Pleural disease Flashcards
What is the pleura? What kind of cells/tissue does it have?
Pleura= serous membranes
mesothelial cells, connective tissue
What does the visceral pleura cover?
the lungs and adjoining structures (blood vessels, bronchi, nerves)
What does the parietal pleura cover? What is it attached to?
Covers the diaphragm
attached to the chest wall
What is the pleural cavity? Does it normally have fluid in it?
pleural cavity= the potential space between the 2 pleurae
Yes, contains a small amount of pleural fluid (5-10 ml)
During expiration, the lungs ascend and what 2 pleura come together? (hint: both are parietal pleura)
the costal and diaphragmatic pleura
What is Pleuritis? Explain why and when the pt has pain
=Inflammation or irritation of the pleura
-the 2 layers rub together, which produces pain w/ inhalation and exhalation
Is Pleuritic pain easy to distinguish from other types of chest pain?
No, keep a wide differential
How is pleuritic chest pain described? What might you hear on PE?
Sharp CP aggregated by breathing, coughing, sneezing (may radiate to shoulder and back)
Pleural friction rub
What would you find on CXR or other imaging in a pt with pleuritis? (semi trick question)
Nothing- cannot visualize pleuritis on CXR
How do you treat pleuritis?
NSAIDs: Naproxen
Steroids: Prednisone
if drug induced, discontinuing the drug may be sufficient
Treat underlying cause
Involvement of ____, _____, and ______ is common in Lupus patients?
lung, pleura, and pulmonary vasculature
What type of effusion is involved in Lupus Pleuritis?
Exudative effusion
Common signs of Rheumatoid pleuritis (3)
pleuritic CP, fever, +/- dyspnea
What is the most common type of pleural dz?
Pleural effusion
How does the pleural cavity normally work?
What is it maintained by?
forms a vacuum that keeps the visceral and parietal pleurae close
small amount of fluid serves as a lubricant to facilitate movement of the pleural surfaces against each other during respirations
maintained by a balance of hydrostatic and oncotic pressures in the pleural capillaries
The majority of pleural effusions are a results of what diseases? (4)
- CHF
- PNA
- Malignancy
- pulmonary embolism
What 2 categories are pleural effusions separated into?
- Transudative effusions
2. Exudative effusions
When listening to Hx of a pt with possible pleural effusion, what do you need to pay close attention to?
Underlying comorbidities (SLE, RA, hypothyroidism, amyloid, hepatic dz)
Drugs (Nitrofurantoin, amiodarone, ovarian stimulation therapy)
Occupational exposures (Asbestos)
You are concerned your patient has a pleural effusion, what are some of their sx?
What might you find on PE?
Dyspnea, cough, pleuritic CP
PE:
- dullness to percussion
- decreased or absent tactile fremitus
- decreased breath sounds
- no voice transmission
CXR in lateral decubitus view can detect as little as _____ of fluid.
What sign would you see caused by the fluid?
50cc
meniscus sign
When performing a thoracentesis, the needle insertion site should be ____ intercostal spaces below the height of the effusion.
Where in the intercostal space do you insert the needle?
1-2 intercostal spaces below
insert along superior edge of rib
What are indications for performing a thoracentesis?
- Newly dx pleural effusion (for dx purposes)
- Atypical features in CHF
- Theraputic sx relief
- If imaging suggests complication effusion
- empyema
What is Light’s Criteria used for?
Explain it
Used to differentiate transudative vs exudative
Exudative if 1 of the following:
-The ratio of pleural fluid protein to serum protein is greater than 0.5
- the ratio of pleural fluid lactate dehydrogenase (LDH) to serum LDH is greater than 0.6
- the pleural fluid LDH level is greater than 2/3 of the upper limit of nl for serum LDH
Transudative effusions result from what?
What are the 3 biggest causes?
result from systemic imbalances in hydrostatic and oncotic forces
Heart failure
nephrotic syndrome
hepatic hydrothorax
How do exudative effusions occur?
when local factors influencing accumulation of pleural fluid are altered
pleural capillary permeability increase leading to elevated protein/cellular content
What are the 4 biggest causes of exudative effusions?
malignancy
infectious
postcardiac injury
pulmonary embolus
What are long-term tx options for pleural effusion?
- tx underlying illness
- PRN thoracentesis
- PleurX catheter (refractory effusions)
- Pleurodesis (destroy area between the 2 layers so fluid cannot build up)
Is a pneumothorax normally spontaneous or gradual?
spontaneous
What is primary spontaneous pneumothorax? (PSP)
Secondary spontaneous? (SSP)
Primary= occurs w/o a precipitating event in a person w/o known lung dz
secondary= occurs as complication of an underlying lung dz
When in the highest risk of reoccurrence of PTX?
in 1st 30 days
most recur within 1st year
Risk factors of PTX
Smoking- 91%!
familial
Marfan syndrome
What are the typical characteristics of a pt with spontaneous PTX? (who it occurs in)
tall, thin, young men, age 20-40
You are concerned your pt has a spontaneous PTX because of their complaints, what are they?
sudden onset dyspnea (80%) and pleuritic CP (90%)
Pain is usually unilateral
What PE findings might you find in a pt with spontaneous PTX?
- hemodynamic compromise is possible (tachy, hypotension)
- decreased chest expansion on 1 side
- diminished breath sounds
- hyperresonant percussions
- labored breathing
- subcutaneous emphysema
1st line imaging for spontaneous PTX? (there are 2, also name what position)
CXR (lateral decubitus) and CT chest
When is US used for spontaneous pneumothorax? What indicates that the pt has a PTX?
- used when dx needed emergently at bedside
- Absence of “sliding lung sign” indicated PTX
What is the first line of tx you give pts with symptomatic PTX? Why?
100% oxygen administration
- reduces partial pressure of nitrogen in pleural capillaries
- quadruples rate of PTX absorption
What is considered a small PTX?
less than or equal to 2-3 cm between lung and chest wall on CXR
In a pt with a first time PSP, small pneumothorax, what can you do if they are clinically stable? (requirements)
obs
- at least 6 hrs
- CXR must demonstrate no progression of PTX
what is considered a large PTX? how do you treat?
over 3 cm between lung and chest wall
needle aspiration
Unstable patients and patients with recurrent PSP or concomitant hemothorax should all have what?
Chest tube insertion
How do you perform a needle aspiration for a PTX?
- Needle inserted in 2ND intercostal space in midclavicular line
- catheter is left in place and attached to a 3-way stopcock and a large syringe
- Air is aspirated until resistance is met or the pt experiences significant coughing
- repeat CXR immediately after aspiration and again in 4-24 hrs to document lung re-expansion
What are some indications for a chest tube for a pt with a PTX?
- no response to needle aspiration
- SSP
- recurrent PTX
- hemothorax
Before removing a chest tube from a pt with PTX, what do you need to do?
Clamp the chest tube for ~12 hrs before removing and repeat CXR to ensure resolution
What are some etiologies of secondary spontaneous PTX?
- COPD
- CF
- Lung malignancy
- necrotizing PNA
- Catamenial
Is primary or secondary PTX generally more severe?
Secondary
typically have less reserve due to underlying lung dz
How do you treat secondary PTX?
Pt should be hospitalized
Is a tension PTX a complication from a primary or secondary PTX?
What is it, presentation, tx?
Occurs in 1-2% of PSP
Medical emergency!
-worsening dyspnea, hypotension, diminished breath sounds, distended neck veins
Tx:
- immediate decompression
- chest tube needs to be placed
On CRX of a pt with tension PTX, what would you see?
- Mediastinal shift
- tracheal deviation to the contralateral side (aka away from the affected side)
- ipsilateral flattening or inversion of the diaphragm
What is acute respiratory distress syndrome?
acute hypoxemic respiratory failure following a systemic or pulmonary insult w/o evidence of HF
-most severe form of acute lung injury
What are the clinical and pathologic hallmarks of acute respiratory distress syndrome?
Clinical:
bilateral radiographic opacities and hypoxemia
Pathologic:
diffuse alveolar damage
How do you dx acute respiratory distress syndrome?
It is a dx of exclusion!
What is Berlin Definition?
All of the following are required for dx of acute respiratory distress syndrome:
- Acute onset within 1 week of known clinical insult
- B/L radiographic pulmonary infiltrates
- respiratory failure not fully explained by HF or volume overload
- Moderate-severe oxygenation impairment
How does acute respiratory distress syndrome occur? (pathophys)
(moves down list)
-acute, diffuse, inflammatory lung or systemic injury
- damage to pulmonary capillary endothelial cells and alveolar epithelial cells
- increased vascular permeability and decrease production and activity of surfactant
- pulmonary edema and alveolar collapse
- hypoxemia
What are some systemic insults and pulmonary insults that can cause acute respiratory distress syndrome?
Systemic: sepsis shock trauma multiple blood transfusions burns
Pulmonary: diffuse PNA aspiration lung contusion toxic inhalation near-drowning
What clinical symptoms would a pt have that would be concerning for acute respiratory distress syndrome?
- Significant SOB 6-72 hrs after inciting event and worsening
- respiratory distress (accessory muscle use, tachypnea, tachy, diaphoresis)
- hypoxemia that is unresponsive to supplemental O2
- diffuse crackles
On CXR and CT of a pt w/ acute respiratory distress syndrome, what do you typically see/what shouldn’t you see?
typically see:
- diffuse patchy B/L infiltrates
- usually spare the costophrenic angles
shouldn’t see:
pleural effusions, enlarged heart
In a pt with acute respiratory distress syndrome, what would would their arterial blood gas show?
- hypoxemia
- PaO2/FiO2 < 300 mm Hg
- acute respiratory alkalosis
- increased alveolar-arterial oxygen gradient
What can you do for tx of acute respiratory distress syndrome?
- Identify initial systemic or pulmonary insult and treat
- supportive care (intubation and mechanical ventilation)
- hemodynamic monitoring
- nutrition support
- DVT and GI prophylaxis
What is the prognosis of a pt w/ acute respiratory distress syndrome?
High mortality (26-58%) -up to 90% w/ sepsis
survivors will likely be left w/ significant reduction in quality of life
