PNA, pleural effusion, pneumothorax, rib fracture
CTA chest - PE
serology - sickle cell anemia, infection, rheumatologic disease

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8
Q

how to treat pleuritis?

A

NSAIDS naproxen 250-500mg q12h

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9
Q

if NSAID does not work, what can you take instead?

A

stop NSAID and start prednisone 20mg/d followed by a 2-3 week taper

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10
Q

define lupus pleuritis

A

involvement in lung, pleura, and pulmonary vasculature
usually manifests as pleuritic CP +/- pleural effusion
exudative effusion

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11
Q

how do you treat lupus pleuritis?

A

NSAIDS

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12
Q

what testing do you do for lupus pleuritis?

A

serologic testing for SLE

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13
Q

common signs of rheumatoid pleuritis?

A

pleuritic CP, fever, +/- dyspnea

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14
Q

what causes rheumatoid pleuritis?

A 
exudative "rheumatoid" effusion
drug-induced pleuritis
empyema
bronchopleural fistula
hemopneumothorax
pyopneumothorax
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15
Q

how do you treat rheumatoid pleuritis?

A

NSAIDS

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16
Q

what causes pleural effusion?

A

excess fluid production

decreased lymphatic absorption

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17
Q

what do you look for on the CXR for pleural effusion?

A

meniscus sign
white out from the fluid
blunted angle

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18
Q

how is the pleural cavity maintained?

A

balance of hydrostatic and oncotic pressures in the pleural capillaries
persistent lymphatic drainage

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19
Q

what are potential mechanisms of pleural effusion?

A

reduction in intravascular oncotic pressure -
hypoalbuminemia
increased capillary hydrostatic pressure -
CHF
altered permeability of the pleural membrane -
inflammation
increased capillary permeability or vascular disruption - PNA
decreased lymphatic drainage - maligancy
increased peritoneal fluid with microstructural diaphragmatic defect -
hepatic hydrothorax
thoracic duct rupture -
chylothorax
decreased intrapleural pressure - atelectasis

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20
Q

majority of pleural effusions are result of?

A

CHF
PNA
malignancy
PE

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21
Q

pleural effusions are separated into two distinct categories, what are they?

A
  1. transudative effusions

2. exudative effusions

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22
Q

what comorbidities are related to pleural effusions?

A 
SLE
RA
hypothyroidism
amyloid
hepatic disease
pancreatic disease
kidney failure
CHF
hypercoagulable state
malignancy
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23
Q

what drugs in the hx should you pay attention to for pleural effusion?

A

nitrofurantoin
amiodarone
ovarian stimulation therapy

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24
Q

what occupational exposure should you pay attention to for pleural effusions?

A

asbestos

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25
Q

what is the clinical presentation of a pt with pleural effusion?

A

dyspnea
cough
pleuritic chest pain

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26
Q

what are the physical exam findings for pleural effusion?

A

dullness to percussion
decreased or absent tactile fremitus
decreased breath sounds
no voice transmission

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27
Q

what is the best CXR view for pleural effusion?

A

lateral decubitus view can detect as little as 50cc of fluid

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28
Q

how much fluid is needed before PA/LAT CXR can detect?

A

300cc

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29
Q

what diagnostic test is more sensitive than CXR?

A

CT chest/US

we don’t start here because of radiation/expensive

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30
Q

when do we want CT chest/US for pleural effusion?

A

if we suspect malignancy in undiagnosed pleural effusion

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31
Q

when do we consider CT Angiogram?

A

to r/o PE if suspicion is high

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32
Q

when do we consider pleural biopsy?

A

if pleural TB is suspected

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33
Q

where do we perform thoracentesis?

A

1-2 intercostal spaces below the height of the effusion

*thoracentesis helps distinguish the etiology of the fluid

34
Q

what are indications for thoracentesis?

A

newly detected pleural effusion for dx purposes
therapeutic symptom relief
empyema
if imaging suggests complicated effusion

35
Q

what are contraindications for thoracentsis?

A

small volume of fluid (<1cm thickness on lateral decubitus film)
high risk for pneumothorax

36
Q

what are complications for thoracentesis?

A

pain at puncture site
internal bleeding
pneumothorax
empyema

37
Q

what does black pleural fluid represent?

A

aspergillosis

38
Q

what does yellow-green pleural fluid represent?

A

rheumatoid pleurisy

39
Q

what does ammonia odor represent?

A

urinothorax

40
Q

what do food particles represent?

A

esophageal rupture

41
Q

what does bloody pleural fluid represent?

A

trauma, malignancy, pulmonary infarct

42
Q

what does white pleural fluid represent?

A

chylothorax, empyema

43
Q

what does brown pleural fluid represent?

A

amebic liver abscess draining into pleural space?

44
Q

what does viscous pleural fluid represent?

A

malignant mesothelioma

45
Q

define Light’s criteria

A

used to differentiate transudate vs exudate
exudative effusion if one the following three is present:
1. ratio of pleural fluid protein to serum protein is > 0.5
2. ratio of LDH to serum LDH is > 0.6
3. LDH > 2/3 of the upper limit of normal for serum LDH

46
Q

what are major causes of transudative effusions?

A

HF
nephrotic syndrome
hepatic hydrothorax

47
Q

what are major causes for exudative effusions?

A

malignancy
postcardiac injury
infectious
PE

48
Q

what are long-term management strategies for pleural effusion?

A

PRN thorancentesis

pleurodesis (surgical, chemical)

49
Q

define pneumothorax

A

present of air/gas in the pleural cavity

usually spontaneous

50
Q

differentiate primary spontaneous pneumothorax (PSP) vs secondary spontaneous pneumothorax (SSP)

A

PSP occurs w/o a precipitating event in person without known lung disease
SSP occurs as a complication of an underlying lung disease

51
Q

what are facts on PSP?

A

males > females
highest risk in first 30 days
smoking is #1 risk factor

52
Q

what is the clinical presentation of a pt with spontaneous pneumothorax?

A

tall, thin, young men from age 20-40
sudden onset of dyspnea and pleuritic CP
pain is usually unilateral and can be sharp

53
Q

what are physical exam findings for spontaneous pneumothorax?

A

decreased chest expansion on one side
hyperresonant percussions
labored breathing

54
Q

what is the 1st line diagnostic for spontaneous pneumothorax?

A

CXR or CT chest

55
Q

what ruptures and can cause pneumothorax?

A

blebs

56
Q

what diagnostic do we use if we need spontaneous pneumothorax diagnosis emergently?

A

US at bedside

57
Q

absence of _______ in US indicates pneumothorax?

A

“sliding lung sign” - small lung with fluid around it

58
Q

what do we give to treat spontaneous pneumothorax?

A

100% oxygen administration

59
Q

how do we treat small pneumothorax (2-3 cm between lung and chest wall on CXR)

A

observe

60
Q

how do we treat large pneumothorax (>3cm between lung and chest wall)?

A

needle aspiration

61
Q

how do we treat recurrent PSP or concomitant hemothorax?

A

chest tube insertion

62
Q

in spontaneous pneumothorax, what does observation consist of?

A

should be at least 6 hours

CXR must demonstrate no progression of pneumothorax

63
Q

define needle aspiration in pneumothorax

A
  1. needle inserted in 2nd ICS in midclavicular line
  2. catheter is left in place
  3. air is aspirated until resistance is met
  4. repeat CXR immediately after aspiration and again in 4-24 hours to document lung re-expansion
64
Q

what are indications for chest tube insertion?

A

no response to needle aspiration
SSP
recurrent pneumothorax
hemothorax

65
Q

define chest tube insertion

A

connected to a water-seal device
left in place until pneumothorax resolves
clamp chest tube for ~12 hours before removing and repeat CXR to ensure resolution

66
Q

what are the indications for VATS procedure?

A 
persistent air leak
recurrence
chest tube required on first occurrence 
job where recurrent could be harmful to others (i.e. pilot)
bleb/bullae resection
67
Q

what are etiologies of SSP?

A

COPD
CF
catamenial (thoracic endometriosis)

68
Q

how to treat SSP?

A

hospitalize
mostly all will require drainage
tube thoracostomy preferred over needle aspiration
smoking cessation

69
Q

what is the clinical presentation of tension pneumothorax?

A 
medical emergency
worsening dyspnea
hypotension
diminished breath sounds
distended neck veins
tracheal deviation
70
Q

how to treat tension pneumothorax?

A

immediate decompression

chest tube needs to be placed

71
Q

define ARDS

A

acute hypoxemic respiratory failure following a systemic or pulmonary insult w/o evidence of HF

72
Q

what are the hallmarks for ARDS?

A

clinical: bilateral radiographic opacities and hypoxemia
pathologic: diffuse alveolar damage

73
Q

ARDS is what type of diagnosis?

A

diagnosis of exclusion

74
Q

what is required for dx ARDS (berlin definition)?

A
  1. acute onset w/in 1 week of a known clinical insult
  2. B/L radiographic pulmonary infiltrates
  3. respiratory failure not explained by HF
  4. moderate-severe oxygenation impairment (ratio of PaO2 to FiO2 <300 mmHg)
75
Q

what is the pathophysiology of ARDS?

A
  1. acute, diffuse, inflammatory lung or systemic injury
  2. damage to pulmonary capillary endothelial cells and alveolar epithelial cells
  3. increased vascular permeability and decreased production and activity of surfactant
  4. pulmonary edema and alveolar collapse
  5. hypoxemia
76
Q

what are the most common causes of ARDS?

A

PNA
sepsis
aspiration

77
Q

about how many blood transfusions causes ARDS?

A

> 15 and develops about 6 hours after being transfused

78
Q

what are the clinical presentations for ARDS?

A

significant SOB 6-72 hrs after inciting event and worsen quickly
respiratory distress
hypoxemia that is unresponsive to supplemental O2
diffuse crackles
cyanosis

79
Q

what do you typically see in CXR/CT chest for ARDS?

A

diffuse/patchy B/L infiltrates

usually spares the costophrenic angles

80
Q

pt with ARDS in acute respiratory acidosis or alkalosis?

A

respiratory alkalosis

81
Q

how to treat ARDS?

A 
supportive care
intubation and mechanical ventilation
hemodynamic monitoring
nutrition support
DVT and GI prophylaxis (DVT- SC heparin or lovenox and GI- PPI)

foundations pulm exam (10 decks)

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