Pleural Disorders Flashcards
what is the pleura
the serous membrane lining the thorax (chest wall) and enveloping the lungs
what is the difference between parietal and visceral pleura
Parietal - attached to the chest wall
Visceral - covers the lungs, blood vessels, bronchi and nerves
(parietal and visceral plerua are continuously connected)
what is the pleural cavity
the thin serous fluid-filled (potential space) between the two pulmonary pleura
(radiographically should not be visualized unless there is pathology)
what is the pleural fluid
fills the pleural space/cavity; helps the two layers of pleura glide smoothly past each other during breathing
what is pleurisy
AKA pleuritis
Inflammation of the pleura that causes sharp pain with breathing
what is a pneumothorax
Buildup of air or gas in the pleural spacew
what is a pleural effusion
a collection of fluid in the pleural space resulting from a disruption in the normal pleural homeostasis
Describe pleurisy (pleuritis) and what is leads to
an inflammation of the parietal pleura leading to pain with respiration
pain fibers are located in the parietal pleura, when it becomes inflamed the normal gliding between the 2 pleura incites pain
this is a common cause of noncardiac chest pain
what are causes of pleurisy/pleuritis
- resp infection
- lung cancer near pleural surface
- trauma (rib fracture)
- certain meds (procainamide, hydralazine, isoniazid)
- PE
- CHF
- AI disorder (lupus, RA, scleroderma)
- GI disorders (pancreatitis, peritonitis, cholecystitis)
- idiopathic
what medications can cause pleurisy
- procainamide
- hydralazine
- isoniazid
what AI disorders can cause pleurisy
- Lupus
- RA
- scleroderma
what GI disorders can cause pleurisy
- pancreatitis
- peritonitis
- cholecystitis
what are the MC symptom of pleurisy
- chest pain that is sharp “knifelike”, feleting pain worsened with inspiration, sneezing, or coughing
- radiation of pain to ispilateral scapula may occur if diaphragmatic pleura is affectd
aside from chest pain…what are the assocaited s/s of pleurisy
- cough, SOB
- symptoms specific to cause! (there are cards on this later!)
what symptoms would accomapany pleurisy caused by an infectious etiology?
- fever
- myalgias
- headache
- nasal congestion
what symptoms would accomapany pleurisy caused by a GI etiology
- abdominal pain
- N/V
what symptoms would accomapany pleurisy caused by CHF
- orthopnea
- paroxysmal nocturnal dyspnea (PND)
- peripheral edema
what symptoms would accomapany pleurisy caused by a PE
- pleural friction rub
- decreased breath sounds
what needs to be ruled out with a patient presenting with pleuritis
concerning sources of chest pain!!! such as:
- pericarditis
- MI
- PE
- pneumothorax
- pleural effusions
what testing should be obtained in a patient with pleurisy
- EKG - normal unless cardiac etiology
- CXR - reflect etiology
- Rib Xray series - r/o rib fracture if trauma
- serology - case based, CBC, Cardiac enzymes, BNP, pancreatic enzymes, inflammatory markers (ESR, CRP), ANA/RF (AI workup)
- CT chest with contrast or CT angiography (if unsure of underlying etiology or worried about PE)
what is the management for pleurisy
- treat underlying cause
- NSAIDS or other analgesics (indomethacin BID-TID for 7-10 days)
- cough suppressent (caution with prod cough)
- abx if indicated
when should you admit a patient with pleurisy
- hypoxemic (o2 sat of <90%)
- parenteral pain control is needed
- underlying etiology requires hospitalization
what cough suppressent should be offered to pleurisy patients, when should it be cautioned
- codeine 30-60 TID
- dextromethorphan combo products
- tessalon perles
- be cautious of retention of airway secretions with cough suppressants!!!
what complications can be seen in pleurisy
pleural effusion - pain will improve transiently due to separation of pleura; SOB and cough will worsen
how is pleural fluid homeostasis maintained
- constant movement of fluid from the capillaries of the parietal and visceral pleura into the pleural space
- absorption of plerual fluid occurs through parietal pleural lymphatics
- resultant homeostasis leaves 5-15 mL of fluid in the normal pleural space
what are the 5 pathophysiologic processes that can lead to pleural effusions
- Increased production of fluid due to increased hydrostatic or decreased oncotic (osmotic) capillary pressures¹ (Transudates)
- Increased production of fluid due to abnormal capillary permeability (Exudates)
- Decreased lymphatic clearance of fluid from the pleural space (Exudates)
- Decreased lymphatic clearance of fluid from the pleural space (Exudates)
- Bleeding into the pleural space (Hemothorax)
what is a transudate in reference to pleural effusion
A fluid that passes through a membrane (capillary wall), which filters out all the cells and much of the protein, yielding a watery solution.
A transudate is a filtrate of blood caused by an imbalance in hydrostatic and colloid osmotic pressure
what are exudates in reference to pleural effusion?
A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues. The altered permeability of blood vessels permits the passage of large molecules and solid matter through their walls
what hx is important when assessing a patient with a possible pleural effusion
- recent illnesses (URI, PNA?)
- chronic med conditions (liver, heart, kidney, cancer, alcoholism)
- trauma?
- recent travel? (increased risk for TB an PE)
- occupational hx? (asbestos)
- medication hx
- TB exposure?
what are the MC presenting symptoms for pleural effusion
- dyspnea
- cough
- pleuritic chest pain
what symptoms would accompany pleural effusions caused by CHF
- lower extremity edema
- orthopnea
- PND
what symptoms would accompany pleural effusions caused by TB
- night sweats
- fever
- hemoptysis
- weight loss
what symptoms would accompany pleural effusions caused by malignancy
- hemoptysis
- weight loss
what symptoms would accompany pleural effusions caused by pneumonia
- fever
- purulent sputum
- pleuritic chest pain
what does clinical presentation likely depend on for pleural effusion?
effusion severity/size (also underlying causes!)
what are PE findings for pleural effusion
- diminished/absent breath sounds
- dullness to percussion
- decreased tactile fremitus
- diminished/delayed chest expansion on side of effusion
- displacement of trachea away from effusion (only with large effusions)
- findings pertinent to etiology
what are the PE findings associated with pleural effusion d/t CHF
- peripheral edema
- JVD
- S3 gallop
what are the PE findings associated with pleural effusion d/t nephrotic syndrome of pericardial disease
peripheral edema
what are the PE findings associated with pleural effusion d/t liver disease
- jaundice
- ascites
what are the PE findings associated with pleural effusion d/t malignancy
- LAD
- palpable mass
what would a CXR show in a patient with pleural effusion
- PA - blunting of the costophrenic angle is evident if there is >175 ml (6oz) of fluid present
- loculation along fissures or chest wall
- deviation of bronchi away from effusion
- possible air bronchogram?
what CXR type is best for evaluation of pleural effusion
lateral decubitus with the patient lying on the affected side
great example of CXR in pleural effusion patient
coolio
when is a CT better than a CXR in pleural effusions
- much more sensitive than CXR in identification of smaller effusions ( as little as 10ml!)
- also much more helpful in determining underlying pathology
NOT ORDERED UNLESS LOOKING FOR SMALL EFFUSION OR UNDERLYING PATHOLOGY
what are the two management options for pleural effusion
- observation
- thoacentesis
what is a thoracentesis
a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall to remove fluid
most often guided by ultrasound!
when is observation of Plueral effusion indicated over thoracocentesis and what does observation consist of
- benign etiology
- small amount with secure clinical diagnosis
- consists of serial imaging and PEs
what are diagnostic indications for thoracentesis
- new onset of pleural effusion without clinically apparent cause
- atypical presentation of pleural effusion in a heart failure patient (Ex: unequal bilat effusions, pleurisy, fever, concern for CA or infection, echo inconsistent with HF, lack of improvement after appropriate acute tx of HF)
what are therapeutic indications for thoracentesis
- symptom relief
- Evidence of loculation on imaging
- risk of pleural thickening/restrictive functional impairment (primary reactivation of TB, hemothorax)
what are absolute contraindications for thoacentesis
- uncooperative patient
- cutaneous disease over the proposed puncture site
What are relative contraindications to thoracentesis
- bleeding diathesis or systemic anticoagulation (US guidance by experienced pperator if benefit outweighs risk)
- a small volume of fluid (<1cm thickness on lateral decubitus film) - this can be considered safe if US guidance is used
when should thoracentesis be cautioned
mechanical ventilation due to risk of tension pneumothorax if lung is punctured
what are possible compications to thoracentesis
- pain at the puncture site
- cutaneous or internal bleeding (lack to intercostal artery or spleen/liver puncture)
- pneumothorax (bigger needle - bigger risk)
- empyema
- reexpansion pulmonary edema¹
- malignant seeding of the thoracentesis tract²
- adverse reactions to anesthetics used in the procedure
what are normal parameters of pleural effusion analysis
what initial testing is done in pleural fluid evaluation
- pleural fluid LDH
- pleural fluid protein
- serum LDH, albumin and globulin (protein)
if initial testing confirms exudative fluid what additional testing should be done
- cell count (RBC, WBC with differential)
- gram stain, C&S
- cytology (looking for malignant cells)
- amylase
- glucose
- marker for TB
what determines whether a fluid is exudative or trasudative
Lights criteria! if one or more of the following is met, it is EXUDATIVE! -
- Pleural fluid protein : serum protein > 0.5
- Pleural fluid LDH : serum LDH > 0.6
- Pleural fluid LDH > ⅔ the ULN serum value
HAVE TO BE ABLE TO CALCULATE THESE FOR TEST. will be given calculator in exam soft!
what is the management for pleural effusion
- treat underlying conditions
- thoracentesis for severe dyspnea
- tube thoracostomy
- pleurodesis
when is a tube thoracostomy indicated
- empyema/complicated effusion d/t rapid coagulation and fibrous peel formation that could require surgery
- large or unstable hemothorax d/t risk of hemorrhage or fibrous tissue formation
what is considered a complicated effusion
often pleural effusions assocaited pneumonia, lung abscesses or bronchiectasis
when should you repeat CXR after a rube thoacostomy has been performed
when drainage decreases to <100mL/day to ensure complete drainage has occurred
when is pleurodesis indicated
recurrent effusions - often related to malignancy
what is pleurodesis
Instillation of an irritant (sclerosing agent¹) to cause inflammatory changes that result in bridging fibrosis between the visceral and parietal pleural surfaces, effectively obliterating the potential pleural space
what is the goal of pleruodesis
palliate sympotms
what are the 5 classifications of pneumothorax
- Primary spontaneous pneumothorax
- Secondary spontaneous pneumothorax
- Traumatic pneumothorax
- Iatrogenic pneumothorax
- Tension pneumothorax
when do primary spontaneous pneumothoraces occur
in the absence of an underlying lung disease most frequently in smokers!
what is the etiology of primary spontaneoud pneumothoraces
unknown:(
often a sign of early lung disease with rupture of subpleural apical blebs (small cystic spaces under visceral pleura) in response to high negative intrapleural pressures¹
who is most affected by primary spontaneous pneumothoraces
affects mainly tall, thin males between 10 and 40 years of age
what are risk factors for Primary spontaneous pneumothoraces
- positive fam hx
- smoking
- 50% recurrence rate
what is the cause of secondary spontaneous pneumothoraces
a complication of preexisting pulmonary disease
such as: COPD, asthma, cystic fibrosis, tuberculosis, Pneumocystis pneumonia, menstruation (catamenial pneumothorax¹), interstitial lung diseases
she talked about menstration alot in class! like endometriosis, so keep that in mind in case its a test question
what causes a traumatic pneumothrax
penetrating trauma - stab wound, gunshot wound
blunt trauma - rib fractures
what causes iatrogenic pneumothoraces
- positive pressure mechanical ventilation
- interventional procedures - thoracentesis, pleural biopsy, subclavian or internal jugular vein catheter placement, percutaneous lung biopsy, bronchoscopy with transbronchial biopsy
what causes tension pnemothoraces
- results from air entering pleural space but not escaping (pleural cavity pressure>atmospheric pressure)
- MC d/t CPR or positive pressure mechanical ventilation
LIFE THREATENING!!!!! d/t cardiopulmonary compromise!
what are unstable vital signs that may be seen in pneumothoraces
- RR > 24
- HR <60 or >120 bpm
- Abnormal BP
- O2 <90%
what symptoms may be seen in patients with pneumothorax
- pleuritic chest pain (mild-severe)
- Tacypnea
- dyspnea/SOB
what are PE findings for pneumothorax
- diminished breath sounds on affected side
- decreased tactile fremitus on affected side
- small pneumothoraces may only cause mild tachypnea
what would a tension pneumothorax present as
- severe resp compromise and CV collapse
- marked tachycardia, hypotension
- unable to speak full sentences
- tracheal deviation
- displacement of PMI
what is usually the diagnostic study for pneumothorax
PA CXR
(expiratory or lateral decubitus veiws may beter visualize small pneumothoraces
what is chest CT used for in pneumothoraces
- helpful in identifying pathology (if present)
- more sensitive than CXR
what is the management for primary spontaneous pneumothoraces
- airway stabilization
- o2 supplement & observation
- determine need for removal of air (needle/cath aspiration or chest tube)
what are indications forO2 supplementation and observation of primary spontaneous pneumothorax
all of the following must be present!
- small pneumothorax (3cm or less at apex or 2cm or less at hilum)
- stable vital signs
- first PSP
- no pleural effusion
if ALL are present give o2 at 6L with goal of SpO2 >96% and repeat the CXR in 6 hours
IF NOT move onto aspiration
what are the indications for aspiration of a PSP
ALL MUST BE PRESENT:
- large pneumothorax (3cm or greater at apex, 2cm or greater at hilum)
- stable vital signs
- first PSP
- provider with expertise in aspirations
if all are present use needle or catherter (needle preferred) to aspirate
what is the procedure for aspiration
- in the 2nd ICS in midclavicular line, air is aspirated using 60mL syringe and one way valve/stopcock
- 2.5-4L should be removed until resistance is met
- lack of resistance after 4 L = persistent air leak (indication for a chest tube)
what is the procedure AFTER a successful aspiration
- observe patient and repeat CXR at 4 hours, if stable remove catheter and repeat CXR at 2 hours
- Discharge if pneumothorax remains resolved, if recurrence occurs insert chest tube and admit
when is a chest tube (tube/catheter thoracostomy) indicated in a PSP
- failure of observation or aspiration
- recurrent PSP
- complete collapse or mediastinal shift
- bilateral pneumothorax
- unstable vital signs
- lack of expertise in aspiration technique
- severe symptoms
- concurrent pleural effusion requiring drainage
- complex, loculated pneumothorax
what is the process of thoracostomy
- Imaging assisted placement is indicated if pneumothorax is loculated
- Location: 4th or 5th intercostal space in the anterior axillary or midaxillary line
- Tube/catheter is attached to water-seal system or light wall suction
compare and contrast tubes v catheters and the pros and cons of each
what is the management of secondary spontaneous pneumothorax (SSP)
- NEVER OBSERVED
- Maintain airway
- Oxygen supplementation (caution if risk of o2 induced hypercapnia)
- tube/cath thoracostomy and admission
- consult pulm
what is the management for tension pneumothoraces
needle decompression
what is the process of needle decompression
- A large-bore needle (14-16 gauge) inserted into the pleural space through the 2nd anterior ICS (between ribs # 2-3) at the midclavicular line
- If large amounts of gas escape from the needle after insertion, the diagnosis is confirmed
- Leave needle in place until a thoracostomy tube can be inserted
what are the 2 needle decompression sites
- 2nd anterior ICS at midclavicular
- some experts recommend 5th ICS in anterior or midaxillary line!
Hang in there yall!
