Pleural diseases Flashcards
What is the definition of a pneumothorax?
A collection of gas in the pleural space
What is the difference between a normal pneumothorax and a tension pneumothorax
The presence of a “one way valve” in the tissues that allows air to enter the chest cavity when there is negative pressure generated during inspiration but does not allow gas to escape during expiration resulting in increased amounts of gas in the pleural space with each breath
What is “special” about a tension pneumothorax?
Will put pressure on the heart and reduce cardiac output
A visual sign of a pneumothorax is what?
Unilateral chest expansion
What is the acronym used in regards to a suspected pneumothorax?
FAST
Focused Assessment with Sonography for Trauma
Standard tool for trauma assessment
How is a pneumothorax emergently treated?
Needle decompression
Where is the needle inserted during a needle decompression?
Second intercostal space
Mid clavicular line
Over top of the rib
Why does the needle need to be inserted over top of the rib?
To avoid nerves arteries and veins on the undersides of the ribs
What should you do if the chest wall is too thick for a normal needle decompression?
Move the insertion site to the 4th or 5th intercostal space at the anterior axillary line
What is a hemothorax?
A collection of blood in the pleural space
What typically follows a needle decompression?
A chest tube
How might a patient with a hemothorax present when you perform a chest assessment?
Dull to percussion
Tachycardia
Hypotension
What can produce a hemothorax?
Aortic rupture
Myocardial rupture
Injuries to hilar structures
Injuries to intercostal blood vessels
Injuries to mammary blood vessels
What are the consequences of a hemothorax?
Crush lungs and heart
Restrictive lung conditions
Compromise of oxygen delivery
Hypovolemic shock
What is the minimum amount of blood required for a hemothorax to be visible on a CXR?
300 ml
Describe acute management of a “mild” hemothorax
28-32 french chest tube
Placed in 4th or 5th intercostal space in mid axillary or anterior axillary line
What position is the best for seeing a hemothorax on a CXR?
Upright
Blood pools in the bases
Describe management of a “severe” hemothorax
Emergent
Massive transfusion protocol
Surgical or ED thoracotomy to drain blood and treat source of bleeding
What qualifies as a “mild” hemothorax?
HTX > 300-500 ml
What qualifies as a “severe” hemothorax?
HTX > 1500 ml
Continuous bleeding
What does massive transfusion mean? Why is it necessary?
Blood loss is replaced with blood product
Normal saline cannot carry oxygen and lacks clotting factors
What are the characteristic patient presentations associated with a pneumothorax?
Sudden onset
Dyspnea
Sharp pleuritic pain
What are the 4 types of pneumothorax?
Tension pneumo
Primary spontaneous pneumo
Secondary spontaneous pneumo
Iatrogenic pneumo
Describe a primary spontaneous pneumothorax
Pneumothorax lacking external cause
Sometimes tied to drug use or increased transpulmonary pressure
Describe a spontaneous pneumothorax
Just happens
More common in tall skinny males
Describe a secondary spontaneous pneumothorax
pneumothorax with causal link to other pathology
What causal pathologies are linked to secondary spontaneous pneumothoraxes?
CF, COPD, Asthma
TB, necrotizing PNA
Marfan syndrome
Lung cancer or metastatic disease
Describe an Iatrogenic pneumothorax
Pneumothorax caused by medical intervention
What are some causes of iatrogenic pneumothorax
Lung biopsy
Seed placement
Central venous catheterization
Mechanical ventilation
Pacemaker insertion
Tracheostomy
What does a pneumothorax look like on an xray?
Lack of vasculature in lung field
Occasionally a border between lung and expanding pleural space is visible
What is deep sulcus sign?
CXR of a supine patient with a pneumothorax where air collects lower in the abdomen forming a deep sulcus sign instead of a sharp costaphrenic angle
How are emergent pneumothoraces treated?
Needle decompression
Finger thoracostomy
Chest tube
How are stable pneumothoraces treated?
Continual assessment of size and impact of pneumothorax
Supplemental oxygen if necessary
Time
How can you increase the speed at which the gas in the pleural space is reabsorbed in a stable pneumothorax?
Give supplemental oxygen increasing the partial pressure of oxygen in the blood and decreasing the partial pressure of nitrogen so that the nitrogen in the pleural space is more readily absorbed by the blood
What is a treatment option for individuals with recurrent pneumothorax?
Pleurodesis
What is a pleurodesis?
Visceral pleura is exposed to irritants to cause inflammation and fibrosis of the tissue resulting in the visceral and parietal pleura being fused together
Describe a pleural effusion
Excessive fluid in the pleural space
What is one of the most important things to consider when evaluating a pleural effusion
What is the liquid in the pleural space and what is causing it?
T/F: 10% of patient will have a pleural effusion after a CABG in the early post op period
False. 90% of patients will have a pleural effusion after a CABG in the early post op period
T/F: 90% of people hospitalized for bacterial PNA will develop a pleural effusion
False. 20-40% of people hospitalized for bacterial PNA will develop a pleural effusion
T/F: there is no link between lung cancer and pleural effusions
False. 15% of patient with lung cancer will develop a malignant pleural effusion
Pleural effusions can be caused by failures in which organs
Lungs
Heart
Liver
Kidneys
Describe how left sided heart failure can lead to a pleural effusion
The left side of the heart fails to move fluid forward
Fluid collects in the pulmonary vasculature
Hydrostatic pressure increases
Fluid pushes out into pleural space
In left sided heart failure, what is the source of the fluid? (where does it leak out from?
Leaks from the vasculature along visceral pleura into pleural space
Describe how right sided heart failure can lead to a pleural effusion
The right side of the heart fails to move fluid forward
Fluid collects in systemic vasculature
Hydrostatic pressure in systemic vasculature increases
Fluid is pushed out into pleural space
How can the liver cause a pleural effusion?
Failure to produce albumin (main protein used to maintain oncontic pressure)
In right sided heart failure, what is the source of the fluid? (where does it leak out from?)
The fluid leaks into the pleural space from the systemic vasculature along the parietal pleura
Describe the pathophysiology of how liver failure can cause a pleural effusion
Liver doesnt produce albumin
Fluid leaks out of blood into peritoneal space
Ascites forms
Hydrostatic pressure of ascites is so great that it pushes fluid through diaphragm into pleural space
Protein poor fluid gathers in pleural space
What condition in the lungs can cause a pleural effusion?
Pulmonary embolism
How can the kidneys cause a pleural effusion?
Failure to retain protein
Passed in urine, lowers oncotic pressure
How can a pulmonary embolism cause a pleural effusion
PE blocks circulation
Causes increased hydrostatic pressure
Increased pressure pushes fluid out into lung and into pleural space
What is a parapneumonic effusion?
Pleural effusion caused by bacterial PNA
Increased fluid collection resulting from the PNA results in fluid leaking into the pleural space
What differentiates a complicated parapneumonic PNA from a simple parapneumonic PNA?
Complicated parapneumonic PNA results when bacteria cross into the pleural fluid resulting in inflammation and infection
What is a collection of pus in pleural space called?
Empyema
How can problems with the gastrointestinal tract cause a pleural effusion?
Issues with lymphatic drainage can misdirect fluids into the pleural space
What cancers are most like to cause pleural effusions?
Lung, breast ovaries
How can cancer cause pleural effusions?
Metastasis near lymph nodes can disrupt lymphatic drainage
What is a malignant pleural effusion/
When cancer cells make in into the pleural space
A patient with a pleural effusion may complain of
Dyspnea
Pleuritic chest pain
Cough
Chest pressure or feeling of fullness
What findings on a chest assessment would be indicative of a pleural effusion?
Diminished breath sounds in affected area
Dull percussion notes in affected area
Decreased vocal fremitus
Egophony
Pleural friction run
Asymmetrical chest excursion
What imaging techniques can be used to detect a pleural effusion
Ultrasound
Chest radiograph
CT scan
What is the term for a pleural effusion that is trapped in one place and doesnt follow gravity?
A loculated pleural effusion
What can be assumed if a patient has transudative fluid in the pleural space?
That the pleural surfaces are healthy
The pleural spaces are diseased
Describe transudate
Thin watery fluid
Protein poor
Describe exudate
Fluid with high viscosity than transudate
Protein rich
Great deal of cell debris
What does straw colored fluid from the pleural cavity indicate?
Transudate
Not from infection
What does red fluid from the pleural cavity indicate?
Malignancy or trauma
What does milky white fluid from the pleural cavity indicate?
Chylothorax or cholesterol effusion
What does brown fluid from the pleural cavity indicate?
Old blood
What does black fluid from the pleural cavity indicate?
Malignancy
What are the tests run on fluid gathered from a thoracentesis?
Cell count and differential
pH
Protein
LDH
Glucose
What are the two “rules” used to differentiate between transudative and exudative pleural effusions
Lights criteria rule
Three test rule
What are options for treating a pleural effusion
Time
Thoracentesis
Chest tube
Pleurodesis
Indwelling pleural catheter
Describe a thoracentesis
Needle inserted into pleura space to drain fluid
No more than 1.5 liters removed at a time to prevent negative consequences
How does a pleurodesis prevent pleural effusions?
Collapses the space between the layers of pleura preventing further fluid collection
Describe an indwelling pleural catheter
Negative pressure bottle pulls fluid out of pleural effusion via indwelling catheter
Offered to patients who do not want pleurodesis
