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2. HDS Pulmonary > Pleural Disease > Flashcards

Pleural Disease Flashcards

1
Q

Pleural Anatomy

A
  • 2 layers made of mesothelial cells
    • Visceral pleura ⇒ lines lungs
    • Parietal pleura ⇒ lings chest wall
  • Normal pleural fluid production ~ 16.8 nl/day for 70 kg adult
  • Fluid flows from visceral to parietal pleura
  • Lymphatic drainage ~ 470 cc/day
    • 28x more than production
    • No fluid in pleural space normally
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2
Q

Pleural Effusion

Definition

A

Accumulation of fluid in the pleural space.

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3
Q

Pleural Effusions

Pathophysiology

A
  • ↑ fluid accumulation
    Entry of fluids into pleural space:
    • ↑ systemic venous pressure
    • ↑ pulmonary venous pressure
    • ↑ permeability of pleural vessels
    • ↓ pleural pressure
    • ↓ microvascular oncotic pressure
  • ↓ fluid removal
    Blockage of lymphatics:
    • Central lymphatic obstruction
    • Obstruction of lymphatic channels at pleural surface by tumor
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4
Q

Transudates

Characteristics

A

Light’s Criteria

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5
Q

Exudates

Characteristics

A

Light’s Criteria

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6
Q

Transudates

Etiologies

A
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7
Q

Exudates

Etiologies

A
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8
Q

Pleural Fluid

Analysis

A
  • Cell count and differential
  • Chemistry
    • Proteins, LDH, albumin, amylase, pH, glucose
    • Obtain concurrent serum values
  • Gram strain and culture
  • Cytology
  • Other tests as indicated
    • Lipids, fungal culture, triglycerides, Ig
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9
Q

Pleural Effusion

History

A
  • Asymptomatic
  • Dyspnea ⇒ d/t compression of underlying lung
  • Pleuritic CP ⇒ see w/ some exudative effusions
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10
Q

Pleural Effusion

Physical Exam

A
  • ↓ tactile fremitus
  • Dullness to percussion
  • ↓ or absent breath sounds
  • Tracheal shift to contralateral side w/ very large effusion
  • Tubular breath sounds, egophany (E to A changes)
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11
Q

CHF Related

Pleural Effusions

A
  • Most common cause of transudates
  • D/t ↑ pulmonary venous pressures from LV dysfunciton
  • Usually bilateral, R > L
  • Thoracentesis often not needed
    • Unless atypical or fail to resolve w/ medical treatment
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12
Q

Image 1

A

Left-sided Massive Pleural Effusion

With contralateral shift of mediastinum and trachea.

Most common cause of non-traumatic massive pleural is cancer.

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13
Q

Parapneumonic Effusions

Definition

A

Exudative effusions in setting of bacterial PNA or lung abscess.

  • Often very high WBCs and LDH levels
  • Effusion on same side as PNA
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14
Q

Uncomplicated Paraneumonic Effusion

Characteristics

A
  • Negative gram stain and culture
  • pH > 7.30
  • Glucose > 40
  • Resolves w/ simple abx treatment of PNA
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15
Q

Complicated Parapneumonic Effusion

A
  • pH < 7.20
  • Glucose < 40
  • Requires chest tube or surgical drainage for resolution
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16
Q

Empyema

A

“Pus” in the pleural space.

  • Will usually have a positive gram stain or culture
  • Treatment same as complicated parapneumonic effusion
17
Q

RA

Pleural Effusions

A
  • Pleural glucose < 30
  • P/S ratio < 0.5
  • pH < 7.3
  • High LDL level > 700
18
Q

TB

Pleural Effusion

A
  • Exudative effusiosn d/t hypersensitivity rxn
  • Usually neg. AFB smear
  • Lymphocytic predominance
  • Culture neg. for AFB
  • Adenosine deaminanse in fluid consistent w/ TB
19
Q

Malignant Pleural Effusion

A
  • 2nd most common cause of exudative effusion
  • Malignant cells seen in 60% of 1st thoracentesis
    • Yield inc. by 20% on second tap
  • Common etiologies
    • Lung Ca
    • Breast Ca
    • Lymphoma
    • Ovarian Ca
20
Q

Chylothorax

A

Disruption or obstruction of thoracic duct ⇒ leakage of chyle fluid.

  • High TAG
  • Milky appearance
  • Lymphocytic predominance
  • Pleural triglyceride > 110 mg/dL ⇒ 85% of pts
  • Etiologies ⇒ trauma, surgery, malignancy (lymphoma)
21
Q

Cholesterol Effusion

A

“Pseudochylothorax”

  • High cholesterol ⇒ milky appearance
  • Chronic inflammatory process such as TB or RA
  • Pleural cholesterol > 200 mg/dL ⇒ 75% of pts
  • Cholesterol crystals in fluid
22
Q

Nephrotic Syndrome

Pleural Effusions

A

Caused by PE and renal vein thrombosis

23
Q

Pleural Effusion

Management

A
  • Treat underlying cause of effusion
  • Thoracentesis
    • Can remove up to 1,500 ml to relieve dyspnea
    • Removing more inc. risk of re-expansion pulmonary edema
  • Chest tube
    • Drain complicated parapneumonic effusion/empyema
    • Palliate SOB d/t recurrent large pleural effusion e.g malignancy
    • Perform chemical pleurodesis to obliterate pleural space & prevent reaccumulation of fluid ⇒ rarely done
  • Surgery ⇒ thoracoscopy or thoracotomy
    • If interventions via chest tube fails
24
Q

Pneumothorax

Definition

A

Air in the pleural space.

25
Q

Image 2

A

Hydropneumothorax

Pneumothorax ⇒ collapsed lung

As lung deflated, injured some vessels.

Also see blood in the pleural cavity ⇒ air fluid line

26
Q

Pneumothorax

History

A
  • Asymptomatic
  • Dyspnea
  • Ipsilateral pleuritic chest pain
27
Q

Pneumothorax

Physical Exam

A
  • ↓ tactile fremitus
  • Hyperresonant to percussion
  • ↓ breath sounds
  • If tension PTX ⇒ ± tracheal shift, tachycardia, hypotension
28
Q

Pneumothorax

Etiologies

A
  • Traumatic PTX ⇒ from penetrating or non-penetrating chest trauma
  • Iatrogenic PTX ⇒ result of a dx or therapeutic medical procedure
  • Spontaneous PTX
    • Primary
      • In absence of known lung disease
      • Men > Women
      • Associated w/ cigarette smoking
      • Cocaine use is a risk factor
    • Secondary
      • In presence of known lung disease
      • COPD most common but there are others
29
Q

Pneumothorax

Treatment

A
  • Observation ⇒ if small and pt stable
    • Rim of air < 2 cm on CXR
  • Simple aspiration ⇒ pneumocentesis
    • Primary spontaneous PTX
    • Emergently in tension PTX ⇒ temporizing
  • Chest tube ⇒ with or without pleurodesis
  • Surgery ⇒ recommended after 2nd PTX
30
Q

Tension Pneumothorax

A

PTX w/ progressive build-up of air in pleural space d/t inability of air to escape.

  • 1-2% of spontaneous PTX
  • More common w/ trauma and positive-pressure ventilation
  • Clinical features:
    • Severe respiratory distress, cyanosis, tachycardia, hypotension
  • Radiographic changes:
    • Mediastinal shift
  • Treatment is immediate decompression
    • Large-bore needle, 2nd anterior intercostal space
  • Ventilator + PTX = automatic chest tube
31
Q

Malignant Mesothelioma

A
  • Occurs after asbestos exposure
    • Latency 30-40 years
  • Symptoms non-specific ⇒ CP, SOB, cough, weight loss
  • Most have pleural effusion
  • Need biopsy to confirm
  • Therapy very limited ⇒ prognosis poor
32
Q

Benign Fibrous Mesothelioma

A
  • Less common
  • No asbestos association
  • Both dx and tx is surgical ⇒ good prognosis

2. HDS Pulmonary (28 decks)

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