Pleural Disease- Bootcamp Flashcards
A pneumothorax is defined as _ in the pleural space
A pneumothorax is defined as air in the pleural space
A pneumothorax will present with symptoms like _
A pneumothorax will present with symptoms like sudden onset dyspnea, chest pain
* Chest pain may be described as unilateral, pleuritic, and sharp
* Pain may radiate to the ipsilateral shoulder
* Note that spontaneous pneumo in otherwise healthy adults may appear with minimal symptoms
Spontaneous pneumothorax are normally caused by _
Spontaneous pneumothorax are normally caused by rupture of subpleural bleb
The two populations most at risk of a spontaneous pneumothorax are _ and _
The two populations most at risk of a spontaneous pneumothorax are tall thin males (Marfan’s) and smokers
What is a subpleural bleb?
Subpleural blebs are local defects in the lung that cause the lung to balloon out
What happens in a spontaneous pneumothorax?
In a spontaneous pneumothorax bleb ruptures –> air rushes from the lungs into the pleural space –> lung collapses and pleural space expands
A tension pneumothorax is more dangerous than a spontaneous pneumo; why?
In a tension pneumothorax, there is a progressive build up of air in the pleural space
* Air can only move unidirectionally, out of the lungs into the pleural space
* Air is accumulating with each breath and creating pressure on other structures
Trauma from chest wall penetration or fractured ribs tend to cause the formation of a _
Trauma from chest wall penetration or fractured ribs tend to cause the formation of a unidirectional valve (tension pneumothorax)
* Fractured rib: air flows from lungs to pleural space
* Chest wall penetration: air flows from atmosphere to pleural space
When air enters during a pneumothorax, it dissects through the liquid of the pleural space and disrupts the vacuum such that the intrapleural pressure is no longer _
When air enters during a pneumothorax, it dissects through the liquid of the pleural space and disrupts the vacuum such that the intrapleural pressure is no longer negative
* Transpulmonary pressure is no longer positive
* The lungs and chest wall are not held together
Tension pneumothorax may cause the trachea to _ and vena cava to _
Tension pneumothorax may cause the trachea to deviate away from the affected side and vena cava to collapse –> drops venous return –> hypotension, tachycardia, JVD –> shock
In a _ pneumothorax Pip = Palv
In a spontaneous pneumothorax Pip = Palv
In a _ pneumothorax Pip > Palv
In a tension pneumothorax Pip > Palv
When auscultating the lungs in a pneumothorax, we should expect to hear _ and _
When auscultating the lungs in a pneumothorax, we should expect to hear hyperresonance and decreased breath sounds
X ray findings of a pneumothorax will show _
X ray findings of a pneumothorax will show collapsed lung with black/ air-filled lung field
Management for pneumothorax includes _ or _
Management for pneumothorax includes needle decompression (tension pneumothorax) or chest tube placement
A chest tube helps to treat a pneumothorax by creating a _
A chest tube helps to treat a pneumothorax by creating a unidirectional valve that allows air out of the pleural space but not in
Tension pneumothorax
* Trachea is deviated
Pulmonary edema is caused by an increase in hydrostatic pressure in the pulmonary _
Pulmonary edema is caused by an increase in hydrostatic pressure in the pulmonary capillaries
* This fluid gets pushed out and collects in the alveoli
Pulmonary edema due to increased hydrostatic capillary pressure is often caused by_
Pulmonary edema due to increased hydrostatic capillary pressure is often caused by left heart failure
_ are “heart failure cells” that may be seen in the alveoli
Hemosiderin laden macrophages are “heart failure cells” that may be seen in the alveoli
* These are macrophages that contain engulged extravasated RBCs
Pulmonary edema can also occur from decreased oncotic pressure secondary to things like _ or _
Pulmonary edema can also occur from decreased oncotic pressure secondary to things like nephrotic syndrome or liver failure
* Less protein in the blood leads to fluid leaking from the pulmonary capillaries into the alveoli
What happens to V/Q, DLCO, and lung compliance when we have pulmonary edema?
V/Q mismatch
Decreased DLCO
Decreased compliance (surfactant dilution)
What does pulmonary edema sound like?
Pulmonary edema presents with bibasilar crackles, rales, dullness to percussion
Pleural effusion can be defined as a collection of _ in the pleural space
Pleural effusion can be defined as a collection of fluid in the pleural space
* Often caused by an increase in inflow or a decrease in outflow
The major contributors of the increased fluid in pleural effusions are the _
The major contributor of the increased fluid in pleural effusions are the pleural blood vessels
* These are intercostal microvessels
* Found in the parietal pleura
We also have pulmonary capillaries in the _ that can cause contribute to pleural effusions in pathological states
We also have pulmonary capillaries in the lungs that can cause contribute to pleural effusions in pathological states
The parietal pleura contains _ to drain excess fluid out of the pleural space
The parietal pleura contains pleural lymphatics to drain excess fluid out of the pleural space
* Sometimes malignant cells can block the pleural lymphatics
Contributors to pleural effusions that should be considered:
- Increased fluid from the pleural blood vessels
- Increased fluid from the pulmonary capillaries
- Thoracic duct rupture
- Blockage of the pleural lymphatic system
In very severe pleural effusions, we can see a deviated trachea (away from/ towards) the side of effusion
In very severe pleural effusions, we can see a deviated trachea away from the side of effusion
Transudative pleural effusions are caused by _ or _
Transudative pleural effusions are caused by increased hydrostatic pressure or decreased oncotic pressure in the pleural vessels/ pulmonary capillaries
Exudative pleural effusions are caused by _
Exudative pleural effusions are caused by increased vascular permeability whereby exudate is able to travel from the vessels to the pleural space
* Parapneumonic effusions
* Malignant pleural effusions
_ effusions are pleural effusions that occur from pneumonia infection
Parapneumonic effusions are pleural effusions that occur from pneumonia infection
Uncomplicated vs. complicated parapneumonic effusions
Uncomplicated: exudate is sterile
Complicated: bacterial seeding of the pleural space
Exudative effusion contains fluid with a low pH, glucose, and high leukocytes; this is likely a _ effusion
Exudative effusion contains fluid with a low pH, glucose, and high leukocytes; this is likely a complicated parapneumonic effusion
Malignant pleural effusions are (transudative/exudative)
Malignant pleural effusions are exudative
* Inflammation causes increased vascular permeability
* Also often have a blockage of outflow due to blocked lymphatics
What does pleural effusion sound like?
_ percussion
_ breath sounds
_ tactile fremitus
What does pleural effusion sound like?
dullness to percussion
decreased breath sounds
decreased tactile fremitus
_ is a procedure conducted for a pleural effusion for both diagnostic and therpeutic reasons
Thoracocentesis is a procedure conducted for a pleural effusion for both diagnostic and therpeutic reasons
In order to determine whether a pleural effusion is transudative or exudative, we can remove fluid via _ and use the _ criteria
In order to determine whether a pleural effusion is transudative or exudative, we can remove fluid via thoracocentesis and use the Light’s criteria
Three elements of Light’s criteria
Light’s criteria states that a pleural effusion is exudative if:
1. Pleural protein/serum protein > 0.5
2. Pleural LDH/ Serum LDH > 0.6
3. LDH is > 2/3 upper limit of normal serum LDH
An increase in RBCs and atypical cells on thoracocentesis indicates _
An increase in RBCs and atypical cells on thoracocentesis indicates malignancy
(Increased/Decreased) glucose levels indicate malignancy or infectious pleural effusions
Decreased glucose levels indicate malignancy or infectious pleural effusions
* Malignant cells take up all the glucose
_ are direct communicators that exist between the pleural space and the underlying lymphatic network, allowing removal of large particles from the pleural space
Stromata are direct communicators that exist between the pleural space and the underlying lymphatic network, allowing removal of large particles from the pleural space
The normal volume of fluid in the intrapleural space is _ mL
The normal volume of fluid in the intrapleural space is 15 mL
Under normal conditions, the hydrostatic pressure is slightly _ than the oncotic pressure gradient in the lungs; this means that there is a net movement of fluid _
Under normal conditions, the hydrostatic pressure is slightly greater than the oncotic pressure gradient in the lungs; this means that there is a net movement of fluid into the pleural space
What is the composition of normal pleural fluid?
< 1500 nucleated cells/ mm3
75% macrophages
23% lymphocytes
pH > 7.5
Low in protein
Non-inflammatory fluid with low protein content describes (transudative/exudative) fluid
Non-inflammatory fluid with low protein content describes transudative fluid
Transudative pleural effusions usually occur due to increased _ or decreased _
Transudative pleural effusions usually occur due to increased hydrostatic pressure or decreased plasma colloid oncotic pressure
Exudative pleural effusions are usually due to _
Exudative pleural effusions are usually due to increased capillary and pleural membrane permeability via an inflammatory process
* Pleural disease, pneumonia, infection, cancer, obstruction to lymphatic channel
Inflammatory proteinaceous fluid describes (transudative/exudative) effusions
Inflammatory proteinaceous fluid describes exudative effusions
Right sided effusion
Pleural effusion
Transudative thoracentesis fluid should appear _
Transudative thoracentesis fluid should appear clear, straw colored, non-viscid, odorless
Blood thoracentesis may indicate _
Blood thoracentesis may indicate cancer, pulmonary infarction, trauma, recent surgery
A true hemothorax is indicated when pleural fluid hematocrit/ Blood hematocrit > _
A true hemothorax is indicated when pleural fluid hematocrit/ Blood hematocrit > 50%
Turbid or milky thoracentesis fluid may indicate _
Turbid or milky thoracentesis fluid may indicate a chylothorax (thoracic duct injury)
Light’s criteria
High neutrophils in the pleural fluid may indicate _
High neutrophils in the pleural fluid may indicate acute inflammatory process
High lymphocytes in the pleural fluid may indicate _
High lymphocytes in the pleural fluid may indicate malignancy or TB (if > 50%)
High LDH may be indicative of _
High LDH may be indicative of malignancy, parapneumonic effusion
R sided pneumothorax
Pneumothorax
