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Foundations II Exam 3 (Jess) > Pleural disease > Flashcards

Pleural disease Flashcards

1
Q

What is the pleura? What kind of cells/tissue does it have?

A

Pleura= serous membranes

mesothelial cells, connective tissue

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2
Q

What does the visceral pleura cover?

A

the lungs and adjoining structures (blood vessels, bronchi, nerves)

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3
Q

What does the parietal pleura cover? What is it attached to?

A

Covers the diaphragm

attached to the chest wall

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4
Q

What is the pleural cavity? Does it normally have fluid in it?

A

pleural cavity= the potential space between the 2 pleurae

Yes, contains a small amount of pleural fluid (5-10 ml)

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5
Q

During expiration, the lungs ascend and what 2 pleura come together? (hint: both are parietal pleura)

A

the costal and diaphragmatic pleura

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6
Q

What is Pleuritis? Explain why and when the pt has pain

A

=Inflammation or irritation of the pleura

-the 2 layers rub together, which produces pain w/ inhalation and exhalation

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7
Q

Is Pleuritic pain easy to distinguish from other types of chest pain?

A

No, keep a wide differential

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8
Q

How is pleuritic chest pain described? What might you hear on PE?

A

Sharp CP aggregated by breathing, coughing, sneezing (may radiate to shoulder and back)

Pleural friction rub

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9
Q

What would you find on CXR or other imaging in a pt with pleuritis? (semi trick question)

A

Nothing- cannot visualize pleuritis on CXR

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10
Q

How do you treat pleuritis?

A

NSAIDs: Naproxen
Steroids: Prednisone

if drug induced, discontinuing the drug may be sufficient

Treat underlying cause

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11
Q

Involvement of ____, _____, and ______ is common in Lupus patients?

A

lung, pleura, and pulmonary vasculature

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12
Q

What type of effusion is involved in Lupus Pleuritis?

A

Exudative effusion

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13
Q

Common signs of Rheumatoid pleuritis (3)

A

pleuritic CP, fever, +/- dyspnea

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14
Q

What is the most common type of pleural dz?

A

Pleural effusion

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15
Q

How does the pleural cavity normally work?

What is it maintained by?

A

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

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16
Q

The majority of pleural effusions are a results of what diseases? (4)

A
  • CHF
  • PNA
  • Malignancy
  • pulmonary embolism
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17
Q

What 2 categories are pleural effusions separated into?

A
  1. Transudative effusions

2. Exudative effusions

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18
Q

When listening to Hx of a pt with possible pleural effusion, what do you need to pay close attention to?

A

Underlying comorbidities (SLE, RA, hypothyroidism, amyloid, hepatic dz)

Drugs (Nitrofurantoin, amiodarone, ovarian stimulation therapy)

Occupational exposures (Asbestos)

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19
Q

You are concerned your patient has a pleural effusion, what are some of their sx?

What might you find on PE?

A

Dyspnea, cough, pleuritic CP

PE:

  • dullness to percussion
  • decreased or absent tactile fremitus
  • decreased breath sounds
  • no voice transmission
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20
Q

CXR in lateral decubitus view can detect as little as _____ of fluid.

What sign would you see caused by the fluid?

A

50cc

meniscus sign

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21
Q

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?

A

1-2 intercostal spaces below

insert along superior edge of rib

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22
Q

What are indications for performing a thoracentesis?

A
  • Newly dx pleural effusion (for dx purposes)
  • Atypical features in CHF
  • Theraputic sx relief
  • If imaging suggests complication effusion
  • empyema
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23
Q

What is Light’s Criteria used for?

Explain it

A

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
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24
Q

Transudative effusions result from what?

What are the 3 biggest causes?

A

result from systemic imbalances in hydrostatic and oncotic forces

Heart failure
nephrotic syndrome
hepatic hydrothorax

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25
Q

How do exudative effusions occur?

A

when local factors influencing accumulation of pleural fluid are altered

pleural capillary permeability increase leading to elevated protein/cellular content

26
Q

What are the 4 biggest causes of exudative effusions?

A

malignancy
infectious
postcardiac injury
pulmonary embolus

27
Q

What are long-term tx options for pleural effusion?

A
  • tx underlying illness
  • PRN thoracentesis
  • PleurX catheter (refractory effusions)
  • Pleurodesis (destroy area between the 2 layers so fluid cannot build up)
28
Q

Is a pneumothorax normally spontaneous or gradual?

A

spontaneous

29
Q

What is primary spontaneous pneumothorax? (PSP)

Secondary spontaneous? (SSP)

A

Primary= occurs w/o a precipitating event in a person w/o known lung dz

secondary= occurs as complication of an underlying lung dz

30
Q

When in the highest risk of reoccurrence of PTX?

A

in 1st 30 days

most recur within 1st year

31
Q

Risk factors of PTX

A

Smoking- 91%!
familial
Marfan syndrome

32
Q

What are the typical characteristics of a pt with spontaneous PTX? (who it occurs in)

A

tall, thin, young men, age 20-40

33
Q

You are concerned your pt has a spontaneous PTX because of their complaints, what are they?

A

sudden onset dyspnea (80%) and pleuritic CP (90%)

Pain is usually unilateral

34
Q

What PE findings might you find in a pt with spontaneous PTX?

A
  • hemodynamic compromise is possible (tachy, hypotension)
  • decreased chest expansion on 1 side
  • diminished breath sounds
  • hyperresonant percussions
  • labored breathing
  • subcutaneous emphysema
35
Q

1st line imaging for spontaneous PTX? (there are 2, also name what position)

A

CXR (lateral decubitus) and CT chest

36
Q

When is US used for spontaneous pneumothorax? What indicates that the pt has a PTX?

A
  • used when dx needed emergently at bedside

- Absence of “sliding lung sign” indicated PTX

37
Q

What is the first line of tx you give pts with symptomatic PTX? Why?

A

100% oxygen administration

  • reduces partial pressure of nitrogen in pleural capillaries
  • quadruples rate of PTX absorption
38
Q

What is considered a small PTX?

A

less than or equal to 2-3 cm between lung and chest wall on CXR

39
Q

In a pt with a first time PSP, small pneumothorax, what can you do if they are clinically stable? (requirements)

A

obs

  • at least 6 hrs
  • CXR must demonstrate no progression of PTX
40
Q

what is considered a large PTX? how do you treat?

A

over 3 cm between lung and chest wall

needle aspiration

41
Q

Unstable patients and patients with recurrent PSP or concomitant hemothorax should all have what?

A

Chest tube insertion

42
Q

How do you perform a needle aspiration for a PTX?

A
  1. Needle inserted in 2ND intercostal space in midclavicular line
  2. catheter is left in place and attached to a 3-way stopcock and a large syringe
  3. Air is aspirated until resistance is met or the pt experiences significant coughing
  4. repeat CXR immediately after aspiration and again in 4-24 hrs to document lung re-expansion
43
Q

What are some indications for a chest tube for a pt with a PTX?

A
  • no response to needle aspiration
  • SSP
  • recurrent PTX
  • hemothorax
44
Q

Before removing a chest tube from a pt with PTX, what do you need to do?

A

Clamp the chest tube for ~12 hrs before removing and repeat CXR to ensure resolution

45
Q

What are some etiologies of secondary spontaneous PTX?

A
  • COPD
  • CF
  • Lung malignancy
  • necrotizing PNA
  • Catamenial
46
Q

Is primary or secondary PTX generally more severe?

A

Secondary

typically have less reserve due to underlying lung dz

47
Q

How do you treat secondary PTX?

A

Pt should be hospitalized

48
Q

Is a tension PTX a complication from a primary or secondary PTX?
What is it, presentation, tx?

A

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
49
Q

On CRX of a pt with tension PTX, what would you see?

A
  • Mediastinal shift
  • tracheal deviation to the contralateral side (aka away from the affected side)
  • ipsilateral flattening or inversion of the diaphragm
50
Q

What is acute respiratory distress syndrome?

A

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

-most severe form of acute lung injury

51
Q

What are the clinical and pathologic hallmarks of acute respiratory distress syndrome?

A

Clinical:
bilateral radiographic opacities and hypoxemia

Pathologic:
diffuse alveolar damage

52
Q

How do you dx acute respiratory distress syndrome?

A

It is a dx of exclusion!

53
Q

What is Berlin Definition?

A

All of the following are required for dx of acute respiratory distress syndrome:

  1. Acute onset within 1 week of known clinical insult
  2. B/L radiographic pulmonary infiltrates
  3. respiratory failure not fully explained by HF or volume overload
  4. Moderate-severe oxygenation impairment
54
Q

How does acute respiratory distress syndrome occur? (pathophys)

A

(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
55
Q

What are some systemic insults and pulmonary insults that can cause acute respiratory distress syndrome?

A 
Systemic:
sepsis
shock
trauma
multiple blood transfusions
burns
Pulmonary:
diffuse PNA
aspiration
lung contusion
toxic inhalation
near-drowning
56
Q

What clinical symptoms would a pt have that would be concerning for acute respiratory distress syndrome?

A
  • 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
57
Q

On CXR and CT of a pt w/ acute respiratory distress syndrome, what do you typically see/what shouldn’t you see?

A

typically see:

  • diffuse patchy B/L infiltrates
  • usually spare the costophrenic angles

shouldn’t see:
pleural effusions, enlarged heart

58
Q

In a pt with acute respiratory distress syndrome, what would would their arterial blood gas show?

A
  • hypoxemia
  • PaO2/FiO2 < 300 mm Hg
  • acute respiratory alkalosis
  • increased alveolar-arterial oxygen gradient
59
Q

What can you do for tx of acute respiratory distress syndrome?

A
  • Identify initial systemic or pulmonary insult and treat
  • supportive care (intubation and mechanical ventilation)
  • hemodynamic monitoring
  • nutrition support
  • DVT and GI prophylaxis
60
Q

What is the prognosis of a pt w/ acute respiratory distress syndrome?

A 
High mortality (26-58%)
-up to 90% w/ sepsis

survivors will likely be left w/ significant reduction in quality of life

Foundations II Exam 3 (Jess) (6 decks)

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