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Pulmonary > Pleural Diseases > Flashcards

Pleural Diseases Flashcards

1
Q

Pleural space is lined with what cells?

A

mesothelial cells

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2
Q

What pneumothorax mean?

A

Accumulation of air in the pleural space

air in the lungs

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3
Q

What are the types of pneumothorax?

A

Spontaneous (primary and secondary)
Tension
Iatrogenic

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4
Q

What causes primary spont. pneumothorax?

A

Rupture of subpleural blebs (more common in tall thin young males)

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5
Q

What is pneumothorx secondary result to?

A 
Airway and pulmonary disease: COPD [most common], Asthma, CF
ILD: pulmonary fibrosis, sarcoidosis
Infectious: TB, HIV
Catamenial
Older patients with pulmonary diseases
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6
Q

What are the symptoms of PTX?

A

sudden onset dyspnea

pleuritic chest pain

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7
Q

What is the first investigation for PTX suspicion?

A

CXRAY

  • there are faint line markings
  • collapsed lung
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8
Q

Whats treatment for PTX?

A

100% O2 –> displaces N2 from capillaries –> higher gradient of N2 in pleural space

OR

Chest tube to drain the air

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9
Q

What kind of PTX develops from trauma?

A

tension pneumothorax

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10
Q

What happen in tension PTX?

A

Air enters pleural cavity but cannot leave

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11
Q

T or F: Tension pneumothorax is a medical emergency

A

T:

bc the pleural pressure can start compressing on vessels –: life threatening

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12
Q

What is treatment for tension PTX?

A

Thoracentesis or Chest tube placement

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13
Q

T or D: trachea deviates to affected side

A

F:

Spontaneous it goes to affected side
Tension goes away

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14
Q

What is pleural effusion?

A

accumulation of fluid in pleural space

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15
Q

What can be seen on CXR for Pleural effeusions?

A

no or blunted costophrenic reccess
miniscus sign
less black lung field

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16
Q

What are the etiologies of pleural effusions?

A

Transudative
Exudative
Lymphatic

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17
Q

What is transudative effusions?

A

high hydrostatic pressure or very little protein in blood drive fluid from capillaries into pleural space

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18
Q

What can cause low protein?

A 
nephrotic syndrome (low protein)
cirrhosis (low albumin)
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19
Q

What is exudative effusions?

A

fluid (ie. plasma and proteins) leaking to pleural space due to high vascular pneumonia

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20
Q

What are causes of exudative effusions?

A

malignancy

pneumonia

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21
Q

Whats the treatment for exudative?

A

drainage (as opposed to rectify underlying cause)

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22
Q

How to differentiate between transudative and exudative?

A

perform thoracentesis then test for protein and LDH:
Use then Light’s criteria:
Exudate if:
pleural protein/serum protein ratio greater than 0.5
Pleural LDH/serum LDH greate rthan 0.6
pleural LDH greater than 2/3 upper limits normal LDH

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23
Q

What is chylothorax?

A

Lymphatic effusions

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24
Q

When does a lympatic pleural effusion happen?

A

from thoracic duct obstruction/injury (ie. fluid backs up and then floods to pleural space) due

  • Malignancy OR
  • surgical trauma
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25
Q

Whats the characteristics of lymphatic effusions?

A

milky-appearing fluid

very high triglycerides

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26
Q

What are other types of effusions?

A
  • hemothorax

- empyema (infection of pleura)

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27
Q

What is a mesothelioma?

A

pleural tumor due to asbestos exposure (ie. from shipyards)

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28
Q

What is seen in CXR for mesothelioma?

A

pleural thickening with maybe pleural effusions

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29
Q

What are the symptoms of mesothelioma?

A

dyspnea, cough, chest pain

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30
Q

What is work-up for suspected pleural effusion?

A

US-guided thoracentesis

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31
Q

What are the functions of the pleura?

A

Facilitates movement of lungs

Mechanical support
Inflation: maintain shape & limit expansion
Deflation: increase elastic recoil

Route of escape for alveolar edema

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32
Q

What is the characteristics of a normal pleura?

A
  • Volume: ~ 0.26 mL/kg = 18.2 mL in 70kg man
  • low-protein (<15 g/l) filtrate containing few cells
  • No RBCs
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33
Q

Where does the fluid in pleura come from?

A

systemic vessels that supply the parietal and visceral pleura

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34
Q

Where does the pleural fluid drain?

A

lymphatic stoma

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35
Q

What can cause pleural effusions?

A

Increased fluid entry (must be >30x normal)

Decreased fluid clearance

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36
Q

What is the equation for flow?

A

Flow = Permeability x (Hydrostatic pressure – Osmotic pressure)

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37
Q

What can cause increased fluid entry?

A 
Increased hydrostatic pressure (CHF)
Increased permeability (infection, ARDS)
Decreased osmotic pressure (nephrotic syndrome, cirrhosis)
38
Q

What can cause decrease fluid clearance?

A

Lymphatics have one-way valves that propel lymph using rhythmic contractions and respiratory movements of chest
Flow is affected by intrinsic and extrinsic factors

39
Q

What instrinic factoes?

A

Cytokine production
Injury due to radiation or drugs
Infiltration of lymphatics by cancer

40
Q

What are extrinsic factors?

A

Extrinsic compression of lymphatics (pleural fibrosis)

Blockage of lymphatic stoma (pleural malignancy ie. mesothelioma)

41
Q

T or F: pleural effusion lead to increased work of breathing and dyspnea

A

T
Chest wall recoils outward, and lungs recoil inwards –> mechanical inefficiency
Remember pleural pressure is due to patient effort

42
Q

T or F: physical maneuvers are relatively insensitive

A

T

cannot detect fluid less than 300 mL

43
Q

What physical findings would be present in pleural effusion?

A

Dullness to percussion
Decreased chest wall movement

Decreased tactile fremitus
Absent breath sounds
Bronchial breath sounds and Egophony at top of pleural effusion

44
Q

What physical findings would be present in consolidation?

A 
Dullness to percussion
Decreased chest wall movement
Increased tactile fremitus
Bronchial breath sounds 
Egophony
45
Q

Can chest xray help in the detection of pleural effusion?

A

YES PA & Lateral scans can BUT fluid greater than 150 mL

  • especially lateral decubitus (side down)
46
Q

what is thoracic ultrasound usually help in?

A

helps to guide thoracentesis procedure

47
Q

T or F: thoracic ultrasound is highly sensitive and specific for the detection of pleural fluids

A

T:

able to detect 10-50 mL

48
Q

Which diagnostic imaging tool is more sensitive than TUS?

A

CT chest

49
Q

T or F: thoracentesis is only diagnostic

A

F:

Diagnostic and therapeutic

50
Q

What are contraindications for thoracentesis?

A
  • bleeding disorder
  • anticoagulation meds
  • no consent/cooperation
  • small pleural effusion
  • cutaneous disease at injection site
  • on mechanical ventilation
51
Q

What are some complications of thoracentesis?

A 
Pneumothorax 
<3% with ultrasound
Up to 12-30% without ultrasound
Hemothorax
Infection – cellulitis/empyema
Puncture of abdom structures (i.e. liver, spleen)
Rare with ultrasound
Re-expansion pulmonary edema
52
Q

Is Light’s criteria sensitive and specific?

A

Yes! (Sens 98%, Spec 83%)

53
Q

T or F: in transudative effusions, pleural capillaries are normal

A

T:

Due to imbalance between hydrostatic [congestive heart failure] and oncotic pressure [nephrotic sydrome/cirrhosis]

54
Q

Will thoracentesis work for transudative effusions?

A

No - the underlying cause must be treated

55
Q

What is causes exudative effusions?

A

implies the leakage of protein-rich plasma across an injured endothelial barrier

56
Q

What may cause exudative effusions?

A

Infection:
Parapneumonic effusion
Empyema

Malignancy:
Lung
Lymphoma
Mesothelioma

Pulmonary Embolism/Infarction

Trauma

57
Q

After a fluid from thoracentesis for diagnostic, what workups should follow?

A 
Cell count and differential 
Total Protein
Lactate dehydrogenase (LDH)
Glucose
Gramstain and Culture
Cytology

Blood should be sent at the same time for LDH and Total protein levels

58
Q

What are the treatment if chylothorax is present after thoracentesis?

A

Restrict lipid intake and treat cause

59
Q

What are the treatment if hemothorax is present after thoracentesis?

A

Consider chest tube insertion; consider referral to thoracic surgery

60
Q

The pleural effusion is exudative and has a pH less than 7.2, what does it suggest?

A

Complicated parapneumonic effusion/Empyema
Esophageal rupture
Rheumatoid arthritis

61
Q

The pleural effusion is exudative and has a glucose less than 3.4mmol/L, what does it suggest?

A

Complicated parapneumonic effusion/empyema

62
Q

The pleural effusion is exudative and has a RBC greater than 100,000 cells/mm^3 less what does it suggest?

A

Malignancy

63
Q

The pleural effusion is exudative and has a hemotocrit greater than 50% of systemic, what does it suggest?

A

Hemothorax

64
Q

The pleural effusion is exudative and has a lymphocyte count greater than 50%, what does it suggest?

A

Lymphoproliferative disorder

Other malignancy

65
Q

The pleural effusion is exudative and has increased pleural eosinophil count, what does it suggest?

A 
Air in the pleural space = PNEUMOTHORAX
Blood = HEMOTHORAX
Idiopathic
Drugs:Sulfasalazine, Nitrofurantoin, epival
Benign Asbestos-related pleural disease
66
Q

Increased eosinophil (PFE, also called eosinophilic pleural effusion) happensat different rates in spont. pneumothorax ans hemothorax, elaborate:

A

In contrast to the rapid development of PFE after spontaneous pneumothorax, PFE is delayed following hemothorax, typically appearing by the tenth day,

67
Q

The pleural effusion is exudative and has amylase level greater than Upper Lower limits of normal (ULN) for serum, what does it suggest?

A

Esophageal rupture
Pancreatitis
Malignancy

68
Q

What does Elevated pleural fluid triglyceride levels (>1.24mmol/L) in exudative fluid suggest?

A

Chylothorax

69
Q

If the values for pleural effision fluid falls between exudative and transudativem how can you differentiate?

A

Serum protein – pleural protein > 31 g/L

= TRANSUDATE

70
Q

What to do if diagnosis fails after 1st thoracentesis?

A

REPEAT THORACENTESIS
BRONCHOSCOPY – suspicion of lung cancer
CLOSED PLEURAL BIOPSY – suspicion of tuberculosis

71
Q

What happens if 1st thoracentesis and other further diasgnostic tool cannot pinpoint a diagnosis?

A

Thorascopy (provides 92% diagnosis for NYD)

72
Q

When would you to bronchoscopy for pleural effusion?

A

hemoptysis

CT chest findings concerning for lung cancer

73
Q

When would you do drainage for pleural effusions?

A

For transudative effusions, usually unsuccessful and rarely part of the management

For exudative effusions, often a necessary component of the treatment plan

74
Q

What are some options for aggressive drainage?

A 
Tube thoracostomy (chest tube insertion):
CT- or ultrasound-guided

Thoracic surgery referral:
Thoracoscopy
Open surgical drainage/decortication

75
Q

What is pleurodesis?

A

Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae

76
Q

How can pleurodesis be achieved?

A

Chest tube + Sclerosing agent

Thoracoscopy + Rough pad

77
Q

What would you do if fluid re-accumulate/continue to cause symptoms ?

A

Pleurodesis:
Surgical
Thoracostomy

Indwelling pleural catheter

78
Q

What is the etiologies of pneumothorax?

A

Rupture of visceral pleura with secondary airleak from lung
Rupture of bronchus or trachea
Rupture of esophagus
Loss of integrity of chest wall

79
Q

What are physiological effects of pneumothorax?

A 
Apex to base pressure gradient
Lung compliance 
FRC
Ventilation   
Oxygenation   
Progressive shift of the mediastinum
Decreased venous return to the heart → obstructive shock
80
Q

What are some symptoms of pneumothorax?

A

Sudden
Chest pain
Shortness of breath

81
Q

What are signs of PTX?

A 
Tachypnea / tachycardia
Hypoxia
Hypotension
Elev. JVP
Dec breath sounds
Hyperessonance
Tracheal deviation
82
Q

What are blebs?

A

Blebs – small, subpleural collection of air resulting from ruptured alveoli
- apex of upper/lower lobe

83
Q

What are bullae?

A

large air filled spaces within the lung associated, with any form of emphysema

84
Q

How to diagnose PSP?

A

Symptoms / signs
C- x-ray – PA film with insp. & exp. views
Quantification – nomograms vs. description
CT scan – only used in complicated pneumothorax

85
Q

What is management for PSP?

A

Observation – select few; small asymptomatic p.; resolving; good follow up

Tube thoracostomy – most common & safe;can be ambulatory or in hospital; lung must be reexpanded

Chemical pleurodesis - tetracycline, talc

- only used if patient refuses surgery   or is high risk
- induces pleural fibrosis and adhesions
86
Q

What are some surgical therapy for PSP?

A

Resect blebs
Obliterate the pleural space
- apical pleurectomy
- pleural abrasion

87
Q

What is the risk of recurrence based on the given therapeutic intervention?

A

Observation – 30%
Chest tube – 20-30 %
Chemical pleurodesis – 7-20%
Surgery – 2-5%

88
Q

T or F: secondary spontaneous pneumothorax has higher motarlity

A

T

89
Q

What is catamenial pneumothorax?

A

associated with menstration ( 48-72 hrs) in 20-30yrs old where air reaches chest from cervix via diaphragm pleural endometrial implants

90
Q

Where is needle thorascotomy performed?

A

2nd intercostal space , mid clavicular line

91
Q

What always follows needle thorascotomy?

A

Chest tube

92
Q

Where is the chest tube placed?

A

mid axillary line, in line with nipple

Pulmonary (25 decks)

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