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pulmonology > Pleural disorders > Flashcards

Pleural disorders Flashcards

1
Q

Describe the parietal pleura

A
  • it lines the thoracic cavity, including the thoracic cage, mediastinum and diaphragm
  • contains sensory nerve ending that can detect pain: pleuritis can be painful!!
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2
Q

Describe the visceral pleura

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
  • potential space between the parietal pleura and visceral pleura filled with pleural fluid
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4
Q

What is pleural fluid?

A
  • serous fluid that allows for parietal pleura (outer lining) and visceral pleura (inner lining) to glide over each other without separation
  • provides lubrication and surface tension
  • pleural fluid is prod by the parietal pleura and is absorbed by the visceral pleura as a continuous process
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5
Q

What are the mechanics of pulmonary ventilation? (relationship between the lungs and thoracic wall)

A
  • lungs are surrounded by pleural fluid that lubricates movement of lungs within the cavity
  • continual sunction of excess fluid into lymphatic channels acts like a glue to hold the lungs to the thoracic wall (allows for smooth movement)
  • pleural pressure is a negative pressure that holds the lungs open (more negative pressure with inspiration)
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6
Q

What is intrapulmonary pressure?

A
  • pressure within the alveoli
  • as the chest expands on inspiration the intrapulmonary pressure becomes more negative, which causes air to be sucked into the lungs
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7
Q

What is intrapleural pressure?

A
  • negative pressure is created in the pleural space as the thoracic cage enlarges and the lungs recoil during normal inspiration
  • negative pressures may be lost if fluid collects in the pleural space, making the lung unable to expand fully
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8
Q

What is Pleuritis?

A
  • it is a localized inflammation of pleural surfaces that produces sharp localized pain
  • also known as pleurisy
  • pleuritic pain is sharp, stabbing pain with splinting on inspiration
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9
Q

What is the clinical picture of pleuritis?

A
  • localized, pleuritic chest pain increased with deep inspiration and coughing and may be associated with pleural rub
  • pleural rub is a fine crackles best heard during inspiration and expiration at the site of chest pain
  • ipsilateral shoulder pain
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10
Q

What are the causes of Pleuritis?

A
  • viral infection (coxsackie B virus)
  • thoracic trauma
  • secondaray to pulm disorders: bronchiectasis, pneumonia, TB, pulmonary infarction, and lung cancer
  • secondary to systemic diseases: RA, SLE, and metastatic cancer
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11
Q

How do you dx Pleuritis?

A
  • CXR: normal unless primary lung disease

so dx is typically clinical, may do a work up to determine cause

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12
Q

What is the treatment of pleuritis?

A
  • tx of primary cause

- sx tx of chest pain: moderate analgesics: NSAIDs, some pts may need course of narcotics or both

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13
Q

What is a pleural effusion?

A

results when fluid collects b/t the parietal and visceral pleural layers
- occurs when the normal flow of fluid is disrupted: too much fluid is produced and not enough fluid is removed

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14
Q

Clinical features of Pleural effusion?

A
  • SOB
  • cough
  • pleuritic chest pain
  • other signs and sxs depends on etiology
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15
Q

What are the 3 main causes of pleural effusion?

A
  • CHF
  • pneumonia
  • malignancy
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16
Q

Dx of pleural effusion?

A
  • careful hx
  • thorough exam
  • CXR
  • chest CT
  • pleural fluid analysis
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17
Q

What will you see on CXR that is a pleural effusion?

A
  • order a PA and lateral decub
  • if you see blunting of either costophrenic angle - indicates accumulation of between 250-500 ml of fluid
  • lateral decubitus films will should fluid shift to dependent portion of thoracic cavity
  • sub-pulmonic effusion: is accum of fluid between lung and diaphragm which gives false impression of elevated semi-diaphragm
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18
Q

Why is a thoracentesis helpful in pleural effusion eval?

A
  • simple bedside procedure that permits fluid to be rapidly sampled visualized, and examined microscopically and quantified
  • a systemic approach to analysis of fluid in conjunction with clinical presentation should allow the clinician to dx the cause of effusion in about 75% of pts
  • this can be therapeutic as well as dx
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19
Q

How do you determine if pleural fluid is transudate vs exudate?

A
  • gross appearance
  • pH
  • Gram stain, C & S
  • cytology
  • LDH
  • protein
  • glucose
  • cholesterol
  • amylase
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20
Q

What is Light’s criteria?

A

if at least one of following 3 criteria present, the fluid is defined as exudate:

  • pleural fluid protein/serum protein ratio greater than 0.5
  • pleural fluid LDH/serum LDH ratio greater than 0.6
  • pleural fluid LDH greater than 2/3 the upper limits of lab’s normal serum LDH
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21
Q

What are exudative causes of pleural effusions?

A
  • anything that causes inflammatory or infiltrative disease of the pleura (damaging capillary membranes):
    neoplasm - disruption causes increased permeabiltity with lymphatic obstruction as well - lung cancer, breast cancer, lymphoma responsible for 75% of all malignant pleural effusions

infections: uncommonly assoc with acute bacterial pneumonias (small and transient), empyema (not just disruption of capillary membranes but the organisms have entered the pleural space), TB, viral pneumonitis, and mycoplasmal pneumonia

  • autoimmune disease
  • pulmonary infarction (PE)
  • intra-abdominal pathology (development of sub diaphragmatic abscess, pancreatitis)
22
Q

Transudative causes of pleural effusion? What it looks like?

A
  • straw colored, clear, odorless fluid
  • anything that causes increased hydrostatic pressure or decreased capillary colloid osmotic pressure such as:
    CHF (most common), severe hypoalbuminemia (nephrotic and liver failure), and cirrhosis (assoc with ascites)
  • if transudate: no further lab analysis is indicated
23
Q

If exudate you should consider what tests?

A
  • WBC with diff
  • bacterial culture
  • cytological exam
  • glucose level
  • amylase
24
Q

Tx focus of pleural effusions?

A
  • transudative effusion: focus on systemic cause
  • exudative: dependent on exact subtype
  • consider chest thoracostomy: if gross pus/empyema, hemothorax, complicated parapneumonic processes, and malignant effusion
25
Q

What is a parapneumonic effusion?

A
  • pleural effusions that occur in the pleural space adjacent to a bacterial pneumonia
  • typically are small and resolve with approp abx therapy
  • however if bacteria invade the pleural space, a complicated parapneumonic effusion or empyema may result
26
Q

What are the characteristics of a complicated parapneumonic effusion?

A
  • persistent bacterial invasion of pleural space
  • glucose less than 60 mg/dl
  • pH less than 7.2
  • positive culture
  • pleural LDH greater than 3x the upper limit for serum
  • pleural fluid is loculated (compartmentalized)
27
Q

What cancers are the most common cause of malignant pleural effusions?

A

Lung cancer and breast cancer account for 50-65% of malignant pleural effusions
- others are: lymphoma and pleural mesothelioma

28
Q

What type of effusion is a very likely indication of neoplasm?

A
  • bloody pleural effusion occuring in a pt without a hx of trauma or pulmonary infarction is indicative of neoplasma in 90% of cases
29
Q

Tx of malignant pleural effusions?

A
  • serial thoracentesis (getting tapped regularly)
  • chest tube with pleurodesis
  • pleuroperitoneal shunt
  • pleurectomy
30
Q

What is a mechanical pleurodesis?

A
  • ## electro-cautery scratch pad: the surgeon gently strokes the pleura, this roughens up the pleura so that when the abrasion heals the lung will adhere to the chest wall
31
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 doxy
  • admin through a chest tube or by VATS to create inflammation and subsequent fusion of the parietal and visceral pleura
  • goal is to cause an irritation b/t the 2 layers covering the lung
  • the sclerosant irritates the pleurae which results in inflammation and causes the pleurae to stick together
  • the procedure can be done at the bedside or in the operating room
32
Q

What is a hemothorax, what is the cause?

A
  • hemorrhagic pleural effusion
  • results from blood accumulating in the pleural cavity
  • usually due to trauma: a blunt or penetrating injury to the thorax, resulting in a rupture of the pleura, and this rupture allows blood to spill into the pleural space, equalizing the pressures between it and the lungs
33
Q

What are causes of a spontaneous hemothorax?

A
  • pulmonary: bullous emphysema, PE, infarction, TB, AVMs
  • pleural: torn adhesions, endometriosis
  • neoplastic: primary, metastatic
  • blood dyscrasias: thrombocytopenia, hemophilia, and anticoagulation
  • thoracic pathology: ruptured aorta, dissection
  • abdominal pathology: pancreatic pseudocyst, hemoperitoneum
34
Q

Goal of hemothorax tx? options for tx?

A
  • to remove pleural blood and allow for complete lung re-expansion
  • tx:
    thoracentesis: bedside/US guided/ CT guided
    thoracostomy drainage: the mainstay (chest tube)
    thorascopic surgery
    thoracotomy: massive hemothorax/instabiity/chronic hemothorax
35
Q

What is atelectasis?

A
  • incomplete expansion of lung which leads to the collapse of alveoli
  • increased negative pressure can lead to collection of fluid in the porton of the lung which isn’t expanding
  • this can cause an effusion by fluid leaking out of the lung into the chest cavity
  • atelectasis typically leads to small pleural effusions not requiring intervention
36
Q

What are the clinical manifestations of atelectasis?

A
  • pain
  • cough
  • dyspnea
  • dullness to percussion
  • diminished or absent vocal resonance
  • diminished or absent tactile vocal fremitus
  • friction rub
37
Q

What is a pneumothorax?

A
  • collection of air within the pleural space
  • pleural pressure in the affected hemithorax exceeds atmospheric pressure, from the result of a check valve mechanism that facilitates the ingress of gas into the pleural space during inspiration, but blocks the egress of gas from the pleural space during expiration
  • impairs respiratory function
  • decreases venous return to the right side of the heart
  • pt can become toxic very quickly
38
Q

What is the general management for a pneumothorax?

A
  • first: evacuate the air
  • second: address the underlying cause
  • third: promote pleural symphysis
39
Q

What is the classification system of a pneumothorax?

A
  • spontaneous pneumo: primary and secondary
  • traumatic pneumothorax:
    pulmonary source, tracheobronchial source and esophageal source
40
Q

Who is most likely to get a primary spontaneous pneumothorax?

A
  • disease in younger peeps (15-35)
  • affects males more than females
  • tall, slim, body habitus (marfans body type)
  • cigarette smoking implicated
  • usual cause: rupture of subpleural bleb - small air filled lesions just under pleural surface
41
Q

tx for primary spontaneous pneumothorax?

A
  • tx is hospitalization, tube thoracostomy to closed drainage, lung re-expansion against chest wall, and control of any persistent air leak (if sig. pneumo)
  • sometimes you can just observe pt if not in distress
42
Q

What is a secondary spontaneous pneumo due to? Tx?

A

underlying pulmonary disease

  • COPD/lung malignancy/CF
  • necrotizing infections like TB, pneumocystis jirovecii
  • Tx: O2, tube thoracostomy, persistent: VATS for resection or if pleurodesis needed
43
Q

Causes of traumatic Ptx?

A
  • parenchymal injury vs. Tracheobronchial vs Esophageal
  • blunt or penetrating
  • iatrogenic: hospital caused:
    central lines/thoracentesis/bx
    ET tube placement
    endoscopy/ dilational techniques
    operative
  • barotrauma: ventilation/blast injury
  • boerhave’s syndrome (esophageal rupture)
44
Q

What is an open pneumothorax?

A
  • sucking-chest wound
  • when a traumatic chest wall defect persists, through which ambient air enters the pleurals space during inspiration creating complete lung collapse
  • dressing
  • thoracostomy away from traumatic wound
45
Q

Tx options for a pneumothorax?

A
  • observation: inpatient vs outpatient
  • oxygen
  • thoracostomy drainage: 3rd interpsace - 5th interspace
  • VATS if surgery reqd
46
Q

What causes asbestosis? Characteristics? Spectrum of disease?

A
  • caused by inhalation of asbestos fibers
  • characterized by slowly progressive, diffuse pulmonary fibrosis.
  • The spectrum of pulmonary disorders associated with asbestos exposure includes:
    asbestosis, pleural disease (focal and diffuse benign pleural plaques)
  • malignacies (non-small cell and small cell carcinoma of the lung as well as malignant mesothelioma)
47
Q

Clinical findings of asbestosis?

A
  • most pts are asymptomatic for at least 20-30 years after the initial exposure
  • usually the first sx is the insidious onset of breathlessness with exertion
  • progressive dyspnea and may develop bibasilar crackles
  • cough, sputum production, and wheezing are unusual
  • lab studies not useful
  • radiography: wide spectrum but ***pleural involvement is a hallmark
48
Q

Tx or preventative measures for Asbestosis?

A
  • no specific tx
  • focus should be on preventive measures:
    smoking cessation
    early detection of physiologic and radiographic abnormalities (CXR and PFTs recommended every 3 to 5 years)
  • prevention of further airborne asbestos exposure
  • supp O2 when there is resting hypoxemia or exercise induced oxygen desaturation
  • prompt tx of respiratory infections
  • pneumococcal and influenza vaccination
49
Q

What is mesothelioma?

A
  • insidious neoplasm arising from the mesothelial surfaces of the pleural
  • 70% of cases 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
50
Q

Presentation and common physical findings of Mesothelioma?

A
  • typical pt presents in 5th-7th decades with dyspnea and nonpleuritic chest pain
  • common physical findings: unilateral dullness to percussion at lung base, palpable chest wall masses (endstage), and scoliosis towards the side of malignancy
    radiology: most will show unilateral pleural abnormality with a large, unilateral pleural effusion
51
Q

What are the different collagen-vascular diseases that can affect the pleura?

A
  • RA
  • SLE
  • sarcoidosis
  • mixed CT disease
  • Wegener’s Granilomatosis
  • Sjogren’s syndrome
52
Q

Causes of pleuritic chest pain?

A
  • viral pleurisy
  • pneumonia
  • acute PE
  • pneumothorax
  • pericarditis
  • collagen vascular disease
  • drug induced lupus
  • IBD
  • familial mediterranean fever
  • radiation pneumonitis
  • pulmonary histoplasmosis, infection with lung fluke paragonimus

pulmonology (20 decks)

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