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Clinical Medicine II > Pleural Diseases > Flashcards

Pleural Diseases Flashcards

1
Q

What are the 2 layers of the pleura?

A

visceral pleura and parietal pleura

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2
Q

What is the pleura?

A

an elastic serous membrane with a smooth lubricating surface and is divided into 2 layers: visceral and parietal pleura

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3
Q

What is the visceral pleura?

A

covers the lung parenchyma and extends b/w the lobes (lining of the lung)-Contains NO pain fibers-Drained by the pulmonary venous system

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4
Q

What is the parietal pleura?

A

covers the inner surface of the thoracic cavity, diaphragm and mediastinum (lining of the inner chest wall)-Contains sensory nerves-Drained by the lymphatic system in the upper abdomen

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5
Q

What is the pleural cavity?

A

potential space b/c in normal people you can’t see the space -It’s not until air or fluid gets in b/w the 2 layers that you start seeing the 2 separate linings

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6
Q

What nerves supply the costal pleural & the peripheral portion of the diaphragm?

A

intercostal nerves

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7
Q

What nerve supplies the central portion of the diaphragm?

A

phrenic nerve E.g. If putting in a chest tube and it hits the diaphragm, pt get referred pain up to the shoulder

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8
Q

What is the primary function of the pleura?

A

to provide a smooth surface, which reduces friction as the pleurae move against each other As you breathe in and out, want very minimal friction b/w the surfaces

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9
Q

under normal conditions, what is in the pleural cavity?

A

Under normal conditions, there is a small amount of fluid in the pleural cavity; approx. 1-10mLs (0.1-0.2 ml/kg)

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10
Q

what are the characteristics of normal pleural fluid?

A

-Clear ultrafiltrate of plasma – looks light beer color -A pH of 7.6-7.64 -Protein count of less than 2% (1-2 g/dL)-Fewer than 1000 WBC’s per cubic millimeter -Glucose content similar to that of plasma -LDH less than 50% of plasma

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11
Q

how is pleural fluid formed?

A

Starling’s law of trans-capillary exchange -2 forces: hydrostatic pressure & oncotic pressure -> push & pull fluid back & forth in b/w the membranes

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12
Q

what is hydrostatic pressure?

A

Within the capillaries, think of hydrostatic pressure as the “pushing force” -Pushing fluid out of the capillaries, into the pleural space

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13
Q

what is oncotic pressure?

A

Think of oncotic pressures as the “pulling force;” -Pulling fluid from the surrounding tissues into the capillaries from the interstitium back into the vasculature -Water gets pulled from pleural space back to vessels

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14
Q

what happens when hydrostatic pressure is greater than oncotic pressure?

A

fluid will leave the capillaries

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15
Q

what happens when oncotic pressure is greater than hydrostatic pressure?

A

fluid will enter the capillaries

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16
Q

what is the hypothesis of how pleural fluid gets absorbed?

A

lymphatic stomata of the parietal pleura

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17
Q

what are pleural effusions?

A

abnormal accumulation of fluid in the pleural cavity

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18
Q

what are pleural effusions an indicator of?

A

pathologic process Manifestation of an underlying illness -primary pulmonary origin, or an origin related to another organ system, or to systemic disease

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19
Q

what is the most common etiology of pleural effusions?

A

increased hydrostatic pressure caused by CHF -back flow into pulmonary vasculature and fluid gets pushed out

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20
Q

what are etiologies of pleural effusions?

A

-increased capillary permeability (Pneumonia) -***increased hydrostatic pressure (CHF-most common)*** -increased (-) intrapleural pressure (atelectasis) -decreased oncotic pressure (nephrotic/hypoalbuminemia) -decreased visceral pleural drainage (Lymphoma) -decreased lymphatic drainage (Mediastinal node)

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21
Q

what is the clinical presentation of pleural effusions?

A

-Dyspnea (on exertion) -Cough - as fluid accumulates in confined space, it starts compressing in the lungs & lungs have less space to expand into -Chest pain Others: -Lower extremity edema (CHF) -Night sweats, fevers, weight loss (TB, malignancy)

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22
Q

what are the 4 physical exam signs for moderate to large pleural effusions?

A

-Dullness to percussion -Decreased tactile fremitus (pt says 99) -Diminished or inaudible breath sounds -Egophony (E to A transition) ***Little physical findings for effusions smaller than 250 cc*** If effusion is small, probably won’t have these

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23
Q

how do you diagnose a pleural effusion?

A

Pleural effusions of >150ml are usually seen on upright chest radiographs as blunting of the costophrenic angle -CT scans can detect very small effusions that can easily be missed by chest radiographs

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24
Q

When do you do a thoracentesis?

A

Effusion of unknown cause

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25
Q

What are the C/Is for doing a thoracentesis?

A

-Systemic anticoagulation

-Area of infected skin on chest wall
I.e. trauma patients -> don’t push needle through infection or burn b/c can push bacteria into pleural space

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26
Q

How much fluid should be drained during a single thoracentesis?

A
  1. 5-2.L
    - usually go for as much as the patient can tolerate unless in smaller community hospital then stop at 1.5-2.0L

Why not more? Re-expansion pulmonary edema (RPE)

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27
Q

what is re-expansion pulmonary edema (RPE)?

A

Etiology: Unknown

  • when lung expands it’ll soak up more fluid in a rapid amount of time
  • Hypoxic injury
  • Mechanical stress

*Not every patient that you tap large amounts of effusion will get this

MAIN REASON TO WATCH PTS AFTER A THORACENTESIS

-Seen within the hour after you have tapped

-Patients get symptomatic – start coughing, O2 status starts to drop

-Get CXR after tapped to see if lung has re-expanded

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28
Q

what is the main reason to watch pts after a thoracentesis?

A

re-expansion pulmonary edema (RPE)

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29
Q

what are the 4 types of fluid that can accumulate in the pleural space?

A

Serous Fluid (Hydrothorax) - primarily seen; water in the chest

Chyle (chylothorax) - lymphatic fluid that’s high in fat (when injure thoracic duct that goes from L&R chest, get chyle); these pts lose fluid quickly so need to rehydrate them

Blood (hemothorax)

Pus (empyema) - if pleural cavity gets infected

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30
Q

what is light’s criteria?

A

tells you if fluid is transudative or exudative

  • Criteria isolates an exudative effusion
  • Exudative is malignant, infectious causes
  • Transudative is not as serious, systemic issues and non-life threatening
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31
Q

what are transdative effusions due to?

A

imbalances in hydrostatic and oncotic pressures in the chest

***CHF = #1 cause of TRANSUDATIVE EFFUSIONS

***Exam question: elderly male with CHF and bilateral effusion à think for systemic causes

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32
Q

what is the #1 cause of transudative effusions?

A

CHF

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33
Q

what is Meig’s syndrome?

A

it’s NOT a transudative effusion

Consists of a triad of:

  • ascites
  • pleural effusion
  • benign ovarian tumor (fibroma)
34
Q

what are exudative effusions?

A

Disease in any organ can cause an exudative effusion, however, more commonly a result from pleural/lung inflammation or impaired lymphatic drainage

  • Pneumonia
  • Malignancy - Lung cancers = most common cause
  • Pulmonary embolism

***All of these cause exudative effusions b/c they cause damage to the lung

-more severe causes vs transudative effusion causes

35
Q

what is the most common cause of exudative effusions?

A

lung cancers

36
Q

what is an empyema?

A

infection of the pleural space (which is normally sterile)

37
Q

what are causes of empyema?

A

-**Complication of pneumonia, where bacteria escape into the pleural space**

  • Trauma (penetrating chest trauma)
  • Esophageal rupture (i.e. Mallory Weiss tear)
  • Complication of lung surgery, thoracentesis, chest tube placement
38
Q

pathophysiology of empyema

A

pneumonia -> parapneumonic effusion -> complicated parapneumonic effusion -> Empyema

  • pts that don’t abide by abx regimen
  • seen in elderly, immunosuppressed, poor nutrition
39
Q

fluid analysis of empyema

A
  • Grossly purulent fluid
  • pH level less than 7.2
  • WBC > 50,000 cells
  • Glucose < 60 mg/dL
  • LDH > 1,000 IU/ml
40
Q

what is the treatment for empyema?

A

DRAINAGE!!!

done by:

  • abx therapy w/thoracentesis
  • intrapleural fibrinolytic/abx infusion
  • VATs thoracoscopy with the tube drainage
  • Clagett Window – open drainage of the empyema cavity
  • Decortication and pulmonary resection
41
Q

what is the etiology of malignant pleural effusions (MPE)?

A
  • Increased capillary permeability
  • Disruption of capillary endothelium
  • Impaired lymphatic drainage
  • Direct invasion of pleural space by tumor
  • Malnourishment/hypoalbuminemia
42
Q

what are the primary sites for malignant pleural effusion?

A

-***Lung - 36%

  • Lymphoma
  • Breast
  • Ovary
43
Q

what MPE has the longest life expectancy?

A

Ovary - 9.4 months

44
Q

what is the treatment & goal of treatment for malignant pleural effusions?

A

***Goal is to drain the fluid and treat the underlying malignancy

  • Repeat thoracenteses
  • Tube thoracostomy – not ideal in outpatient setting

-***Chemical pleurodesis (beside or OR)

-***Indwelling catheters: Denver, Bard

-Pleurectomy/Decortication – aggressive approach

45
Q

what are the 2 main ways to treat Malignant pleural effusions?

A

Pleurodesis and Indwelling Catheters

46
Q

what is pleurodesis?

A

treatment for malignant pleural effusions

A medical procedure in which the pleural space is artificially obliterated by causing the visceral and parietal pleural to stick together

  • Instillation of a chemical sclerosant (chemical irritant)
  • Pleural abrasion (mechanical)
47
Q

what are the indications to do pleurodesis?

A

Recurrence of effusion or pneumothorax (do a tap & it comes back)

Lung re-expansion after thoracentesis*

  • After you tap, what you want to see on the X-ray after is full expansion of the lungs
  • If see lung hasn’t expanded into space, hydropneumothorax -> won’t do well with pleurodesis

Symptomatic improvement after thoracentesis* -> no more pain

Inability to control effusion with chemotherapy

48
Q

what scleorsing agents do you use for pleurodesis?

A

Talc & doxycycline

-docycycline acts as irritant in pleural space and causes inflammatory reaction and helps adhere 2 layers together

49
Q

what indicates success for pleurodesis?

A
  • Apposition of the pleural membranes (most important after 48 hours of pleurodesis)
  • Adequate pleural drainage from the chest tubes (If fluid gets in the way, then get pockets of fluid that will accumulate)
  • Ability of the lung to re-expand fully
  • Uniform distribution of the sclerosing agent
50
Q

what 2 indwelling catheters are used for treatment of malignant pleural effusions?

A
  • Denver Biomedical: PleurX
  • Bard: Aspira
51
Q

what are the indications for indwelling catheters in malignant pleural effusions?

A

-Rapid recurrence of effusion* - 1 biggest indication

-Failure of lung re-expansion after thoracentesis* - 1 biggest indication

52
Q

what are the pros & cons of indwelling catheters?

A

Pros:

  • Less pain
  • Shorter hospital stay

Cons:

  • Obstruction of catheter
  • Risk of infection
  • Loculation of effusion (Get small compartments of fluid b/c fluid is protein-rich)
53
Q

what is a pneumothorax?

A

presence of air or gas in the pleural cavity

Air can enter the intrapleural space through a communication from the chest wall (i.e. Trauma) or more commonly, through the lung parenchyma across the visceral pleura (i.e. rupture of bleb)

54
Q

what are the 4 types of pneumothorax?

A
  • Primary Spontaneous Pneumothorax
  • Secondary Spontaneous Pneumothorax
  • Traumatic Pneumothorax
  • Tension Pneumothorax
55
Q

what is a primary spontaneous pneumothorax?

A
  • Occurs in patients without underlying lung disease
  • Caused by rupture of small pulmonary blebs*
  • Blebs are air sacs that expand but don’t contract (little bubbles) -> rupture -> air leaks into the pleural space
  • Patient’s are typically aged 18-40 years, tall, thin, and are often smokers
56
Q

what is secondary sponteaneous pneumothorax?

A
  • Occurs in patients with underlying lung disease
  • *COPD is the MOST COMMON and accounts for about 70% of cases (These patients have poor lung compliance and thin tissues à break down and cause pneumothorax)

Other causes include:

-severe asthma, CF, lung infections (TB, necrotizing PNA), sarcoidosis, Marfan syndrome, lung cancer, sarcomas, catamenial PTX

57
Q

what is Catamenial PTX?

A

-endometriosis of the chest – common in women

  • Endometrial tissue will embed itself on the lung parenchyma and when they have their period, the little tissues of endometrium will swell and rupture
  • These patients come in with pneumothorax about 48-72 hours after their period à good question to ask about the timing of their period
58
Q

what is a traumatic (blunt or penetrating) PTX?

A

Most common is due to penetration of sharp bone points at a new rib fracture

59
Q

What is an iatrogenic PTX?

A

Caused by:

-Central venous catheter placement, CT guided needle biopsy of lung, thoracentesis, mechanical ventilation

60
Q

what are the signs & symptoms of pneumothorax?

A
  • Dyspnea
  • Chest pain
  • Shoulder pain (referred pain)
  • Percussion -> hyperresonant (b/c instead of lung tissue it’s hollow air)
  • Decreased tactile fremitus
  • Decreased/Absent breath sounds
61
Q

what is the best modality to diagnose a pneumothorax?

A

Chest ultrasound

62
Q

what is the treatment for small PTX?

A

conservative treatment

-watch them by getting serial x-rays to see if air space is getting bigger

63
Q

if patient has a large PTX, what’s the treatment?

A

chest decompressin via chest tube or pigtail catheter

64
Q

what must you give to someone who has a pneumothorax?

A

*Oxgyen:

-Supplemental O2 should be given in order to maintain adequate oxygenation, but this also lowers the partial pressure of nitrogen, which may in turn accelerate the rate of absorption of air from the pleural cavity and hasten lung re-expansion

-

Graham’s Law of Diffusion:

  • Gases move from high to low concentrations
  • Air in the pleural space is comprised mostly of Nitrogen
  • If give O2 ->Nitrogen wants to diffuse across -> shrinks down the pneumothorax
65
Q

what surgery can do you for PTX?

A

VATs blebectomy

-try to find the bleb (the source of the air leak)

66
Q

what is a tension pneumothorax?

A

Progressive build-up of air within the pleural space

-rapid progression of air in small amount of time

67
Q

what is a tension pneumothorax usually due to?

A

Usually due to a lung laceration via trauma or iatrogenic, which allows air to escape into the pleural space

68
Q

what does a tension pneumothorax lead to?

A

Progressive build-up pushes the mediastinum to the opposite hemithorax and obstructs venous return to the heart causing cardiac arrest

69
Q

how do you dx a tension pneumothorax?

A

Ultrasound and needle decompression

70
Q

what is the clinical presentation of a tension pneumothorax?

A
  • Diaphoretic/cyanotic
  • Tachycardia (HR > 135)
  • Hypotension (b/c heart is being compressed and can’t fill -> severe hypotension and chest pain)
  • Chest pain
71
Q

what are the classic physical exam findings for a tension pneumothorax?

A
  • Deviation of the trachea to the contralateral side (b/c air is pushing everything over)
  • Hyper-expanded chest
  • Absent breath sounds
  • Distended neck veins
72
Q

who are foreign body aspirations most common in?

A

children

  • Common cause of morbidity and mortality in children under the age of 2
  • 80% occurs in children < 3 years of age with peak incidence b/w 1 to 2 years of age
73
Q

what is the most common aspirated foreign body?

A

nuts

74
Q

what objects are commonly involved in fatal childhood foreign body aspiration?

A

toy balloons, rubber gloves, and marbles

75
Q

what factors make FBs more dangerous?

A
  • roundness
  • failure to break apart easily
  • smooth slipper surface
76
Q

what are the signs & symptoms of foreign body aspirations?

A

***Severe respiratory distress, cyanosis, mental status change = MEDICAL EMERGENCY!!!

77
Q

radiologic evaluation of foreign body aspirations

A

-Chest X-rays may be helpful if the object is radiopaque (i.e. plastic objects won’t light up on x-ray)

Lower airway FBA:

  • Hyperinflated lungs
  • Atelectasis – lung collapses distal to occlusion
  • Pneumonia – get this when lung collapses -> good environment for bateria
78
Q

what are late manifestations of a retained foreign body?

A

Pulmonary abscesses and bronchiectasis are late manifestations of a retained foreign body

79
Q

what are the main determinants of whether or not a bronchoscopy is needed for FBA’s?

A

detailed clinical hx and PE

80
Q

management of FBA’s

A

-***rigid/flexible bronchoscopy is almost always successful in FB removal (95% of the cases)

-surgery may be needed if FBs can’t be removed

Clinical Medicine II (10 decks)

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