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Pulmonary Week 3 > Pleural Effusion and Pneumothorax > Flashcards

Pleural Effusion and Pneumothorax Flashcards

1
Q

Under normal circumstances, what is the volume of the pleural space?

A

1-20cc

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2
Q

Describe pleural fluid

A

clear, odorless with some nucleated cells whose function is lubrication of the pleural surface

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3
Q

What is the cellular composition of pleural fluid?

A

less than 1.5l/ul

70-80% macrophages
10% lymphocytes
2% PMNs

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4
Q

Normal protein conc in the pleural space?

A

1-1.5g/dL

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5
Q

What factors contribute to the development of pleural effusion?

A
  • hydrostatic pressure
  • lymphatic drainage
  • colloid oncotic pressure
  • tissue pressure

airway pressure does not

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6
Q

T or F. The parietal pleura has a low hydrostatic pressure

A

F. It is high which promotes movement of fluid into the pleural space through junctions (100ml/hr)

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7
Q

T or F. The visceral pleura has a low hydrostatic pressure

A

T. So it functions to move fluid out (300ml/hr)

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8
Q

What is the difference between a transudate or an exudate?

A

In a pleural effusion, different fluids can enter the pleural cavity. Transudate is fluid pushed through the capillary due to high pressure within the capillary (i.e. low proteins). Exudate is fluid that leaks around the cells of the capillaries caused by inflammation.

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9
Q

What are the pressure-based causes of pleural effusion?

A
  • increased hydrostatic pressure
  • decreased pleural pressure
  • increased OR decreased oncotic pressure
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10
Q

When are hydrostatic pressures increased?

A

heart failure (transudate)

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11
Q

When are pleural pressures decreased?

A

atelectasis (transudate)

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12
Q

When are oncotic pressures increased?

A

inflammation (exudate)

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13
Q

When are oncotic pressures decreased?

A

low albumin (transudate)

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14
Q

T or F. In pleural effusion due to CHF, both the parietal and visceral pleura are adding fluid into the space

A

T. Oncotic pressure gradient not affected

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15
Q

Characteristics of CHF pleural effusion

A
  • frequently bilateral

- cardiomegaly

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16
Q

The quantity of effusion related to CHF is based on what?

A

proportional to elevation in pulmonary artery capillary wedge pressure (24+ mm Hg)

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17
Q

What are some pathologies that might promote an exudative pleural effusion?

A
  • infection
  • inflammation
  • cancer
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18
Q

What happens to the oncotic pressure gradient in exudate rich pleural effusions?

A

it decreases. Hydrostatic pressures not affected

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19
Q

T or F. In pleural effusion due to inflammation, both the parietal and visceral pleura are adding fluid into the space

A

T.

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20
Q

Physical findings of pleural effusion?

A
  • dullness to percussion

- decreased vocal fremitus

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21
Q

What happens to RR in pleural effusion?

A

increased more as more fluid enters

22
Q

What happens to breath sounds in pleural effusion?

A

they decrease and become more vesicular and then bronchovesicular as more fluid enters and then become absent

23
Q

The fluid associated with malignancy is most likely ____

A

exudate

24
Q

What pleural:serum protein ratio suggests transudate effusion?

A

less than 0.5

25
Q

What pleural:serum LDH ratio suggests transudate effusion?

A

less than 0.6

26
Q

What serum LDH level suggests transudate?

A

less than 200U/L

A single criteria is enough to call it an exudate

27
Q

What are some common causes of transudates?

A
  • CHF
  • Nephrotic syndrome
  • Cirrhosis with ascites
28
Q

What are some common causes of exudates?

A
  • Peritoneal dialysis
  • viral infection
  • malignancy
  • pancreatitis
  • atelectasis
  • pulmonary embolism
29
Q

Determining cause of effusion based on cell count. Less than 1000/ul suggests what?

A

transudate

30
Q

Determining cause of effusion based on cell count. Greater than 5000/ul suggests what?

A

chronic exudate (lymphocytes)- TB or malignancy

31
Q

Determining cause of effusion based on cell count. Greater than 10,000/ul suggests what?

A

substantial inflammation (neutrophils)

  • parapneumonic
  • pancreatitis
  • pulmonary infarction
32
Q

Determining cause of effusion based on cell count. Greater than 50,000/ul suggests what?

A

parapneumonic effusions ONLY

33
Q

High neutrophils equals what?

A

acute inflammation

34
Q

85-95% lymphocytes in pleural fluid suggests what?

A

TB, lymphoma, sarcoidosis, R.A.

35
Q

50+% lymphocytes in pleural fluid suggests what?

A

in 2/3 of carcinomatous effusions

36
Q

If mesothelial cells are greater than 5%, what does it suggest?

A

excludes tuberculous pleurisy

37
Q

What is the first thing that should be done when a pleural effusion is seen?

A

assess size- size (less than 10mm thick on lateral decubitus or asymptomatic does not need treatment)

38
Q

What id the PE is large?

A

order LDH, protein, cholesterol, cell count and differential

39
Q

T or F. Negative AFB on pleural fluid does not rule out TB

A

T.

40
Q

What is primary spontaneous pneumothorax?

A

patients without identifiable lung diseases but have SUBPLEURAL BLEBS that can rupture and trap air (ball-valve mechanism)

41
Q

How does primary spontaneous pneumothorax present?

A
  • young previously healthy (tall and thin) patient with acute onset of pleuritic chest pain and dyspnea
    4: 1 male:female
42
Q

What is the first thing that should be done in a tension pneumothorax?

A

needle decompression in the 2nd ICS anteriorly (16-18 gauge needle)

43
Q

How does tension pneumothorax present?

A
  • hypotension

- hypoxemia

44
Q

Which way does the mediastinum shift with a tension pneumothorax? Triad?

A

away

Triad: Lung collapse, contralateral mediastinum shift, and depression of diaphragm

45
Q

What kind of probe is used for lung ultrasound?

A

low frequency probe (or high frequency in thin patients)

46
Q

What has to happen for lung sliding to occur?

A

there has to be apposition between the visceral and parietal pleura (there cannot be air)

47
Q

Lung sliding rules out (100%) ____ at the interspace being imaged

A

pneumothorax

48
Q

Pneumothorax

A
  • Absent lung sliding
  • Barcode sign on M mode
  • Absent B lines
  • may or may not have A lines

-Lung point

49
Q

What is a lung point?

A

the point where it goes from lung sliding to no lung sliding (dynamic sign)

100% specific for pneumothorax

50
Q

What does a B line indicate?

A

thickened interlobular septae or early filling of alveoli

51
Q

When are/can B lines seen?

A
  • Pulmonary edema
  • Interstitial edema
  • Interstitial fibrosis
52
Q

How big must a pleural effusion be for a CXR to detect it?

A

150cc (ultrasound can detect 5 cc)

Pulmonary Week 3 (18 decks)

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