Pleural effusion and pneumothorax Flashcards
Three “parts” of parietal pleura
- costal
- mediastinal
- diaphragmatic
2 recesses (1 important and 1 useless)
- costomediastinal recess (more prominent on left) useless one
- costodiaphragmatic - important one
What does the presence of air in the pleural space indicate
pneumothorax
What is increased fluid in the pleural space called
pleural effusion
Pleural effusion definition
fluid in the pleural space in between the visceral and parietal pleura
How does pleural effusion effect breathing
restrict respiration/gas exchange by mechanically taking up space in the pleural cavity
Pulmonary edema definition
fluid accumulation within the lungs, in the alveoli
How does pulmonary edema effect breathing
reduces alveoli’s ability to manage gas exchange = respiratory distress or failure
How to distinguish pleural effusion from pulmonary edema using radiology
lateral decubitus position X-ray. Effusion will move with gravity but edema will not
Difference between respiratory distress and respiratory failure
distress: making extra effort to breathe
failure: not keeping up with O2 demands, SpO2 falls, ABGs out of whack
What shape is typically seen in a pleural effusion
a meniscus
What anatomical part of the lung is effected by pleural effusion and a good sign for dx
blunting of the costodiaphragmatic angles
What does pulmonary edema look like on CXR
- can see through edema, not fully white
- can see costodiaphragmatic angle
what med treats pulmonary edema
morphine
6 mechanisms that cause pleural effusion
- increased hydrostatic pressure in microcirculation
- decreased oncotic pressure in microcirculation
- Decreased pressure in the pleural space
- Increased permeability in microcirculation
- Impaired lymphatic drainage
- Movement of fluid from peritoneal space
When does increased hydrostatic pressure cause pleural effusion?
left-sided heart failure (bilateral)
**most common cause of pleural effusion
When does decreased oncotic pressure cause pleural effusion?
hypoalbuminemia (bilateral)
When does decreased pressure in the pleural space cause pleural effusion?
collapsed lung
When does increased permeability in microcirculation cause pleural effusion?
pneumonia (unilateral or bilateral)
*if did lateral position X-ray or CT and lung that is now visible looks healthy, this is not your dx!
When does impaired lymphatic drainage cause pleural effusion?
malignancy - most often lung ca, breast ca, and lymphoma (unilateral or bilateral)
When does movement of fluid from peritoneal space cause pleural effusion?
ascites
What is common finding in elderly patients on CXR
calcified aortic arch - white ring around the aorta
Silhouette sign
two things with same density can’t be distinguished when they are “on top” of each other in an xray
What must determine about pleural effusion’s fluid?
transudate or exudate
When does transudate occur?
when systemic factors that control formation and absorption of pleural fluid are altered
- ex. left sided heart failure and cirrhosis
When does exudate occur
when local factors that control formation and absorption of pleural fluid are altered
- ex. bacterial pneumonia, malignancy, viral infection, pulmonary embolism
clinical manifestations of pleural effusion
- dyspnea, cough, chest pain
- decreased breath sounds, dullness to percussion, absent tactile fremitus
what causes cough and chest pain in pleural effusion
irritation of the pleura
Two ways to dx pleural effusion
- CXR
- Labs
What does a CXR show in pleural effusion
- blunting of margins
- pleural fluid moves if also take lateral decubitus CXR
Lab results in pleural effusion
testing of pleural fluid:
- protein-to-serum >0.5
- LDH-to-serum >0.6
- LDH more than 2/3 the normal upper limit for serum LDH value
What should also have done to withdrawn pleural fluid?
- gram stain
- pathologist take a look for presence of malignant cells
Pleural effusion tx
thoracentesis - also therapeutic
What situations are thoracentesis inappropriate for tx of pleural effusion
- when treating the underlying condition will also fix it. For ex. treat CHF and effusion will go away
Common dz cause pleural effusion
- CHF
- Cirrhosis with hepatic hydrothorax
- nephrotic syndrome
- peritoneal dialysis/continuous ambulatory peritoneal dialysis
- hypoproteinemia
- glomerulonephritis
- superior VC obstruction
What do all the diseases that have the potential to cause exudative pleural effusion have in common?
related to inflammation
Empyema def
pus effusion (exudate)
What is most common pneumonia org that causes empyema
staph aureus
what is the only way can have bilateral pleural effusion (crossed the midline)
if BEHIND the parietal pleura, the two pleural cavities are separate!
Tapped exudative fluid of pleural effusion:
If LDH > 1000 IU/L what three diseases suspect
- empyema
- malignancy
- rheumatoid
Tapped exudative fluid of pleural effusion:
If glucose is <30 mg/dL what two diseases suspect
- empyema
- rheumatoid
Tapped exudative fluid of pleural effusion:
If glucose is 30-50 mg/dL what three diseases suspect
- SLE
- malignancy
- TB
Tapped exudative fluid of pleural effusion:
If WBC diff shows 50-70% lymphs what one disease suspect
malignancy
Tapped exudative fluid of pleural effusion:
If WBC diff shows >90% lymphs what 4 diseases suspect
- TB
- Sarcoid
- RA
- chylothorax
What does subcutaneous emphysema sound like
rice crispies
subcutaneous emphysema
- definition
- plain film appearance
- CT appearance
air escapes respiratory system and enters subq space
- always bad
- looks like spiderweb on plain film
- CT will show air spaces
Pneumomediastinum def
- the conducting airway communicates with the mediastinum
- tumor or trauma can cause
- pushes the parietal pleura off the fibrous pericardium and lets air inbetween
Radiographic signs of pneumomediastinum
- ring around the pulmonary artery (air is the ring)
- spinnaker sign in kids, displaced thymus
- continuous diaphragm sign: lose silhouette of diaphragm/heart, can see diaphragm all the way across
4 causes of pneumothorax
- primary spontaneous pneumothorax (PSP)
- secondary spontaneous pneumothorax (SSP)
- Iatrogenic pneumothorax
- Traumatic pneumothorax
Primary spontaneous pneumothorax
- common population
- what causes?
- healthy young adults (<40)
- no underlying dz or trauma
Secondary spontaneous pneumothorax
- cause
presense of underlying disease - COPD, interstitial lung disease
Iatrogenic pneumothorax cause
practitioner caused!!
- Central venous catheter placement
- permanent pacemaker placement
Primary spontaneous pneumothorax
- other lung disease
- BMI
- black vs. white
- male vs. female
- no underlying dz
- low BMI
- white > black
- male > female
Primary spontaneous pneumothorax
- S&S
- sudden onset of pleuritic chest pain, dyspnea
- tachypnea, hypoxia, asymmetric chest, decreased breath sounds
When look at lung tissue on CXR, what should be able to see to help rule out pneumothorax
vasculature to within 1 cm of the edge of the chest cavity. No vasculature, no lung tissue!
4 Characterisitcs of a simple pneumothorax
- ipsilateral decreased breath sounds
- respiratory distress
- mediastinal shift to pneumothorax side
- exaggerated dome of diaphragm
*things move into the space the lung vacated
Tactile fremitus and simple pneumothorax
will decrease
Tx of simple pneumothorax
- depends on size and clinical stability (O2 and hemodynamic status)
- <10% can be managed conservatively, O2 therapy
- large or clinical instability - drainage procedure
Three common causes of secondary spontaneous pneumothorax
- COPD: emphysema blebs
- interstitial lung disease
- infectious etiologies
What tx is always required for secondary spontaneous pneumothorax
drainage procedure, regardless of size and clinical condition
secondary spontaneous pneumothorax
- Recurrence rate
- what do most pts require
- high recurrence rate
- hospitalization
What must the first episode of secondary spontaneous pneumothorax receive
definite therapy - chest tube, CT if emphysema to look for blebs, etc.
3 tx for pneumothorax
- drainage (large PSP and any SSP)
- Pleural space obliteration in recurrent PSP and any SSP
- video assisted thorascopic surgery (VATS) pleurodesis
What types of substance are used as sclerosing agents in pleurodesis
irritative like talc, doxycycline, tetracycline, minocycline, erythromycin
What does the injection of sclerosing agents into the pleural space cause
aseptic inflammation with dense adhesions, leading to pleural symphysis (visceral pleura adheres to parietal pleura)
7 characteristics of tension pneumothorax
- ipsilateral decrease in breath sounds
- resp. distress
- mediastinal shift away from dec. breath sounds
- flattened hemidiaphragm
- falling BP, increasing pulse
- PEA
- Dead
*things are pushed away from tension side
what is cause of tension pneumothorax
trauma
What happens outside of lungs due to tension in tension pneumothorax
SVC compression
- decreases venous return to RA, decreases cardiac output
Tension pneumothorax tx
- needle decompression (don’t wait for films if suspect, just decompress!)
- second intercostal space
- needle in ABOVE third rib
what must also be used when do needle decompression
chest tube
If suspect pneumothorax but don’t see on image, what second type of image can be helpful
expiratory CXR
- makes pneumothorax look relatively larger
Flail chest def
- traumatic injury to chest
- 3+ ribs broken in 2+ places each
- when breath, chest pulls in with decrease in pressure instead of inflates out
Flail chest tx
- field
pressure over segment
Flail chest tx
- ER
- Intubate immediately if respiratory compromise
- analgesics
- surgical stabilization of rib fragments
