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Clin Med II > pleural diseases > Flashcards

pleural diseases Flashcards

1
Q

visceral pleura

A
  • covers lung parenchyma and is found in between lobes
  • no pain fibers
  • drained by pulmonary venous system
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2
Q

parietal pleura

A
  • covers inner surface of thoracic cavity, diaphragm and mediastinum
  • contains pain fibers
  • costal pleura and peripheral diaphragm supplied by intercostal nn
  • central diaphragm supplied by phrenic n
  • drained by lymphatic system in upper abdomen
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3
Q

normal pleural fluid

A
  • 1-10 mLs
  • clear ultrafiltrate of plasma
  • pH of 7.6
  • protein count < 2%
  • < 1000 wbc
  • glucose similar to plasma
  • LDH <50% of plasma
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4
Q

hydrostatic pressure

A
  • pushing force

- pushes fluid out of capillaries

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5
Q

oncotic pressure

A
  • pulling force

- pulls fluid from surrounding area into capillaries

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6
Q

pleural effusion

A
  • abnormal accumulation of fluid in pleural cavity

- pathologic process

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7
Q

where can pleural effusions originate from

A
  • lungs
  • another organ system
  • systemic diseases
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8
Q

etiology of pleural effusions

A
  • increased capillary permeability
  • increased hydrostatic pressure
  • increased negative intrapleural pressure
  • decreased oncotic pressure
  • decreased visceral pleural drainage
  • decreased lymphatic drainage
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9
Q

clinical presentation of pleural effusion

A
  • dyspnea
  • cough
  • chest pain
  • LE pitting edema if CHF
  • night sweats, fever, weight loss if TB or malignancy
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10
Q

physical exam findings for pleural effusions

A
  • dullness to percussion
  • decreased tactile fremitus
  • diminished or inaudible breath sounds
  • egophony (E -> A)
  • ** few findings if effusion < 250 cc
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11
Q

diagnosis of pleural effusion

A
  • effusion > 150 mL causes blunted costophrenic angles on CXR
  • CT for small effusions
  • US
  • determine if effusion is uni or bilateral
  • if bilateral usually a systemic issue
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12
Q

thoracentesis

A
  • used for effusion of unknown cause

- usually drain 1.5-2 L max

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13
Q

why is there a limit on how much fluid to drain during thoracentesis

A
  • puts pt at risk for re-expansion pulmonary edema (RPE)
  • lung expands and attracts water
  • longer the effusion has been there the more likely to dev RPE
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14
Q

when is thoracentesis C/I?

A
  • pt is on systemic anticoags

- area of infected skin on chest wall

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15
Q

hydrothorax

A
  • serous fluid

- similar color to pale ales

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16
Q

chylothroax

A
  • d/t chyle accumulation

- produced by fat break down and travels through throacic duct

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17
Q

hemothorax

A
  • blood
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18
Q

pleural fluid analysis

A
  • most important= protein and LDH levels**
  • cytology if suspect malignancy
  • culture and gram stain
  • specific gravity
  • cell count with diff
  • glucose
  • pH
  • should also analize blood serum protein and LDH
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19
Q

what specific gravity marks transudative effusion

A
  • < 1.015
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20
Q

what is lights criteria used for

A
  • used to det if fluid is transudative or exudative

- requires one of the markers to be dx as exudative

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21
Q

lights criteria components

A
  • ratio of pleural fluid LDH to serum LDH > 0.6
  • pleural fluid LDH is more than 2/3 ULN for serum LDH
  • ratio of pleural fluid protein to serum protein > 0.5
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22
Q

transudative effusions

A
  • mostly d/t imbalance between hydrostatinc and oncotic pressure in chest
  • CHF
  • atelectasis
  • nephrotic syndrome
  • cirrhosis
  • hypoalbuminemia
  • hypothyroidism
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23
Q

what is the most common cause of transudative effusions

A
  • CHF
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24
Q

exudative effusions

A
  • most commonly d/t pleural/ lung inflammation or impaired lymphatic drainage
  • pneumonia/ infections
  • malignancy
  • PE
  • RA/ SLE/ granulomatous diseases
  • worse prognosis
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25
Q

empyema

A
  • infection of pleural space

- collection of pus

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26
Q

what is the most common cause of empyema

A
  • complication of pneumonia
  • bacteria escape into pleural space
  • parapneumonic effusion -> complicated effusion -> empyema
  • 5-10% of pts dev parapneumonic effusions
27
Q

other causes of empyema

A
  • penetrating trauma
  • esophageal rupture
  • complication of lung surgery, thoracentesis, chest tube placement
28
Q

fluid analysis for empyema

A
  • grossly purulent fluid- very foul smelling
  • pH 7.2
  • WBC > 50,000
  • glucose < 60
  • LDH > 1,000 (very high)
29
Q

treatment for empyema

A
  • drainage**
  • abx with thoracentesis
  • intrapleural fibrinolytic/ abx infusion
  • VATs thoracoscopy with tube drainage
  • clagett window
  • decortication and pulmonary resection
30
Q

malignant pleural effusions

A
  • 25% of all effusions
  • majority are exudative
  • half are positive on first thoracentesis
  • 30 day mortality is 30-50%
31
Q

etiology of malignant pleural effusions

A
  • increased capillary permeability
  • disruption of capillary endothelium
  • impaired lymphatic drainage
  • direct invasion of pleural space by tumor
  • malnourishment/ hypoalbuminemia
32
Q

primary sites for malignant pleural effusions

A
  • lungs*- most common site and worst prognosis
  • lymphoma
  • breast
  • ovary- best prognosis
33
Q

treatment for malignant pleural effusions

A
  • thoracentesis and tx malignancy
  • repeat thoracentesis for palliative care
  • tube thoracostomy
  • chemical pleurodesis
  • indwelling catheter
  • pleurectomy/ decorication
34
Q

pleurodesis

A
  • pleural space is artificially obliterated by causing visceral and parietal pleura to stick together
  • can be done via chemical or mechanical means
35
Q

indications for pleurodesis

A
  • recurrence of effusion or pneumothorax
  • lung re-expansion after thoracentesis
  • sx improvement after throacentesis
  • inability to control effusion with chemotherapy
36
Q

sclerosing agents used for chemical pleurodesis

A
  • talc
  • doxycycline
  • bleomycin
  • quinacrine
  • minocycline
37
Q

indications for indwelling catheters

A
  • rapid recurrence of effusion
  • failure of lung re-expansion after thoracentesis
  • sx improvement after thoracentesis
  • inability to control effusion with chemotherapy
38
Q

pros of indwelling catheters

A
  • less pain and shorter hospital stay than pleurodesis
39
Q

cons of indwelling catheters

A
  • obstruction of catheter
  • risk of infection
  • loculation of effusion
40
Q

pneumothorax

A
  • presence of air or gas in pleural space

- can enter via communication from chest wall or through lung parenchyma across visceral pleura

41
Q

primary spontaneous pneumothorax

A
  • occurs in people without underlying lung disease
  • d/t rupture of blebs usually
  • occurs in pts that are male 18-40, tall, thin, smokers
42
Q

secondary spontaneous pneumothorax

A
  • occurs in pts with underlying lung disease

- COPD most comon cause

43
Q

catamenial pneumothorax

A
  • endometriosis of chest -> pneumo

- occurs around time of menses

44
Q

traumatic pneumothorax

A
  • most commonly penetration of sharp rib fragment

- can be iatrogenic- central line placement, CT guided needle biopsy, thoracentesis, ventillation

45
Q

si/sx of pneumothorax

A
  • dyspnea
  • chest pain
  • shoulder pain
  • hyperresonate percussion
  • decreased tactile fremitus
  • decreased/ absent breath sounds
46
Q

diagnosis of pneumothorax

A
  • CXR
  • CCT
  • US
47
Q

treatment of pneumothorax

A
  • conservative for small- watch with serial CXR
  • chest decompression via chest tube or pigtail catheter
  • O2 even if normal SaO2 levels
  • pleurodesis if recurrent
  • VATs blebectomy
48
Q

what are blebs

A
  • air filled bubbles

- non functioning lung tissue

49
Q

why give supplemental O2 for pneumothorax even of SaO2 levels are normal

A
  • lower partial pressure of nitrogen in chest cavity

- accelerates reabsorption of air -> lung re-expansion

50
Q

tension pneumothorax

A
  • progressive build up of air in pleural space
  • usually d/t lung laceration via trauma or iatrogenic -> air escaping into pleural space
  • more serious
  • pushes mediastinum into opposite hemithorax -> obstructed venous return -> cardiac arrest
51
Q

treatment of tension pneumothorax

A
  • needle decompression in 2nd rib space midclavicular line

- followed by chest tube

52
Q

clinical presentation of tension pneumothorax

A
  • diaphoretic/ cyanotic
  • tachycardia usually > 135
  • hypotension
  • chest pain
  • deviation of trachea
  • hyper-expanded chest
  • absent breath sounds
  • distended neck veins
53
Q

foreign body aspiration

A
  • potentially life threatening
  • more common in kids
  • common cause of morbidity and mortality in kids < 2
54
Q

what is the most common aspirated FB

A
  • nuts
55
Q

what do infants and toddlers most commonly aspirate on

A
  • food items
56
Q

what do most older children most commonly aspirate on

A
  • non-food items
57
Q

what are the most fatal FB

A
  • balloons
  • rubber gloves
  • marbles
58
Q

where do most FB end up when aspirated

A
  • right lung
59
Q

factors that make FB more dangerous

A
  • roundness
  • failure to break apart easily
  • smooth slippery surface
60
Q

si/sx of FB aspiration

A
  • severe respiratory distress, cyanosis, mental status change- emergency
  • stridor
  • hoarseness
  • dyspnea
  • wheezing
61
Q

what are late findings of FB aspiration

A
  • pulmonary abscess

- bronchiectasis

62
Q

lower airway CXR findings for FB aspiration

A
  • hyperinflated lungs
  • atelectasis
  • pneumonia
63
Q

bronchoscopy for FB aspiration

A
  • almost always successful in FB removal
  • can use rigid or flexible scopes
  • allows control of airway, good visualization, manipulation of object, and ready management of hemorrhage

Clin Med II (16 decks)

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