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Clin Med IIB Pulmonology > Pleural disorders > Flashcards

Pleural disorders Flashcards

1
Q

What part of the pleura has nerve endings?

A

Pariteal pleura - meaning that this is where you feel lung pain

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2
Q

What is pleurisy, pneumothorax, and pleural effusion?

A

Pleurisy - Inflammation of the pleura that causes sharp pain with breathing
Pneumothorax - Buildup of air or gas in the pleural space
Pleural Effusion - Excess fluid in the pleural space

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3
Q

What is the MC cause of non-cardial related chest pain?

A

Inflammation of the parietal pleura

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4
Q

What can cause inflammation of the parietal pleura?

A

Respiratory Infection
Lung cancer near the pleural surface
Trauma: Rib fracture
Certain medications
Pulmonary Embolism
Congestive Heart Failure
Autoimmune disorder
GI disorders
Idiopathic (unknown)

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5
Q

What are the meds that cause pleurisy?

A

procainamide, hydralazine, and isoniazid

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6
Q

What are the autoimmune disorders that cause pleurisy?

A

lupus (SLE), rheumatoid arthritis,or scleroderma

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7
Q

What are the Gi disorders that cause pleurisy?

A

pancreatitis, peritonitis, cholecystitis

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8
Q

What is the typical CC of pleurisy?

A

chest pain
a localized, sharp “knifelike”, fleeting pain that is worsened by inspiration, sneezing or coughing - “pleuritic chest pain”
radiation of pain to ipsilateral scapula may occur if diaphragmatic pleura is affected
Associated s/s (depending on the etiology)
cough, SOB
fever, myalgias, headache, nasal congestion (infectious etiology)
abdominal pain, N/V (GI etiology)
orthopnea, paroxysmal nocturnal dyspnea (PND), peripheral edema (CHF related )

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9
Q

What is a common PE finding of pleurisy

A

localized pleural friction rub where the pain is
Often decreased breath sounds because it HURTS to take a deep breath

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10
Q

What is the goal for assessing pleurisy?

A

r/o concerning causes

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11
Q

What testing should you order for pleurisy?

A

Typical workup for chest pain to rule out complications

EKG - normal unless cardiac etiology
CXR - findings will depend on underlying etiology
Rib X-ray series - rule out rib fx if history of trauma
Serology - case based - CBC, cardiac enzymes, BNP, pancreatic enzymes inflammatory markers (ESR, CRP), ANA/RF (autoimmune workup)

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12
Q

When do you order a CT scan for pleurisy?

A

Only if you r/o other causes

CT chest with contrast or CT angiography of the chest

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13
Q

What is the treatment for pleurisy?

A

Symptomatic for pain and inflammation unless other ideology

indomethacin 25 mg BID-TID (short course - < 7-10 d)

cough suppressants if no risk of pneumonia

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14
Q

When do you need to admit someone with pleurisy?

A

Depends on the underlying etiology

hypoxemic (O2 sat of <90%)
parenteral pain control is needed
underlying etiology requires hospitalization

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15
Q

When should you order cough suppressant for Pleurisy and what are they?

A

If it messes with sleep

Codeine 30-60 mg TID - good option for pain and cough suppression
Dextromethorphan combination products
Tessalon Perles (numbs airway to suppress cough)

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16
Q

What is the complication of Pleurisy?

A

pleural effusion - pain will improve transiently due to separation of pleura (because of immunne response leading to build up of fluid); SOB and cough will worsen

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17
Q

What is the function of homeostasis of pleural fluid?

A

is achieved via
A constant movement of fluid from the capillaries of the parietal and visceral pleural into the pleural space
Absorption of pleural fluid occurs through parietal pleural lymphatics
The resultant homeostasis leaves 5–15 mL of fluid in the normal pleural space

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18
Q

What are the 5 pathophysiologies of pleural effusion?

A
  1. transudative fluid (albumin pulls water back into blood vessel and hydrostatic pressure pushes fluid back out to maintain appropriate fluid in cappilary and pleural space. Increased pressure in capplillary pushes cerum into the pleural space, and lack of proteins insisde capillary prevents fluid moving into the capillary.
  2. 3.
    4.
    5.
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19
Q

Explain the transudative pathophys of pleural effusion

A

Inflammatory markers allow WBC to move from inside the capillary to outside of the lung (opening the doors) and do it’s job. If in the pleural space WB Cs build up

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20
Q

Explain how decreased lymphatic drainage leads to pleural effusion?

A

Blocked off drainage build up fluid

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21
Q

Infection in pleural space leads to pleural space by

A

WBCs migrate into pleural space leading to emphyema

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22
Q

Explain how bleeding leads to Pulnonary effusion?

A

Blood from capillaries build up in plueral space

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23
Q

What are the two main pathophys of pleural effusion?

A

Transudate and exudates

Transudate - 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
Exudates - 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

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24
Q

What causes transudates typically?

A

Another organ causes problem

heart failure MC (blood backs up into capillaries back into the interstial space and then the pleural space)

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25
Q

What typically causes exudative pleural effusion?

A

Inflammatory response

MC cancer or bacterial pneumonia

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26
Q

How does pulmonary effusion lead to transudative and exdaitave pleural effusion?

A

Pressure Builds up in capillaries and pushes it into pleural space leading to transudates

When tissues die, there is imflammatory response leading to excudative response.

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27
Q

What is the MC CC of pleural effusion?

A

“I can’t breathe” because the lungs cannot open up properly.

Also dyspnea, cough, pleuritic chest pain

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28
Q

What history should you obtain with CC of I can’t breathe?

A

Travel
recent illness
trauma
occupational hazards
medication history
TB exposure: live or work in a homeless shelter, migrant farm camp, prison/jail
nursing home

29
Q

What do you hear at the base of the lungs for pleural effusion?

A

Decreased lung sounds at base (d/t fluid traveling down)
Diminished breath sounds
Dullness to percussion
Decreased tactile fremitus
Displacement of trachea airway (rare)

Sometimes:

Peripheral edema, JVD, and S3 gallop (CHF)
Peripheral edema (nephrotic syndrome becuase of less protein or pericardial disease)
Jaundice, ascites (liver disease)
Lymphadenopathy, palpable mass (malignancy)

30
Q

Where does lung malignancy first metastize to?

A

Mediastinum, not aillary nodes

meaning that it will likely not pressent with palpable lymphadenaopthy!

31
Q

What do you see in CXR of pleural effusion?

A

Blunted costephrinc angles if > 175 ml (appx 6 oz) of fluid present

32
Q

When do you see pleural effusion with effusion in righ lateral chest wall?

A

Chronic pleural effusion that is walled off to heal, making it higher than the lung bases

33
Q

If you suspect blunting on the right side and suspect pleural effusion, which lateral decubitis do you order?

A

Right side so gravity pulls it down

if you see it move down, it is movable
If it does not move than it is likely walled off

34
Q

What do you sometimes see if severe pulmonary effusion on the left side?

A

Deviation of bronchi to the right causing an air bronchogram because the filled left lung pushes up against it

35
Q

What is an advantage of a CT scan for pleural effusion?

A

Only order if you suspect underlying pathophys

can identify 10 mL of pleural effusion

36
Q

What are the two main management of pleural effusion?

A

Observation (if small and benign - rare to do this)
Thoracentesis (MC - to get fluid and added for laboratory testing - often with catheter)

37
Q

Where do you place a thoracentesis?

A

Right above rib to avoid neuravacular bundle

38
Q

When do you order a thoracentesis?

A
  1. New onset pleural effusion without a 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
  2. theraputic

so it is theraputic and diagnostic

39
Q

What are the absolute and relative contraindications of a throacocentiis?

A

ABSOLUTE: uncoorpartive patient or cutaneous disease where you would insert the needle

Relative: bleeding diathesis or systemic anticoagulation. Small pleural effusion might be better to observe if it is not complicated - risk to rupture the lung might not be worth the benefit). Often US guided

Caution: mechanical ventilation (forcing air into the lung can cause negative pressure and rupture the lung)

40
Q

What are the complications of thoracocentis?

A

Pain
Internal bleeding
Pneumothorax
Empyema (bacteria enter the space)
Reexpansion pulmonary edema (pulling fluid causes capillaries to pull fluid from the capillaires back into the lung)
Malingant seeding if there is lung cancer
adverse, localized problems with lidocaine

41
Q

After you get a thoracentis, what do you order?

A

pleural fluid LDH
pleural fluid protein
serum LDH, albumin and globulin (proteins)

these are used to see if they are eudative or transudative

42
Q

If the pleural fluid from thoracentis is deemed to be exudative, what do you order?

A

cell count (RBC, WBC with differential)
gram stain, C&S
cytology (looking for malignant cells)
amylase
glucose
marker for TB

43
Q

What should pleural fluid look like?

A

Serum - white/yellow clear

44
Q

What are the lights criteria and how mant need to be present for exudative?

A

Just need to meet 1 criteria = exudative
If you meet no criteria = transudative

Pleural fluid protein : serum protein > 0.5
Pleural fluid LDH : serum LDH > 0.6
Pleural fluid LDH > ⅔ the ULN serum value

45
Q

With these values, what lights criteria do you meet?

serum albumin 4.0
serum globulin: 2.8
serum LDH: 200
pleural protein: 3.0
pleural LDH: 130

A

Meets only 2nd criteria

means that it is exudative and narrows your differntials

46
Q

What is the treatment of pleural effusion?

A

Treat underlying condition
If blood put in chest tube
once. <100 mL of fluid per day, stop chest tube

serial CXR s

47
Q

What is a pleurodesis used for and what is it?

A

Indication: recurrent effusions - often related to malignancy

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

Due to limited life expectancy of these patients, the goal of therapy is to palliate symptoms

48
Q

What is the typcial patient of pneurmothorax?

A

Tall, thin, young male smokers (10-40) who suddenly can’t breathe

can also be d/t injury/penetration

49
Q

What are the odds of getting a second pneumothorax?

A

50%

50
Q

What is catamenial pneumorthorax?

A

Pleural ruptures during menstruation

51
Q

How can ILD lead to pnemothoarx?

A

comprimsed lung state

52
Q

What does pneumothorax lead to if untreated and what happens?

A

Tension pnemothorax
results from air entering pleural space but not escaping
the pleural cavity pressure > atmospheric pressure
MC cause: CPR or positive-pressure mechanical ventilation
Life-threatening due to cardiopulmonary compromise

lung ruptures and air enters lung space and cannot get out and builds up in air space, puts tension on the heart and then the heart deviates

it is a problem because eventually the heart cannot dilate and the patient dies of cardiac arrest

53
Q

What is the presentation of pneumothorax?

A

Sudden or gradual
Pleuritic chest pain
ranging from mild-severe
Tachypnea
Dyspnea/SOB

54
Q

What is the vitals of pneumothorax?

A

Unstable:

RR > 24
HR <60 or >120 bpm
Abnormal BP
O2 <90%

55
Q

What is the PE findings of typical pneumothorax?

A

diminished breath sounds
decreased tactile fremitus on affect side

56
Q

What is the PE of tension pneumothorax?

A

severe respiratory compromise and CV collapse
marked tachycardia, hypotension
unable to speak full sentences
tracheal deviation
displacement of the PMI

57
Q

If you order a lateral decubitis for pnemothorax for right sided?

A

Left side

58
Q

What is the advatnage of chest CT for pneumothorax?

A

more sensitive than CXR
often helpful in identifying associated pathology (if present)

59
Q

What do you see on CXR of tension pnemothroax?

A

Trachial deviation putting pressure on the heart

60
Q

What is the initial management of pneumothorax?

A

ABC control

61
Q

When do you only use supplemental oxygen and observation for pneumothroax?

A

SMALL <3 cam at apex and < 2cm at hilum
stable vital signs
first PSP
no plueral effusion

HAVE TO MEET ALL

62
Q

If you are not a candidate for supplemental oxgen and observation, what is the next step of management?

A

Procedure - 2nd ICS in the midclavicular line
Air is aspirated using a 60 mL syringe and a one way valve/stopcock
2.5-4 L should be removed until resistance is met
Lack of resistance after 4 L = persistent air leak

indication for chest tube
After 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

63
Q

When do you do a chest tube for pneumothorax management?

A

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

64
Q

Where do you insert a chest tube and how do you find it?

A

4th or 5th intercostal space in the anterior axillary or midaxillary line

At the nipple for men
right under breast for women

65
Q

What are the pros/cons of tube vs catheter?

A

Tubes
≥ 16 French diameter
larger and require surgical incision
more painful, less risk of plugging/kinking
Catheters
≤ 14 French diameter
smaller, can be introduced with guidewire
less pain, increase risk for plugging or kinking

66
Q

What differs primary vs secondary penumothorax?

A

Primary = no known cause
Secondary = underlying cause - ALWAYS ADMITTED TO PULM, pulm decides if there is pleurodesis which is definitive treatment

67
Q

How do you manage tension pneumothroax?

A

Needle decompression because there is not enough time to prep everything else

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 (air wooshes out)

Some experts also recommend the 5th ICS in the anterior or midaxillary 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 (because it is at the same space that a chest tube would be placed anyways).

Severe symptoms and deviation of trachea = tension pneumothorax

68
Q
A

Clin Med IIB Pulmonology (12 decks)

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