Pleural Disorders Flashcards
Which layer of the pleura contains sensory nerve endings and can detect pain?
-Parietal pleura
Pleural Fluid
- what color should this be?
- purpose
- where is this produced?
- should be light amber/yellow
- provides lubrication and surface tension, continual suction of excess fluid into lymphatic channels acts like a glue to hold lungs to thoracic wall.
- pleural fluid is produced by the parietal pleura and absorbed by the visceral pleura.
Is intrapleural pressure positive or negative?
-negatives, this holds the lungs open
Pleuritis
- what is this?
- aka
- describe pleuritic pain
- localized inflamm of pleural surfaces
- aka: pleurisy
- pleuritit pain is sharp, stabbing pain with “splinting” on inspiration.
Pleuritis
-what lung sounds are associated with pleuritis?
pleural rub (walking on snow, cat purr, “fine crackles”
Causes of pleuritis
- viral infection (Coxsackie B)
- Thoracic Trauma (Rib fx)
- Secondary to pulmonary disorders:
- -bronchiectasis (common)
- -Pneumonia
- -TB
- -Pulmonary Infarct
- -Lung Cancer
- Secondary to systemic dz:
- -rhematoid arthritis
- -systemic lupus
- -metastatic cancer
Pleuritis
Dx
TX
- CXR, normal unless lung dz
- dx is clinical
Tx:
- tx primary cause
- sx tx of chest pain
- -NSAIDS/narcotics
Pleural Effusion
- what is this?
- why does this occur?
- Sx
What is this: fluid collection between the parietal and visceral layers
Why does this occur? when the normal flow of fluid is disrupted d/t either too much fluid produced or not enough fluid removed.
Sx:
- SOB
- Cough
- Pleuritic chest pain
Pleural Effusion
- causes
- dx
- types of exudate
- ***CHF
- pneumona
- malignancy
- pulmonary embolism
- viral
- Mesothelioma
Dx:
- CXR (blunting of costophrenic angle 250-500ml PA)(sub-pulmonic effusion: accumulation of fluid between the lung and diaphragm giving false impression of elevated hemidiaphragm)
- Chest CT
- Pleural fluid analysis
How do you obtain pleural fluid for anaysis?
-thoracentesis
Pleural Fluid Analysis- what tests are included?
- gross appearance
- pH
- gram stain, C&S
- cytology
- LDH
- Protein
- glucose
- cholesterol
- amylase
What is Lights Criteria?
if at least ONE of the following three criteria is present, the fluid is defined as an exudate.
- pleural protein vs serum protein
- pleural LDH vs serum LDH
- Plueral fluid LDH greater than 2/3 the upper limits of the labs normal LDH
What are some exudative causes of pleural effusions?
- anything that causes inflammatory or infiltrative dz of the pleura)
- Neoplasm (lung, breast cancer, lymphoma)
- Infection (Viral pneumonitis, empyema, TB, mycoplasmal pneumonia
- autoimmune dz
- pulmonary infarction
- intra-abdominal pathology
What is a Transudative effusion? What color is this?
- anything that causes increased hydrostatic pressure or decreased capillary colloid osmotic pressure ex:
- CHF
- Sever hypoalbuminemia (nephrotic syndrome and liver failure)
- Cirrhosis (associated with ascites)
Color: straw-colored, clear, odorless fluid
Once you have determined if you pleural fluid is transudative or exudative, how do you treat it?
Transudative: treat the underlying cause, focus on the systemic cause.
Exudative: treat the underlying cause, dependent on the exact cause.
For both considerChest thoracostomy
What is parapneumonic effusion?
-plueral effusions that occur in the pleural space adjacent to a bacterial pneumonia, where bacteria from the lung have invaded the pleural space.
Characteristics of complicated parapneumonic effusion?
- persistent bacterial invasion of the pleural space
- glucose less than 60mg/dL
- positive culture
- pleural LDH
- Pleural fluid is loculated.
- Loculated: compartments/cavities
Malignant Pleural Effusions
- what is this?
- what two major cancers account for the majority of these effusions?
- what finding is indicative of neoplasm?
- cancer causing pleural effusion
- lung and breast cancer account for 50-65% of malignant pleural effusions.
- bloody pleural effusion, w/o trauma.
A true Hemothorax is when the pleural fluid hct exceeds ____ of the peripheral blood hct
50%
Tx of Malignant Pleual effusion
- serial thoracentesis
- chest tube with pleurodesis
- pleuroperitoneal shunt
- pleurectomy
What is Pleurodesis?
What are the typeS?
medical procedure in which the pleura space is artificially obliterated. Used to treat plural effusion.
- Mechanical w/ electrocautery and chemical
- both cause adhesion of the lung to the chest wall by irritation and inflammation.
What is Hemothorax?
Causes
-blood in the pleural space “homorrhagic pleural effusion”
- Causes:
- trauma
- spontaneous
What are some causes of spontaneous pneumothorax?
- pulmonary: emphysema, PE, infarction, TB, AVMs
- Plerual: torn adhesions, endometriosis
- Bood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation
- Thoracic pathology : ruptured aorta, dissection
- Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum
Tx of Hemothorax
- thoracentesis: bedside, ultrasound-guided/CT guided
- thoracostomy drainage: mainsay
- thorascopic surgery
- thoracotomy: massive hemothorax, instability, chronic hemothorax
Atelectasis
- what is this?
- what does this usually lead to?
- incomplete expansion of the alveoli in the lung leading to their collapse.
- increased negative intrapleural pressure can lead to collection of fluid in the portion of the lung which is not expanding.
-typicaly leads to small pleural effusions not requiring interventions
Clinical manifestatins of atelectasis
- pain
- cough
- dyspnea
- dullness to percussion
- diminished/absence vocal resonance and tactile vocal fremitus
- friction rub
Pneumothorax
- what is this?
- whats going on in our chest when this happens?
- collection of air in the pleural space.
- each time you take a breath more air gets in and no air can get out pushing the heart over and making it harder for the hear to fill leading to decreased venous return to the right side of the heart.
Pneumothorax
-Tx
- evacuate the air
- address the underlying cause
- promote pleural symphysis
what are ALL of the classifications of Pneumothorax
- Spontaneous:
- -primary
- -secondary
- Traumatic Pneumothorax:
- -pulmonary source
- -tracheobronchial source
- -esophogeal source
What type of pneumothorax would you expect in a young (15-35) tall, slim, cigarette smoking male?
What is the usual cause?
Primary spontaneous pneumothorax
cause: rupture of a subplueral bleb
What type of pneumothorax would you expect to see with COPD, lung malignancy, CF, Necrotizing infections (TB, pneumocystis jirovecii)?
Secondary Pneumothorax, due to an underlying pulmonary dz
What type of pneumothorax would you expect to see in a pt with parenchymal, tracheobronchial, esophageal injury?
Traumatic Pneumothorax
What type of pneumothorax would you expect to see in a pt with barotrauma(ventilation/blast injury)?
-Traumatic pneumothorax
What are some iatrogenic causes of pneumothorax?
- centra lines/thoracentesis/bx
- et tube placement
- endoscopy/dilation techniques
- operative
Open Pneumothorax
- aka
- causes
- tx
-aka; sucking-chest wound
Cause: when traumatic chest wall defect persists, through which the air enters the pleural space during inspiration creating complete lung collapse.
-Tx: dressing, thoracostomy(3rd-5th interspace) away from the traumatic wound, observations, O2, VATS (video assisted thorascopic surgery)
Asbestosis
- cause
- sx
- CXR findings
- tx
caused by inhalation of asbestos fibers
sx:
- slowly progressive -diffuse pulmonary fibrosis
- asymptomatic for at least 20-30years
- dyspnea
- cough, sputum production an wheezing are UNUSUAL!
CXR:
-plueral involvement is hallmark!!
Tx:
- no specific tx
- smoking cessation
- early detection on CXR and PFTs (q 3-5years)
- supplemental O2 when there is resting hypoxemia
- tx of respiratory infections
- pneumococcal and influenza vaccinations.
Mesothelioma
- what is this?
- caused by
- presentation
- CXR
What is this: an insidious neoplasm arising from the mesothelial surfaces of the pleura.
-caused by asbestos exposure
-presentation:
dypsnea, non-pleuritic chest pain
dullness to percussion at lung base, palpable chest wall masses, scoliosis towards malignancy (usually end stage illness)
- CXR:
- unilateral pleural abnormality with a large unilateral pleural effusion.
What are some causes of collage-vascular disease of the pleura?
- RA
- SLE
- Sarcoidosis
- Mixed connective tissue dz
- Wegeners Granulomatosis
- Sjogrens syndrome
