Pleural Diseases Flashcards
Describe the normal physiology of the pleural space
- fluid enters from capillaries in the visceral pleura
- fluid absorbed via lymphatics in the parietal pleura
Define pleural effusion
- abnormal build up of fluid in the pleural space
What can cause a pleural effusion?
- pleural fluid formation > absorption
- rate of absorption is decreased
- transport of peritoneal fluid from the abdominal cavity through the diaphragm or via lymphatics from a subdiaphragmatic process
Describe the physiology of pleural effusion and the result of each
- increased production of fluid in normal capillaries (abnormal pressure changes) ==> low protein “transudates”
- increased production of fluid d/t abnormal capillary permeability/inflam ==> high-protein “exudates”
- decreased lymphatic clearance ==> high protein “exudates”
Define empyema
- infection in pleural space
Define hemothorax
- bleeding into the pleural space
Define chylothroax
- lymphatic leakage from the thoracic duct or one of the main lymphatic vessels that drains into it
What are the types of pleural effusions?
- transudative
- exudative
- pus
- blood
- chyle
When do transudative type pleural effusion occur?
- altered systemic factors
- absence of local pleural disease
- leakage of fluid from intact normal capillaries d/t increased hydrostatic or decreased oncotic pressures
What are the causes of pleural effusion?
- MC: CHF
- nephrotic syndrome
- atelectasis
- chirrhosis
When do exudative pleural effusions occur?
- altered local factors
- presence of pleural disease
- increased production by the capillaries or blocking of lymphatics
- impaired lymphatic drainage/leaky capillaries
What are the causes of exudative pleural effusions?
- MC: parpneumonic effusion
- 2nd MC: 2ndary to malignancy
- mesothelioma
- PE
- trauma
- 2ndary to viral infection
What are the 3 types of parapneumonic pleural effusions?
- simple/uncomplicated
- complicated
- empyema
What causes hemothorax?
- MC: trauma
- surgery
- tumor
- ruptured blood vessel
- spontaneous
What is diagnostic of hemothorax?
- pleural fluid hematocrit:peripheral blood hematocrit > 0.5
What causes chylothorax?
- MC: lymphoma & surgical trauma
What does the cylothorax fluid look like?
- milky, white
What are the symptoms of pleural effusion?
- dyspnea
- pleuritic chest pain
- cough
What are the signs of pleural effusion?
- hypoxic
- decreased unilateral chest movement on affected side
- decreased breath sounds over area
- dull to percussion
- decreased tactile fremitus
- pleural friction rub
- tracheal deviation to contalateral side if large
- egophony
What does a pleural friction rub indicate?
- infarction
- pleuritis
What diagnostic tests are ordered for pleural effusion?
- CXR
- CT
What amount of fluid is required to see pleural effusion
- 75-100mL on lateral view
- 175-200mL on AP/PA view
How is a lateral decubitus CXR view helpful for pleural effusion?
- identifies free flowing vs. loculated effusions
What is the treatment of pleural effusion?
- thoracentesis
- tx underlying dz
What would purulent fluid from a thoracenteis point towards?
- empyema
What would putrid odor from a thoracenteis point towards?
- anaerobic empyema
What would milky, white fluid from a thoracenteis point towards?
- chylothorax
What would blood from a thoracenteis point towards?
- trauma
- malignancy
What is the traditional method to ddx between exudative and trasudative pleural effusions?
- Lights Criteria
What would the Lights Criteria yield in exudative pleural effusion?
- meets at least 1 criteria
What would the Lights Criteria yield in transudative pleural effusion?
- meets no criteria
What is the treatment for malignant effusion?
- pleurodesis
- serial thoracentesis if recurs
What is the treatment for empyemas?
- drainage
- long term abx
What is the treatment for hemothorax?
- immediate large bore chest tube placement
What is the definition of pleuritis/pleurisy?
- pain d/t acute pleural inflam caused by iritation of the parietal pleura
What causes pleuritis/pleurisy?
- anything that causes inflam
What are S&S of pleuritis/pleurisy?
- sharp, localized chest pain
- worsened by sneezing, deep breathing, or movement
What is the treatment for pleuritis/pleurisy?
- tx underlying dz
- anti-inflam
- pain control
Define pneumothorax
- collection of gas/air in the pleural space ==> collapsed lung
What are the types of Ptx?
- primary spontaneous
- secondary spontaneous
- traumatic
- iatrogenic
- tension
What causes a primary spontaneous Ptx?
- absence of underlying lung dz
What causes a secondary spontaneous Ptx?
- presence of underlying lung dz
What causes a traumatic Ptx?
- penetrating or blunt trauma
- open wound
What causes iatrogenic Ptx?
- s/p procedures
What causes tension Ptx?
- trauma
- lung infections
- mechanical ventilation
- resucitative efforts
What patient population is at highest risk for primary spontaneous Ptx?
- tall, thin, males 10-30 y/o
What is the suspected etiology of primary spontaneous Ptx?
- rupture of a subpleural apical bleb
For _______ Ptx, air pressure in the _______ _______ exceeds _______ pressure throughout the respiratory cycle
- tension
- pleural space
- ambient
What happen to the internal chest organs in tension Ptx?
- pushed to contralateral side
What are two events that occur with tension Ptx?
- hypoxia
- CV system collapse
What are the S&S of all types of Ptxs?
- chest pain on affected side
- dyspnea
- anxiety
- fatigue
- acute epigastric pain
What is seen on PE for Ptx?
- respiratory distress
- tachycardia
- unilateral chest expansion
- decreased breath sounds on affected side
- decreased tactile fremitus
- hyperressonace
Which of the common PE findings for Ptx suggest tension Ptx?
- tachycardia
- hypotension
- mediastinal/trachial shift
What tests should be ordered for Ptx?
- CXR
- ABG
- EKG
- CT
- US
What will be seen on CXR for Ptx?
- ipsilateral lung edge/visceral pleural line parallel to chest wall
- increased lucency
- deep sulcus sign
What is the tx for Ptx?
- small ( observation
- supplemental O2 to increase rate of reabsorption
- chest tube
- immediate decompression for tension
How can Ptxs be prevented in patients w/ (+) hx of Ptx?
- surgical removal of blebs or broncho-pleural fistulas
- smoking cessation
- minimize high altitude flying
- avoid SCUBA diving
