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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
empyema
- infection of pleural space | - collection of pus
26
what is the most common cause of empyema
- complication of pneumonia - bacteria escape into pleural space - parapneumonic effusion -> complicated effusion -> empyema - 5-10% of pts dev parapneumonic effusions
27
other causes of empyema
- penetrating trauma - esophageal rupture - complication of lung surgery, thoracentesis, chest tube placement
28
fluid analysis for empyema
- grossly purulent fluid- very foul smelling - pH 7.2 - WBC > 50,000 - glucose < 60 - LDH > 1,000 (very high)
29
treatment for empyema
- drainage** - abx with thoracentesis - intrapleural fibrinolytic/ abx infusion - VATs thoracoscopy with tube drainage - clagett window - decortication and pulmonary resection
30
malignant pleural effusions
- 25% of all effusions - majority are exudative - half are positive on first thoracentesis - 30 day mortality is 30-50%
31
etiology of malignant pleural effusions
- increased capillary permeability - disruption of capillary endothelium - impaired lymphatic drainage - direct invasion of pleural space by tumor - malnourishment/ hypoalbuminemia
32
primary sites for malignant pleural effusions
- lungs*- most common site and worst prognosis - lymphoma - breast - ovary- best prognosis
33
treatment for malignant pleural effusions
- thoracentesis and tx malignancy - repeat thoracentesis for palliative care - tube thoracostomy - chemical pleurodesis - indwelling catheter - pleurectomy/ decorication
34
pleurodesis
- pleural space is artificially obliterated by causing visceral and parietal pleura to stick together - can be done via chemical or mechanical means
35
indications for pleurodesis
- recurrence of effusion or pneumothorax - lung re-expansion after thoracentesis - sx improvement after throacentesis - inability to control effusion with chemotherapy
36
sclerosing agents used for chemical pleurodesis
- talc - doxycycline - bleomycin - quinacrine - minocycline
37
indications for indwelling catheters
- rapid recurrence of effusion - failure of lung re-expansion after thoracentesis - sx improvement after thoracentesis - inability to control effusion with chemotherapy
38
pros of indwelling catheters
- less pain and shorter hospital stay than pleurodesis
39
cons of indwelling catheters
- obstruction of catheter - risk of infection - loculation of effusion
40
pneumothorax
- presence of air or gas in pleural space | - can enter via communication from chest wall or through lung parenchyma across visceral pleura
41
primary spontaneous pneumothorax
- 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
secondary spontaneous pneumothorax
- occurs in pts with underlying lung disease | - COPD most comon cause
43
catamenial pneumothorax
- endometriosis of chest -> pneumo | - occurs around time of menses
44
traumatic pneumothorax
- most commonly penetration of sharp rib fragment | - can be iatrogenic- central line placement, CT guided needle biopsy, thoracentesis, ventillation
45
si/sx of pneumothorax
- dyspnea - chest pain - shoulder pain - hyperresonate percussion - decreased tactile fremitus - decreased/ absent breath sounds
46
diagnosis of pneumothorax
- CXR - CCT - US
47
treatment of pneumothorax
- 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
what are blebs
- air filled bubbles | - non functioning lung tissue
49
why give supplemental O2 for pneumothorax even of SaO2 levels are normal
- lower partial pressure of nitrogen in chest cavity | - accelerates reabsorption of air -> lung re-expansion
50
tension pneumothorax
- 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
treatment of tension pneumothorax
- needle decompression in 2nd rib space midclavicular line | - followed by chest tube
52
clinical presentation of tension pneumothorax
- diaphoretic/ cyanotic - tachycardia usually > 135 - hypotension - chest pain - deviation of trachea - hyper-expanded chest - absent breath sounds - distended neck veins
53
foreign body aspiration
- potentially life threatening - more common in kids - common cause of morbidity and mortality in kids < 2
54
what is the most common aspirated FB
- nuts
55
what do infants and toddlers most commonly aspirate on
- food items
56
what do most older children most commonly aspirate on
- non-food items
57
what are the most fatal FB
- balloons - rubber gloves - marbles
58
where do most FB end up when aspirated
- right lung
59
factors that make FB more dangerous
- roundness - failure to break apart easily - smooth slippery surface
60
si/sx of FB aspiration
- severe respiratory distress, cyanosis, mental status change- emergency - stridor - hoarseness - dyspnea - wheezing
61
what are late findings of FB aspiration
- pulmonary abscess | - bronchiectasis
62
lower airway CXR findings for FB aspiration
- hyperinflated lungs - atelectasis - pneumonia
63
bronchoscopy for FB aspiration
- 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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