Pleural Disorders - Exam 2 Flashcards
What is the pleura? ______ is attached to the chest wall. _____ covers the lungs, blood vessels, bronchi and nerves
the serous membrane lining the thorax (chest wall) and enveloping the lungs
parietal= attached to the chest wall
visceral= covers the lungs, blood vessels, bronchi and nerves
Which pleura has nerve endings?
parietal pleura
What is the pleural cavity? What is the pleural fluid?
the thin serous fluid-filled (potential space) between the two pulmonary pleura
fills the pleural space/cavity; helps the two layers of pleura glide smoothly past each other during breathing
Is pleural fluid normally seen on imaging?
pleural fluid is NOT normally seen on imaging, only if there is a problem
What is pleurisy? What is pleural effusion?
Pleurisy - Inflammation of the pleura that causes sharp pain with breathing
Pleural Effusion - Excess fluid in the pleural space
What medications can lead pleurisy?
procainamide, hydralazine, and isoniazid
What AI disorders lead to pleurisy? What GI disorders lead to pleurisy?
lupus (SLE), rheumatoid arthritis,or scleroderma
pancreatitis, peritonitis, cholecystitis
a localized, sharp, stabbing, fleeting pain that is worsened by inspiration, sneezing or coughing
What am I?
What does it radiate towards?
pleurisy
radiation of pain to ipsilateral scapula may occur if diaphragmatic pleura is affected
What will you hear on PE in pleurisy?
pleural friction rub and decreased breath sounds
If CT is indicated, what kind do you need to order?
chest CT with contrast or CT angiography
Name 3 reasons you would want to admit a pt for pleurisy
hypoxemic (O2 sat of <90%)
parenteral pain control is needed
underlying etiology requires hospitalization
What is the tx for pleurisy?
NSAIDs!! indomethacin 25 mg BID-TID (short course - < 7-10 d)
cough suppressant (codeine, dextromethorphan, tessalon perles)
What does using cough suppressant put you at risk for?
pneumonia due to build up on airway secretions that are NOT coughed out due to cough suppressant
What is a pleural effusion? How much fluid is normal?
a collection of fluid in the pleural space resulting from a disruption in the normal pleural homeostasis
leaves 5–15 mL of fluid in the normal pleural space (1 teaspoon or 1 tablespoon)
What are the 5 pathophys processes that account for most pleural effusions?
What is the pathophsy behind transudate fluid?
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
What is the pathophys behind exudative fluid?
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
transudate want to think ?????
exudate want to think ?????
transudate think imbalance in pressure
exudate think inflammation or infection
**______ falls under both transudate and exudate
pulm embolism
What are the 3 MC s/s of a pleural effusion?
dyspnea, cough and pleuritic chest pain
a small pleural effusion will present like ???
a large pleural effusion will present like ????
small= less symptoms with normal physical exam
larger= more symptomatic with abnormal physical exam findings
What are 2 important questions to ask you pt when considered about a pleural effusion?
When did it start? has it gotten worse?
What are 3 things that will be DECREASED over the area that has the pleural effusion?
Diminished or absent breath sounds
Dullness to percussion
Decreased tactile fremitus
also have diminished or delayed chest expansion on the side with the effusion
What is a common CXR finding with pleural effusion?
blunting of the costophrenic angle is evident if there is > 175 ml (appx 6 oz) of fluid present
What is a helpful diagnostic imaging for pleural effusions?
CXR first then chest CT
CT is helpful when determining the underlying pathology
What are the 2 treatment options for pleural effusions?
observation vs thoracentesis
What are the indications for pleural effusion observation?
benign cause (overt CHF, viral pleurisy, recent thoracic or abdominal sx)
small amount of pleural fluid and there is a secure clinical diagnosis
What is the correct needle placement in a thoracentesis in a supine or posterior position? upright or seated?
supine/posterior: Midaxillary line between the 7th and 9th rib insert needle just superior to rib to avoid neurovascular bundle
upright/seated: midscapular line between the 7th and 9th rib insert needle just superior to rib to avoid neurovascular bundle
What are the diagnostic indications for thoracentesis?
- new onset pleural effusion without a clinical apparent cause
- atypical presentation of pleural effusion in a heart failure pt (unequal bilateral effusions, CHH pleural effusions should be equal and bilateral)
What are the therapeutic indications for thoracentesis?
Symptom relief
Evidence of loculation on imaging
Risk of pleural thickening/restrictive functional impairment
**What are the absolute contraindications for thoracentesis?
uncooperative patient
cutaneous disease over the proposed puncture site
What are the relative contraindications for thoracentesis?
bleeding diathesis or systemic anticoagulation (use US guidance is preferred)
small volume of fluid (< 1 cm thickness on a lateral decubitus film)
What is a caution with thoracentesis? What are they at risk for?
mechanical ventilation - risk of tension pneumothorax if lung is punctured
What are the 7 complications of thoracentesis?
pain at the puncture site
cutaneous or internal bleeding
pneumothorax
empyema
re-expansion pulmonary edema
malignant seeding of the thoracentesis tract
adverse reactions to anesthetics used in the procedure
Under what conditions does the risk of pneumothorax increase for a thoracentesis?
use of a needle larger than a 20 gauge and a lack of US guidance
What 5 lab values are part of the initial pleural fluid evaluation?
pleural fluid LDH
pleural fluid protein
serum LDH, albumin and globulin (proteins)
What are the normal serum lab values for albumin, globin and LDH? What makes up total serum protein?
total serum protein = albumin + globulin
**What is Light’s criteria? What does it indicate?
if ONE criteria is met
fluid is exudative
What is the management for a pleural effusion?
thoracentesis can be transiently therapeutic for severe dyspnea
tube thoracostomy indicated in empyema, complicated effusion, large or unstable hemothorax
When is a tube thoracostomy indicated for pleural effusion?
empyema, complicated effusion, large or unstable hemothorax
aka especially if bloody or pus in the pleural fluid
complicated pleural effusions are often associated with _______, ______ and ______
pneumonia, lung abscess or bronchiectasis
What does a hemothorax put you at risk for?
risk of hemorrhage and fibrous tissue formation
At what point should you order a repeat chest xray in a pleural effusion?
repeat CXR when drainage decreases to < 100 mL/day to ensure complete drainage has occurred
What is a pleurodesis? When is it commonly used?
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
commonly used in limited life expectancy when the goal of therapy is to palliate symptoms
What is a pneumothorax? What are the 5 pneumothorax classifications?
The abnormal presence of air or gas in the pleural cavity
- Primary spontaneous pneumothorax
- Secondary spontaneous pneumothorax
- Traumatic pneumothorax
- Iatrogenic pneumothorax
- Tension pneumothorax
What is a primary spontaneous pneumothorax? What pt population?
occurs in the ABSENCE of an underlying lung disease
most common in frequently in smokers and tall, thin, males between 10 and 40 years old
What is the etiology of a primary spontaneous pneumothorax?
eitology is unknown
but possibility a sign of early lung dz with rupture of subpleural apical blebs
What are 2 risk factors for primary spontaneous pneumothorax?
Positive family history and cigarette smoking are risk factors
What is a secondary spontaneous pneumothorax?
a complication of preexisting pulmonary disease
presenting s/s are more severe due to impaired baseline lung function
What is a catamenial pneumothorax?
- recurrent spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation. It is thought to be related to endometrial tissue affecting the pleura.
What is the MC cause of iatrogenic pneumothorax?
positive pressure mechanical ventilation
What is a tension pneumothorax caused by? What are the 2 MC causes? Why is it considered an emergency?
results from air entering pleural space but not escaping
MC cause: CPR or positive-pressure mechanical ventilation
Life-threatening due to cardiopulmonary compromise
**What are the unstable vital signs?
tachypnea, pleuritic chest pain, dyspnea, SOB, diminished breath sounds, decreased tactile fremitus
What am I?
pneumothorax
What will a tension pneumothorax present like?
**severe respiratory compromise and **CV collapse
marked tachycardia, hypotension
unable to speak full sentences
**tracheal deviation
displacement of the PMI
What is the imaging work-up needed for pneumothorax?
CXR: PA, expiratory and lateral decubitus views
then
Chest CT with or without contrast- more sensitive and helpful to identify pathology
What is the management of a primary spontanous pneumothorax?
1 priority is airway stablization!!
What are the indications for supplemental oxygen and observation as a tx for pneumothorax?
very small pneumothorax (≤ 3 cm at the apex or ≤ 2 cm at the level of the hilum)
stable vital signs
first PSP
no pleural effusion
ALL OF THE ABOVE MUST BE MEET
What are the criteria to be considered a small pneumothorax?
(≤ 3 cm at the apex or ≤ 2 cm at the level of the hilum)
What is the oxygen goal for a very mild primary spontaneous pneumothorax? Then what do you do?
Oxygen at 6 L with goal of SpO2 of >96%
repeat CXR after 6 hours
What are the indications to do aspiration as a tx for primary spontaneous pneumothorax? What kind of aspiration is preferred?
large pneumothorax : (≥ 3 cm at the apex or ≥ 2 cm at the hilum)
stable vital signs
first PSP
provider with expertise in aspirations
catheter is preferred over needle due to many complications when needle is used
Where is aspiration procedure done? What materials do you need? How much air should be removed?
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
After aspirating the pt and not meeting resistance after _____, What does that make you think? What is the next step?
Lack of resistance after 4 L = persistent air leak
indication for chest tube
After the successful aspiration of pneumothorax, What do you need to do next? What do you do if the pneumothorax persists?
observe patient and repeat CXR at 4 hours, if stable remove catheter and repeat CXR at 2 hours
if recurrence occurs insert chest tube and admit
What are the indications for a chest tube?
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
Where do you place a chest tube? What material is commonly used?
4th or 5th intercostal space in the anterior axillary or midaxillary line-> use the nipple as an anatomical landmark
catheter is attached to water-seal system or light wall suction
What french size is commonly used for a chest tube? What french size if using a catheter?
tube: greater than 16mm
catheter: less than 14mm, less pain but increased risk for plugging or kinking
What is the secondary spontaneous pneumothorax treatment?
maintain airway
oxygen supplementation
tube or catheter thoracostomy and admission
What is the management for a tension pneumothorax? What confirms the dx? What do you do next?
1st line: 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
OR
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
