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Pulmonology > Pleural Disorders > Flashcards

Pleural Disorders Flashcards

1
Q

What does the parietal pleura line? 3

What does it contain and what do they do?

A

Lines the thoracic cavity, including the thoracic cage, mediastinum, and diaphragm

Contains sensory nerve endings that can detect pain
Pleuritis can be painful

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2
Q

What does the visceral pleura line?

Does it detect pain?

A

Lines the entire surface of the lung

Contains NO sensory nerve endings that detect pain

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3
Q

What is the pleural space?

A

A potential space between the parietal pleura and visceral pleura, filled with pleural fluid.

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4
Q

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?

A

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.

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5
Q

Mechanics of Pulmonary Ventilation

  1. 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)

A
  1. pleural fluid

lymphatic channels

negative
negative

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6
Q

Intrapulmonary pressure
is what?

As the chest expands on inspiration the intrapulmonary pressure becomes more _______, which causes air to be sucked into the lungs

A

the pressure within the alveoli

negative

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7
Q

Intrapleural pressure is what?

negative pressure may be lost if fluid collects in the pleural space, making the lung unable to _____ _____?

A

Negative pressure is created in the pleural space as the thoracic cage enlarges and the lungs recoil during normal inspiration

expand fully

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8
Q

What is pleuritis?

A

Is a localized inflammation of pleural surfaces that produces sharp localized pain.

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9
Q

Describe the pain that is associated with pleuritis?

A

Take home….pleuritic pain is sharp, stabbing pain with “splinting” on inspiration

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10
Q

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?

A
  • -deep inspiration and coughing
  • -pleural rub

–fine crackles

Ipsilateral shoulder pain

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11
Q

Causes of Pleuritis

4

A
  1. Viral infection (Coxsackie B virus)
  2. Thoracic trauma (fractured rib)
  3. Secondary to pulmonary disorders e.g.
  4. Secondary to systemic diseases e.g.
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12
Q

Pleuritis can be secondary to pulmonary disorders such as? 5

Can also be secondary to systemic diseases such as? 3

A
  1. Bronchiectasis (common)
  2. Pulmonary infarction
  3. Pneumonia
  4. Lung cancer
  5. Tuberculosis
  6. rheumatoid arthritis,
  7. systemic lupus,
  8. metastatic cancer
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13
Q

Diagnosis of Pleuritis

2

A
  1. Chest X- ray
    Normal unless primary lung disease
  2. Diagnosis is typically clinical… May do a work-up to determine cause
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14
Q

Treatment of Pleuritis

3

A

Treatment of the primary cause of pleurisy

  1. Symptomatic treatment of chest pain
  2. Moderate analgesics……NSAIDS
  3. Some patients may need short course of narcotics
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15
Q

What is pleural effusion?

When does it occur?

A

Results when fluid collects between the parietal and visceral pleural layers.

the normal flow of fluid is disrupted

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16
Q

What are two ways the normal flow of fluid is dirupted in pleural effusion?

A
  1. Too much fluid produced

2. Not enough fluid removed

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17
Q

Clinical features of pleural effusion?

4

A

Clinical Features:

  1. SOB
  2. Cough
  3. Pleuritic chest pain
  4. Other signs and symptoms depends on etiology
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18
Q

Causes of Pleural Effusion?

12 (most most common to least common)

A
  1. Congestive heart failure 500,000
  2. Pneumonia 300,000
  3. Malignancy 200,000
  4. Pulmonary embolism 150,000
  5. Viral 100,000
  6. S/P CABG surgery 70,000
  7. Cirrhosis with ascites 50,000
  8. GI disease 25,000
  9. Collagen-vascular disease 6,000
  10. Tuberculosis 2,500
  11. Asbestos 2,000
  12. Mesothelioma 1,500
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19
Q

Diagnosis of Pleural effusion?

5

A

Diagnosis:

  1. Careful History
  2. Thorough exam
  3. CXR
  4. Chest CT
  5. Pleural Fluid analysis
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20
Q

Radiologic Assessment

  1. 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?)

A
  1. Chest X-Ray: PA and Lateral-Decub
  2. 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

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21
Q

Whats a Sub-Pulmonic Effusion?

A

accumulation of fluid between the lung and the diaphragm which gives the false impression of an elevated hemi-diaphragm

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22
Q

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

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
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23
Q

Pleural Fluid Analysis:
Two kinds?
What things are we analyzing in the effusion?
9

A

Transudate vs. Exudate

  1. Gross Appearance
  2. pH
  3. Gram Stain, C & S
  4. Cytology
  5. LDH
  6. Protein
  7. Glucose
  8. Cholesterol
  9. Amylase
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24
Q

What is Light’s Criteria? 3

How many must be met to be defined as an exudate?

A

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)

  1. Pleural fluid protein/serum protein ratio > 0.5.
  2. Pleural fluid LDH/serum LDH ratio > 0.6.
  3. Pleural fluid LDH greater than two thirds the upper limits of the laboratory’s normal serum LDH
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25
Q

Criteria for “Exudative Effusion”

3 criteria and their values?

A
  1. Pleural Protein/Serum Protein ratio > 0.5
  2. Pleural LDH/Serum LDH ratio > 0.6
  3. 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
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26
Q

Pleural effusion exudative causes?

11

A
  1. Anything that causes inflammatory or infiltrative disease of the pleura (damaging capillary membranes)
  2. Neoplasm (disruption causes increased permeability with lymphatic obstruction as well)
    Lung Cancer, Breast Cancer,
  3. Infection
    Uncommonly associated with acute bacterial pneumonias (small and transient)
  4. Empyema (not just disruption of the capillary membranes but the organisms have entered the pleural space)
  5. Tuberculosis
  6. Viral pneumonitis
  7. Mycoplasmal pneumonia
  8. Anything that causes inflammatory or infiltrative disease of the pleura (damaging capillary membranes)
  9. Autoimmune disease
  10. Pulmonary infarction (pulmonary embolus for example)
  11. Intra-abdominal pathology (e.g. development of subdiaphragmatic abscess, pancreatitis)
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27
Q

What is responsible for 75% of all malignant pleural effusions?

A

Lymphoma

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28
Q

30

A

30

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29
Q
  1. Describe a trandudative pleural effusion?

And what would cause it? 2 general. 3 examples

A

Transudative
1. straw-colored, clear, odorless fluid

  1. Anything that causes
  • -increased hydrostatic pressure or
  • -decreased capillary colloid osmotic pressure such as…
  1. Congestive Heart Failure (most common cause)
  2. Severe hypoalbuminemia (nephrotic syndrome and liver failure)
  3. Cirrhosis (associated with ascites)
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30
Q

What should we order when we find out if the pleural effusion is:
Transudate?
Exudate? 5

A

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
31
Q

Treatment:
Transudative Effusion?
Exudative Effusion?

A

Transudative Effusion: focus on the systemic cause

Exudative Effusion: dependent on the exact sub-type

  1. Consider Chest Thoracostomy
32
Q

If we did a chest thracostomy for an exudative effusion what might we find?
4

A
  1. Gross Pus / Empyema (collection of pus in pleural cavity)
  2. Hemothorax
  3. Complicated Parapneumonic Processes
  4. Malignant Effusion…….the role of pleurodesis!
33
Q

What are Parapneumonic Effusions?

Describe their size and prognosis?

However, if bacteria invade the pleural space a complicated ______ _______ or _______may result.

A

Pleural effusions that occur in the pleural space adjacent to a bacterial pneumonia.

Typically are small and resolves with appropriate antibiotic therapy.

  1. parapneumonic effusion
  2. empyema
34
Q

Characteristics of a Complicated Parapneumonic Effusion

6

A
  1. Persistent bacterial invasion of the pleural space
  2. Glucose less than 60 mg/dL
  3. pH less than 7.2
  4. Positive culture
  5. Pleural LDH > 3x the upper limit for serum
  6. Pleural fluid is loculated
35
Q

Malignant Pleural Effusions:

Cancer causes the pleural effusion

How would we find this out?

What kind of cancers cause this mostly? 4

A
  1. 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

36
Q

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 !

A

Indicative of Neoplasm in 90 % of cases!

50 %

37
Q

Treatment of Malignant Pleural Effusions?

4

A
  1. Serial thoracentesis
  2. Chest tube with pleurodesis
  3. Pleuroperitoneal shunt
  4. Pleurectomy
38
Q

What are the two kind of Pleurodesis?

What are we treating with thesE?

A

Mechanical pleurodesis
Chemical pleurodesis

Malignant pleural effusions

39
Q

What is a Mechanical pleurodesis?

A

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

40
Q

What is a Chemical pleurodesis?

A

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

41
Q

The goal of chemical pleurodesis is to cause what?

The sclerosant irritates the pleurae which results in what?

Where is the procedure done?

A

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.

42
Q

What is a Hemothorax?

What does it result from?

A

Hemorrhagic pleural effusion

results from blood accumulating in the pleural cavity usually trauma

43
Q

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

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.

44
Q

Causes of a Spontaneous Hemothorax

most common?

A
  1. Pulmonary: bullous emphysema, PE, infarction, Tb, AVMs
  2. Pleural: torn adhesions, endometriosis
  3. Neoplastic: primary, metastatic****
  4. Blood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation
  5. Thoracic Pathology: ruptured aorta, dissection
  6. Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum
45
Q

Hemothorax goal of treatment?

A

to remove the pleural blood
and allow for
complete lung re-expansion

46
Q

Hemothorax general managment options? (most common?)

4

A
  1. thoracentesis: bedside / ultrasound-guided / CT-guided
  2. thoracostomy drainage: the mainstay**
  3. thorascopic surgery
  4. thoracotomy: massive hemothorax / instability / chronic hemothorax

Thoracostomy - chest tube

47
Q

What is atelectasis?

How does it affect the pressure in the lungs?

What can this cause?

What does it typically lead to?

A

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

48
Q

Atelectasis-Clinical Manifestations

9

A
  1. Pain
  2. Cough
  3. Dyspnea
  4. Dullness to Percussion
  5. Diminished or Absent Vocal
  6. Resonance
  7. Diminished or Absent Tactile
  8. Vocal Fremitus
  9. Friction Rub
49
Q

Whats a pneumothorax?

A

collection of air within the pleural space

50
Q

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

A

exceeds

“check valve”

blocks

  • -Impairs respiratory function
  • -decreases venous return to the right-side of the heart
51
Q

Pneumothorax general management?

Three steps

A

First: evacuate the air

Second: address the underlying cause

Third: promote pleural symphysis

52
Q 
Pneumothorax classification system?
2 kinds (2 and 3 subcategories)
A

Spontaneous Pneumothorax

  1. Primary
  2. Secondary (like tumor)

Traumatic Pneumothorax

  1. Pulmonary source
  2. Tracheobronchial source
  3. Esophageal source
53
Q

Primary Spontaneous Pneumothorax:

Found in what age and gender?

What kind of body type?

Major risk factor?

What is the usual cause?

A

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

54
Q

Treatment of Primary Spontaneous Pneumothorax?

4

A

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

55
Q

Secondary Ptx: due to underlying pulmonary disease such as?

Treatment? 2
If it persists? 1

A

COPD / Lung Malignancy / Cystic Fibrosis
Necrotizing Infections

Treatment:

  1. Oxygen
  2. Tube thoracostomy
  3. Persistant: VATS for resection or if pleurodesis needed
56
Q

What are the necrotizing infections that could cause secondary ptx? 2

A

TB

Pneumocystis jirovecii

57
Q

What areas are mostly involved in injuries of Traumatic Pneumothorax? 3

What kind of injuries are these? 4

A
  1. Parenchymal Injury vs.
  2. Tracheobronchial vs.
  3. Esophageal
  4. Blunt or Penetrating
  5. Iatrogenic
  6. Barotrauma/Ventilation / blast injury
  7. Boerhave’s syndrome (esophageal rupture)
58
Q

What kind of iatrogenic injuries are associated with traumatic pneumothorax?
7

A
  1. central lines /
  2. thoracentesis /
  3. biopsy
  4. endotracheal tube placement
  5. endoscopy /
  6. dilational techniques
  7. operative
59
Q

What is The Open Pneumothorax: sucking-chest wound?

Management?

A

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!)

60
Q

Treatment Options
for a pneumothorax?
4

A
  1. Observation: Inpatient vs. Outpatient
  2. Oxygen
  3. Thoracostomy Drainage
  4. VATS ( “standard” if surgery required)
61
Q

Where should we do a Thoracostomy Drainage?

A

3rd Interspace -5th Interspace

62
Q

Asbestosis is caused by what?

What is it characterized by?

A

Caused by inhalation of asbestos fibers

Characterized by slowly progressive, diffuse pulmonary fibrosis

63
Q

The spectrum of pulmonary disorders associated with asbestos exposure includes?
3

A
  1. Asbestosis
  2. Pleural disease (focal and diffuse benign pleural plaques)
  3. Malignancies (non-small cell and small cell carcinoma of the lung as well as malignant mesothelioma)
64
Q

Asbestosis clinical findings

4

A
  1. Most patients are asymptomatic for at least 20 to 30 years after the initial exposure
  2. Usually first symptom is the insidious onset of breathlessness with exertion
  3. Progressive dyspnea an may develop bibasilar crackles
  4. Cough, sputum production, and wheezing are unusual
65
Q

What lab studies would we do for asbestosis?

Imaging?

A

Laboratory studies not useful

Radiography – wide spectrum but pleural involvement is a hallmark

66
Q

How should we treat asbestosis?

6

A

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

67
Q

What is mesothelioma?

A

Mesothelioma is an insidious neoplasm arising from the mesothelial surfaces of the pleural

68
Q

What is 70% of pleural mesothelioma associated with?

Increased risk of cancer combined with what?

Describe the onset?

A

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

69
Q

Mesothelioma Presentation?

2

A

Typical patient presents in 5th to 7th decades with dyspnea and nonpleuritic chest pain

70
Q

Mesothelioma Common physical findings?

3

A
  1. Unilateral dullness to percussion at the lung base
  2. Palpable chest wall masses
  3. Scoliosis towards the side of the malignancy
71
Q

Mesothelioma Radiology?

2

A

Most cases show a

  1. unilateral pleural abnormality with a
  2. large, unilateral pleural effusion
72
Q

What will the CT scan show in a mesothelioma pt?

A

circumferential pleural thickening-mesothelioma

73
Q

Collagen-Vascular Disease of the Pleura include which diseases?
6

A
  1. Rheumatoid Arthritis
  2. Systemic Lupus Erythematosis
  3. Sarcoidosis
  4. Mixed connective tissue disease
  5. Wegener’s Granulomatosis
  6. Sjogren’s syndrome
74
Q

Causes of pleuritic chest pain

11

A
  1. Viral pleurisy
  2. Pneumonia
  3. Acute pulmonary embolus
  4. Pneumothorax
  5. Pericarditis
  6. Collagen vascular disease (lupus, RA, connective tissue disease)
  7. Drug induced lupus
  8. IBS/IBD
  9. Familial mediterranean fever
  10. Radiation pneumonitis
  11. Pulmonary histoplasmosis

Pulmonology (16 decks)

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