Pleural Disorders Flashcards
What does the parietal pleura line? 3
What does it contain and what do they do?
Lines the thoracic cavity, including the thoracic cage, mediastinum, and diaphragm
Contains sensory nerve endings that can detect pain
Pleuritis can be painful
What does the visceral pleura line?
Does it detect pain?
Lines the entire surface of the lung
Contains NO sensory nerve endings that detect pain
What is the pleural space?
A potential space between the parietal pleura and visceral pleura, filled with pleural fluid.
Serous fluid that allows for the parietal pleura (outer lining) and visceral pleura (inner lining) to glide over each other without separation is what?
What does it provide? 2
What is it produced by and absorbed by?
Pleural fluid
Provides lubrication and surface tension
Pleural fluid is produced by the parietal pleura and absorbed by the visceral pleura as a continuous process.
Mechanics of Pulmonary Ventilation
- Lungs are surrounded by _____ ____ that lubricates movement of lungs within the cavity
Continual suction of excess fluid into ______ _______ acts like a glue to hold the lungs to the thoracic wall (allows for smooth movement)
Pleural pressure is a pressure _______that holds the lungs open (more _____ pressure with inspiration)
- pleural fluid
lymphatic channels
negative
negative
Intrapulmonary pressure
is what?
As the chest expands on inspiration the intrapulmonary pressure becomes more _______, which causes air to be sucked into the lungs
the pressure within the alveoli
negative
Intrapleural pressure is what?
negative pressure may be lost if fluid collects in the pleural space, making the lung unable to _____ _____?
Negative pressure is created in the pleural space as the thoracic cage enlarges and the lungs recoil during normal inspiration
expand fully
What is pleuritis?
Is a localized inflammation of pleural surfaces that produces sharp localized pain.
Describe the pain that is associated with pleuritis?
Take home….pleuritic pain is sharp, stabbing pain with “splinting” on inspiration
Clinical Picture of Pleuritis
Localized, pleuritic chest pain increased with _____ _______ and ______ and may be associated with ______ ____.
Pleural rub is a ____ ______ best heard during inspiration and expiration at site of the chest pain.
What kind of extrapulmonary pain is associated with pleuritis?
- -deep inspiration and coughing
- -pleural rub
–fine crackles
Ipsilateral shoulder pain
Causes of Pleuritis
4
- Viral infection (Coxsackie B virus)
- Thoracic trauma (fractured rib)
- Secondary to pulmonary disorders e.g.
- Secondary to systemic diseases e.g.
Pleuritis can be secondary to pulmonary disorders such as? 5
Can also be secondary to systemic diseases such as? 3
- Bronchiectasis (common)
- Pulmonary infarction
- Pneumonia
- Lung cancer
- Tuberculosis
- rheumatoid arthritis,
- systemic lupus,
- metastatic cancer
Diagnosis of Pleuritis
2
- Chest X- ray
Normal unless primary lung disease - Diagnosis is typically clinical… May do a work-up to determine cause
Treatment of Pleuritis
3
Treatment of the primary cause of pleurisy
- Symptomatic treatment of chest pain
- Moderate analgesics……NSAIDS
- Some patients may need short course of narcotics
What is pleural effusion?
When does it occur?
Results when fluid collects between the parietal and visceral pleural layers.
the normal flow of fluid is disrupted
What are two ways the normal flow of fluid is dirupted in pleural effusion?
- Too much fluid produced
2. Not enough fluid removed
Clinical features of pleural effusion?
4
Clinical Features:
- SOB
- Cough
- Pleuritic chest pain
- Other signs and symptoms depends on etiology
Causes of Pleural Effusion?
12 (most most common to least common)
- Congestive heart failure 500,000
- Pneumonia 300,000
- Malignancy 200,000
- Pulmonary embolism 150,000
- Viral 100,000
- S/P CABG surgery 70,000
- Cirrhosis with ascites 50,000
- GI disease 25,000
- Collagen-vascular disease 6,000
- Tuberculosis 2,500
- Asbestos 2,000
- Mesothelioma 1,500
Diagnosis of Pleural effusion?
5
Diagnosis:
- Careful History
- Thorough exam
- CXR
- Chest CT
- Pleural Fluid analysis
Radiologic Assessment
- What positions would we order on pleural effusions?
What is indicative of the accumulation of between 250 - 500 ml of fluid?
What would a Lateral-Decubitus films show? (differenciate it from what?)
- Chest X-Ray: PA and Lateral-Decub
- blunting of either costophrenic angle
Lateral-Decubitus films (that allow fluid to shift to the dependent portion of the thoracic cavity) help differentiate fluid from pleural thickening and fibrosis
Whats a Sub-Pulmonic Effusion?
accumulation of fluid between the lung and the diaphragm which gives the false impression of an elevated hemi-diaphragm
Pleural Effusion Evaluation:
What is a Thoracentesis?
A WHAT in conjunction with WHAT should allow the clinician to diagnose the cause of an effusion in about 75 % of patients.
a simple bedside procedure that permits fluid to be rapidly sampled, visualized, examined microscopically, and quantified.
- -A systematic approach to analysis of the fluid
- -the clinical presentation
Pleural Fluid Analysis:
Two kinds?
What things are we analyzing in the effusion?
9
Transudate vs. Exudate
- Gross Appearance
- pH
- Gram Stain, C & S
- Cytology
- LDH
- Protein
- Glucose
- Cholesterol
- Amylase
What is Light’s Criteria? 3
How many must be met to be defined as an exudate?
If at least one of the following three criteria is present, the fluid is defined as an exudate
(please note that serum samples must be taken as well)
- Pleural fluid protein/serum protein ratio > 0.5.
- Pleural fluid LDH/serum LDH ratio > 0.6.
- Pleural fluid LDH greater than two thirds the upper limits of the laboratory’s normal serum LDH
Criteria for “Exudative Effusion”
3 criteria and their values?
- Pleural Protein/Serum Protein ratio > 0.5
- Pleural LDH/Serum LDH ratio > 0.6
- Pleural fluid LDH > 200LDH (typically > than two thirds the upper limits of the laboratory’s normal serum LDH)only need 1 critical value to establish the diagnosis of exudate
Pleural effusion exudative causes?
11
- Anything that causes inflammatory or infiltrative disease of the pleura (damaging capillary membranes)
- Neoplasm (disruption causes increased permeability with lymphatic obstruction as well)
Lung Cancer, Breast Cancer, - Infection
Uncommonly associated with acute bacterial pneumonias (small and transient) - Empyema (not just disruption of the capillary membranes but the organisms have entered the pleural space)
- Tuberculosis
- Viral pneumonitis
- Mycoplasmal pneumonia
- Anything that causes inflammatory or infiltrative disease of the pleura (damaging capillary membranes)
- Autoimmune disease
- Pulmonary infarction (pulmonary embolus for example)
- Intra-abdominal pathology (e.g. development of subdiaphragmatic abscess, pancreatitis)
What is responsible for 75% of all malignant pleural effusions?
Lymphoma
30
30
- Describe a trandudative pleural effusion?
And what would cause it? 2 general. 3 examples
Transudative
1. straw-colored, clear, odorless fluid
- Anything that causes
- -increased hydrostatic pressure or
- -decreased capillary colloid osmotic pressure such as…
- Congestive Heart Failure (most common cause)
- Severe hypoalbuminemia (nephrotic syndrome and liver failure)
- Cirrhosis (associated with ascites)
What should we order when we find out if the pleural effusion is:
Transudate?
Exudate? 5
Transudate?
No further laboratory analysis indicated
Exudate?... Consider the following 1. WBC count with differential 2. Bacterial culture 3. Cytological examination 4. Glucose level 5. Amylase Others
Treatment:
Transudative Effusion?
Exudative Effusion?
Transudative Effusion: focus on the systemic cause
Exudative Effusion: dependent on the exact sub-type
- Consider Chest Thoracostomy
If we did a chest thracostomy for an exudative effusion what might we find?
4
- Gross Pus / Empyema (collection of pus in pleural cavity)
- Hemothorax
- Complicated Parapneumonic Processes
- Malignant Effusion…….the role of pleurodesis!
What are Parapneumonic Effusions?
Describe their size and prognosis?
However, if bacteria invade the pleural space a complicated ______ _______ or _______may result.
Pleural effusions that occur in the pleural space adjacent to a bacterial pneumonia.
Typically are small and resolves with appropriate antibiotic therapy.
- parapneumonic effusion
- empyema
Characteristics of a Complicated Parapneumonic Effusion
6
- Persistent bacterial invasion of the pleural space
- Glucose less than 60 mg/dL
- pH less than 7.2
- Positive culture
- Pleural LDH > 3x the upper limit for serum
- Pleural fluid is loculated
Malignant Pleural Effusions:
Cancer causes the pleural effusion
How would we find this out?
What kind of cancers cause this mostly? 4
- Positive fluid cytology and/or pleural biopsy for cancer
Lung cancer and breast cancer account for about 50-65% of malignant pleural effusions
Others
lymphoma
pleural mesothelioma
What would a bloody pleural effusion occurring in a patient without a history of trauma or pulmonary infarction indicate?
A True Hemothorax is when the Pleural Fluid Hct exceeds ____of the Peripheral Blood Hct !
Indicative of Neoplasm in 90 % of cases!
50 %
Treatment of Malignant Pleural Effusions?
4
- Serial thoracentesis
- Chest tube with pleurodesis
- Pleuroperitoneal shunt
- Pleurectomy
What are the two kind of Pleurodesis?
What are we treating with thesE?
Mechanical pleurodesis
Chemical pleurodesis
Malignant pleural effusions
What is a Mechanical pleurodesis?
Electro-cautery scratch pad or 4 by 4 sponge
Surgeon gently strokes pleura….roughens up the pleura so that when the abrasion heals the lung will adhere to the chest wall
What is a Chemical pleurodesis?
instill chemical irritant into pleural space which causes adhesion of the lung to the chest wall
Sclerosing agents used: Talc, bleomycin, or doxycyline
Administered through a chest tube or by VATS (video assisted thorascopic surgery) to create inflammation and subsequent fusion of the parietal and visceral pleura
The goal of chemical pleurodesis is to cause what?
The sclerosant irritates the pleurae which results in what?
Where is the procedure done?
irritation between the two layers covering the lung.
inflammation and causes the pleurae to stick together.
The procedure can be done at the bedside or in the operating room.
What is a Hemothorax?
What does it result from?
Hemorrhagic pleural effusion
results from blood accumulating in the pleural cavity usually trauma
What kind of trauma results in a hemothorax?
Resulting in what?
This rupture allows what to happen and how does it affect the pressure in the lungs?
a blunt or penetrating injury to the thorax
resulting in a rupture of the pleura
This rupture allows blood to spill into the pleural space, equalizing the pressures between it and the lungs.
Causes of a Spontaneous Hemothorax
most common?
- Pulmonary: bullous emphysema, PE, infarction, Tb, AVMs
- Pleural: torn adhesions, endometriosis
- Neoplastic: primary, metastatic****
- Blood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation
- Thoracic Pathology: ruptured aorta, dissection
- Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum
Hemothorax goal of treatment?
to remove the pleural blood
and allow for
complete lung re-expansion
Hemothorax general managment options? (most common?)
4
- thoracentesis: bedside / ultrasound-guided / CT-guided
- thoracostomy drainage: the mainstay**
- thorascopic surgery
- thoracotomy: massive hemothorax / instability / chronic hemothorax
Thoracostomy - chest tube
What is atelectasis?
How does it affect the pressure in the lungs?
What can this cause?
What does it typically lead to?
Atelectasis is an incomplete expansion of the lung which leads to collapse of the alveoli
Increased negative intrapleural pressure can lead to the collection of fluid in the portion of the lung which is not expanding
This can cause an effusion by fluid leaking out of the lung and into the chest cavity
Atelectasis typically leads to small pleural effusions not requiring intervention
Atelectasis-Clinical Manifestations
9
- Pain
- Cough
- Dyspnea
- Dullness to Percussion
- Diminished or Absent Vocal
- Resonance
- Diminished or Absent Tactile
- Vocal Fremitus
- Friction Rub
Whats a pneumothorax?
collection of air within the pleural space
The pleural pressure in the affected hemithorax _______ atmospheric pressure, from the result of a _____ ______mechanism that facilitates the ingress of gas into the pleural space during inspiration, but ______ the egress of gas from the pleural space during expiration.
What does this result in? 2
exceeds
“check valve”
blocks
- -Impairs respiratory function
- -decreases venous return to the right-side of the heart
Pneumothorax general management?
Three steps
First: evacuate the air
Second: address the underlying cause
Third: promote pleural symphysis
Pneumothorax classification system? 2 kinds (2 and 3 subcategories)
Spontaneous Pneumothorax
- Primary
- Secondary (like tumor)
Traumatic Pneumothorax
- Pulmonary source
- Tracheobronchial source
- Esophageal source
Primary Spontaneous Pneumothorax:
Found in what age and gender?
What kind of body type?
Major risk factor?
What is the usual cause?
a disease of younger individuals (15 - 35 yrs of age)
males > females
tall, slim body habitus (Marfans)
cigarette smoking implicated
usual cause: rupture of a subpleural bleb
small air-filled lesions just under the pleural surface
Treatment of Primary Spontaneous Pneumothorax?
4
in most instances, the treatment
of a first-occurrence consists of
1. hospitalization,
2. tube-thoracostomy to closed drainage,
3. lung-re-expansion against the chest wall,
and
4. control of any persistent air-leak
Secondary Ptx: due to underlying pulmonary disease such as?
Treatment? 2
If it persists? 1
COPD / Lung Malignancy / Cystic Fibrosis
Necrotizing Infections
Treatment:
- Oxygen
- Tube thoracostomy
- Persistant: VATS for resection or if pleurodesis needed
What are the necrotizing infections that could cause secondary ptx? 2
TB
Pneumocystis jirovecii
What areas are mostly involved in injuries of Traumatic Pneumothorax? 3
What kind of injuries are these? 4
- Parenchymal Injury vs.
- Tracheobronchial vs.
- Esophageal
- Blunt or Penetrating
- Iatrogenic
- Barotrauma/Ventilation / blast injury
- Boerhave’s syndrome (esophageal rupture)
What kind of iatrogenic injuries are associated with traumatic pneumothorax?
7
- central lines /
- thoracentesis /
- biopsy
- endotracheal tube placement
- endoscopy /
- dilational techniques
- operative
What is The Open Pneumothorax: sucking-chest wound?
Management?
when a traumatic chest wall defect persists, through which ambient air enters the pleural space during inspiration creating complete lung collapse
dressing
thoracostomy away from the traumatic wound (different hole!)
Treatment Options
for a pneumothorax?
4
- Observation: Inpatient vs. Outpatient
- Oxygen
- Thoracostomy Drainage
- VATS ( “standard” if surgery required)
Where should we do a Thoracostomy Drainage?
3rd Interspace -5th Interspace
Asbestosis is caused by what?
What is it characterized by?
Caused by inhalation of asbestos fibers
Characterized by slowly progressive, diffuse pulmonary fibrosis
The spectrum of pulmonary disorders associated with asbestos exposure includes?
3
- Asbestosis
- Pleural disease (focal and diffuse benign pleural plaques)
- Malignancies (non-small cell and small cell carcinoma of the lung as well as malignant mesothelioma)
Asbestosis clinical findings
4
- Most patients are asymptomatic for at least 20 to 30 years after the initial exposure
- Usually first symptom is the insidious onset of breathlessness with exertion
- Progressive dyspnea an may develop bibasilar crackles
- Cough, sputum production, and wheezing are unusual
What lab studies would we do for asbestosis?
Imaging?
Laboratory studies not useful
Radiography – wide spectrum but pleural involvement is a hallmark
How should we treat asbestosis?
6
No specific treatment
Focus should be on preventive measures:
1. Smoking cessation
2. Early detection of physiologic and radiographic abnormalities (CXR and PFTs recommended every 3 to 5 years)
3. Prevention of further airborne asbestos exposure
4. Supplemental oxygen when there is resting hypoxemia or exercise-induced oxygen desaturation
5. Prompt treatment of respiratory infections
6. Pneumococcal and influenza vaccination
What is mesothelioma?
Mesothelioma is an insidious neoplasm arising from the mesothelial surfaces of the pleural
What is 70% of pleural mesothelioma associated with?
Increased risk of cancer combined with what?
Describe the onset?
70% of cases of pleural mesothelioma being associated with documented asbestos exposure.
Synergistically increased risk of cancer if combined with smoking
Long latency of around 30-40 years from exposure to development of malignancy
Mesothelioma Presentation?
2
Typical patient presents in 5th to 7th decades with dyspnea and nonpleuritic chest pain
Mesothelioma Common physical findings?
3
- Unilateral dullness to percussion at the lung base
- Palpable chest wall masses
- Scoliosis towards the side of the malignancy
Mesothelioma Radiology?
2
Most cases show a
- unilateral pleural abnormality with a
- large, unilateral pleural effusion
What will the CT scan show in a mesothelioma pt?
circumferential pleural thickening-mesothelioma
Collagen-Vascular Disease of the Pleura include which diseases?
6
- Rheumatoid Arthritis
- Systemic Lupus Erythematosis
- Sarcoidosis
- Mixed connective tissue disease
- Wegener’s Granulomatosis
- Sjogren’s syndrome
Causes of pleuritic chest pain
11
- Viral pleurisy
- Pneumonia
- Acute pulmonary embolus
- Pneumothorax
- Pericarditis
- Collagen vascular disease (lupus, RA, connective tissue disease)
- Drug induced lupus
- IBS/IBD
- Familial mediterranean fever
- Radiation pneumonitis
- Pulmonary histoplasmosis
