Pleural Diseases Flashcards
Visceral Pleura – Single layer of mesothelial cells with
microvilli projections and a ___ connective tissue layer
Parietal Pleural – Single layer of mesothelial cells with
microvilli projections and a ___ loose connective tissue
layer with lymphatic stomata
Visceral Pleura – Single layer of mesothelial cells with
microvilli projections and a thick connective tissue layer Parietal Pleural – Single layer of mesothelial cells with
microvilli projections and a thin loose connective tissue
layer with lymphatic stomata
pleural function
allows extensive movement of the lung relative to thec hest wall.
the visceral pleural mya provide mechanical support to the lung since it has thick CT.
- pleural space and parietal pleural lymphatics can drain edema.
- mesothelial cells have a number of immune and metabolic functions.
explain the microcirculation of the pleural space.
in the pleural space, it is slightly negative pressure. this allows for lymphatic fluid and lubricating fluid to come in and circulate. it gets circulated by lymphatic stoma.
what is pleural effusion
when the increased fluid entry rate is too high for the rate of fluid exit in the pleural space.
- causes retrodriaphragmatic opacity, costophrenic blunting, and can see fluid levels on XR
transudate vs exudate
transudate; leaking due to increased pressures into the pleural space.
exudate; leaking due to broken capillaries and membranes in the pleural space. often results in a hetergenous cell make up.
Lights criteria for transudate vs exudate distinguishment
basically for an exudate, there are higher PF/serume protein and LDF ratios.more protein is leaking into the pleural space.lots of cell breakdown leaking through damaged capillatry.
causes of pleural fluid transudates and exudates.
tests to run on pleural fluid analysis that you got from the pleural effusion
- glucose, ldh, protein serum, PF, pH, triglycerides, cholesterol
- cell count and differential
- culture, cytology
- tumor markesr
Common transudates
heart failure accounts for 90% of transudate cases.
Heart failure
• Account for > ___% of all transudates
• Diagnosis is usually made on ___ grounds
• NT-____can be measured in the pleural fluid to assist with the
diagnosis but is expensive
• Effusion usually resolves after treatment of heart dysfunction and volume overload
Heart failure
• Account for > 90% of all transudates • Diagnosis is usually made on clinical grounds
• NT-proBNP can be measured in the pleural fluid to assist with the diagnosis but is expensive
• Effusion usually resolves after treatment of heart dysfunction and
volume overload
underlying cause of hepatic hydrothorax
liver dysfunction –> increased hepatic portal hypertension –> ascites –> belly full of water –> water drawn up into chest. Fluid migrates across the diaphragm and causes effusion.
Hepatic hydrothorax
• Incidence ~ 6% of patients with cirrhosis
- Diagnosis usually made on clinical grounds
- __ > L > bilateral
- Fluid analysis will have a similar profile as __ fluid
- Effusion usually resolve with drainage of __ and treatment of liver dysfunction (__, transplant)
Hepatic hydrothorax
• Incidence ~ 6% of patients with cirrhosis
- Diagnosis usually made on clinical grounds
- R > L > bilateral
- Fluid analysis will have a similar profile as ascetic fluid
- Effusion usually resolve with drainage of ascites and treatment of liver dysfunction (TIPS, transplant)
Nephrotic syndrome
• Incidence ~ 20% of patients with nephrotic syndrome
- Caused by both ___ pressure and ___ pressure gradients
- Fluid analysis usually with very ___ protein
• As with most other transudates, the treatment is to treat the
underlying disorder
Nephrotic syndrome
• Incidence ~ 20% of patients with nephrotic syndrome
- Caused by both oncotic pressure and hydrostatic pressure gradients
- Fluid analysis usually with very low protein
• As with most other transudates, the treatment is to treat the
underlying disorder
common exudate causes
anything that can cause the lung tissue integrity to be compromised
- pulmonary embolism
- connective tissue disease
- chylothorax
- pleural infection
- pleural malignancy
A pulmonary embolism causes widespread ___ wave depression ECG. It causes ____ of the lung parenchyma.
t wave depression, it causes inflammation of the lung parnchyma.
• No specific treatment is indicated as the
effusion resolves with resolution of
inflammation and clot resorption
outline the characteristic pleural fluid profile in someone with connective tissue disease (RA)
2 characteristic findings on the pleural fluid analysis indicative of RA causing the PE exudate
- cholesterol crystals and comet tail macrophages.
• Most resolve spontaneous • Don’t clearly respond to immune suppression • May persist and cause pleural thickening requiring surgical
decortication
T/F: the pleural fluid analysis profile for SLE has the same profile as RA
false
chylothorax
pleural fluid containing chylomicron rich lymph form the digestive system. type of exudate that is caused by thoracic duct malfunction. causes lymph to lead out of pleural space.
treatment of chylothorax
treated with diet management, drainage, repair/ligation of the thoracic duct or treatment of an underlying disease.
simple parapneumonic effusion, complicated parapneumonic effeusion, and empyema
Simple parapneumonic effusion – Free flowing sterile effusion with normal glucose and pH
Complicated parapneumonic effusion – Loculated effusion or infected or low glucose (< 40 mg/dL) and pH <7.20
Empyema – Pus in the pleural space
out of the three types f pleural infections, which two requie a chest tube?
- complicated para pneumonic effusion
- empyema
incidence of empyema
6/100k. incidence is increasing for unknown reasons.
• Majority of empyema cases are
associated with ___
acquired __
___
• Majority of cases are
associated with community
acquired bacterial
pneumonia
diagnosis of empyema
physical exam or chest imaging necessary to identiy effusion. chest imaging is the mainstay of diagnosis and can offer clues to the nature of the effusion.
characteristic MRI findings of empyema
there is thickened pleural and gas producing bacteria.
3 stages of empyema (EFO)
- exudative phase:leaking of sterile pleural fluid. can cause lung collapse if too much fluid. causes the initial pleural effusion on XRAY..
- fibrosis: migration and proliferation of bacteria resulting in pus formation.
- organization phase: fibroblast growth over pleural surfaces causing loculations
what pleural fluid analysis findings would you find in someone with a pleural effusion caused by infection?
- exudate with high protein and high LDH
- may have low glucose and low pH when complicated
- wbcs
- positive culture.
relationship between dentition and empyema
patients with bad teeth are more likely to develop complicated pleural effusion infections.
outline common bacteria that causes infection and pleural effusion. what’s the most comon?
strep pneumo
styph aureus
haemofilus influ
mrsa
strep pyo
enterococcus
ecoli
e coli
kelbisella
Treatment for empyema
chest tube
TPA and DNASE
Antibiotics for underlying infection
- surgical decortation if there’s lots of fibrosis
two meds in addition to antibiotics that helps with empyema
tpa and Dnase
CAI and HAI outcome differences in empyema
pneurmothorax: • Increasing pressure can collapse the __ __ and ___ ventricle (low pressure systems/systemic ___) and cause circulatory collapse (__ ___ causes pressure on cardiac structures)
• Increasing pressure can collapse the vena cava and right ventricle (low pressure systems/systemic Hypotension) and cause circulatory collapse (tension pneumothorax causes pressure on cardiac structures)
causes of pneumothorax with no damage to visceral pleura
- pneumonectomy– space filled with fluid
- trapped lung
loculated pneumothorax
on ultrasound, which one has pneumothorax? characteristic sign?
on right: barcode sign. pneumothoax.
on left: seashoe sign: normal– the pleural linings are sliding on one another.
treatment of persistent air leak from chest tube.
pleurodesis
4 methods of pleurodesis
Pleurodesis procedures
• Introducing sclerosing agents via chest tube
• Autologous blood patch
• Introducing sclerosing agents during surgery
• Mechanical abrasion of the pleural during surgery
pleural tumors can also cause exudative effusion.
Pleural tumors
• Divided into primary or secondary (metastatic) • ___ pleural tumors are rare whereas ___ pleural disease is
common
Pleural tumors
• Divided into primary or secondary (metastatic) • Primary pleural tumors are rare whereas metastatic pleural disease is
common
most common of the pirmary pleural tumors
mesothelioma.
most common presentation of underlying mesothelioma
common presentation is maligannt pleural effusion (MPE)>
most common types of metastatic cancers causing malignant pleural effusion
lung and breast
diagnosis of MPE (malignant pleural effusion)
- irregular, nodular, thickened pleura on CXR
- thoracentesis has 60-75% sensitivity for malignancy.
- OPEN PLEURAL BIOPSY IS GOLD STANDARD.
management of MPE
we almost always use talc to promote adherence to both pleural layers
pleural mesothelioma
- rare tumor strongly associated with ____ exposure.
3 types of pleural mesothelioma:
- Dx uaully requires pleural biopsy
pleural mesothelioma
- rare tumor strongly associated with asbestosis exposure.
3 types of pleural mesothelioma:
• Epithelioid
• Sarcomatoid
• Biphasic (mixed)
- Dx uaully requires pleural biopsy
