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Pulmonology 2 > Pleural effusion and pneumothorax > Flashcards

Pleural effusion and pneumothorax Flashcards

1
Q

Three “parts” of parietal pleura

A
  1. costal
  2. mediastinal
  3. diaphragmatic
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2
Q

2 recesses (1 important and 1 useless)

A
  • costomediastinal recess (more prominent on left) useless one
  • costodiaphragmatic - important one
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3
Q

What does the presence of air in the pleural space indicate

A

pneumothorax

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4
Q

What is increased fluid in the pleural space called

A

pleural effusion

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5
Q

Pleural effusion definition

A

fluid in the pleural space in between the visceral and parietal pleura

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6
Q

How does pleural effusion effect breathing

A

restrict respiration/gas exchange by mechanically taking up space in the pleural cavity

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7
Q

Pulmonary edema definition

A

fluid accumulation within the lungs, in the alveoli

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8
Q

How does pulmonary edema effect breathing

A

reduces alveoli’s ability to manage gas exchange = respiratory distress or failure

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9
Q

How to distinguish pleural effusion from pulmonary edema using radiology

A

lateral decubitus position X-ray. Effusion will move with gravity but edema will not

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10
Q

Difference between respiratory distress and respiratory failure

A

distress: making extra effort to breathe
failure: not keeping up with O2 demands, SpO2 falls, ABGs out of whack

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11
Q

What shape is typically seen in a pleural effusion

A

a meniscus

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12
Q

What anatomical part of the lung is effected by pleural effusion and a good sign for dx

A

blunting of the costodiaphragmatic angles

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13
Q

What does pulmonary edema look like on CXR

A
  • can see through edema, not fully white

- can see costodiaphragmatic angle

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14
Q

what med treats pulmonary edema

A

morphine

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15
Q

6 mechanisms that cause pleural effusion

A
  1. increased hydrostatic pressure in microcirculation
  2. decreased oncotic pressure in microcirculation
  3. Decreased pressure in the pleural space
  4. Increased permeability in microcirculation
  5. Impaired lymphatic drainage
  6. Movement of fluid from peritoneal space
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16
Q

When does increased hydrostatic pressure cause pleural effusion?

A

left-sided heart failure (bilateral)

**most common cause of pleural effusion

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17
Q

When does decreased oncotic pressure cause pleural effusion?

A

hypoalbuminemia (bilateral)

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18
Q

When does decreased pressure in the pleural space cause pleural effusion?

A

collapsed lung

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19
Q

When does increased permeability in microcirculation cause pleural effusion?

A

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!

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20
Q

When does impaired lymphatic drainage cause pleural effusion?

A

malignancy - most often lung ca, breast ca, and lymphoma (unilateral or bilateral)

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21
Q

When does movement of fluid from peritoneal space cause pleural effusion?

A

ascites

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22
Q

What is common finding in elderly patients on CXR

A

calcified aortic arch - white ring around the aorta

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23
Q

Silhouette sign

A

two things with same density can’t be distinguished when they are “on top” of each other in an xray

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24
Q

What must determine about pleural effusion’s fluid?

A

transudate or exudate

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25
Q

When does transudate occur?

A

when systemic factors that control formation and absorption of pleural fluid are altered
- ex. left sided heart failure and cirrhosis

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26
Q

When does exudate occur

A

when local factors that control formation and absorption of pleural fluid are altered
- ex. bacterial pneumonia, malignancy, viral infection, pulmonary embolism

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27
Q

clinical manifestations of pleural effusion

A
  • dyspnea, cough, chest pain

- decreased breath sounds, dullness to percussion, absent tactile fremitus

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28
Q

what causes cough and chest pain in pleural effusion

A

irritation of the pleura

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29
Q

Two ways to dx pleural effusion

A
  • CXR

- Labs

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30
Q

What does a CXR show in pleural effusion

A
  • blunting of margins

- pleural fluid moves if also take lateral decubitus CXR

31
Q

Lab results in pleural effusion

A

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
32
Q

What should also have done to withdrawn pleural fluid?

A
  • gram stain

- pathologist take a look for presence of malignant cells

33
Q

Pleural effusion tx

A

thoracentesis - also therapeutic

34
Q

What situations are thoracentesis inappropriate for tx of pleural effusion

A
  • when treating the underlying condition will also fix it. For ex. treat CHF and effusion will go away
35
Q

Common dz cause pleural effusion

A
  • CHF
  • Cirrhosis with hepatic hydrothorax
  • nephrotic syndrome
  • peritoneal dialysis/continuous ambulatory peritoneal dialysis
  • hypoproteinemia
  • glomerulonephritis
  • superior VC obstruction
36
Q

What do all the diseases that have the potential to cause exudative pleural effusion have in common?

A

related to inflammation

37
Q

Empyema def

A

pus effusion (exudate)

38
Q

What is most common pneumonia org that causes empyema

A

staph aureus

39
Q

what is the only way can have bilateral pleural effusion (crossed the midline)

A

if BEHIND the parietal pleura, the two pleural cavities are separate!

40
Q

Tapped exudative fluid of pleural effusion:

If LDH > 1000 IU/L what three diseases suspect

A
  • empyema
  • malignancy
  • rheumatoid
41
Q

Tapped exudative fluid of pleural effusion:

If glucose is <30 mg/dL what two diseases suspect

A
  • empyema

- rheumatoid

42
Q

Tapped exudative fluid of pleural effusion:

If glucose is 30-50 mg/dL what three diseases suspect

A
  • SLE
  • malignancy
  • TB
43
Q

Tapped exudative fluid of pleural effusion:

If WBC diff shows 50-70% lymphs what one disease suspect

A

malignancy

44
Q

Tapped exudative fluid of pleural effusion:

If WBC diff shows >90% lymphs what 4 diseases suspect

A
  • TB
  • Sarcoid
  • RA
  • chylothorax
45
Q

What does subcutaneous emphysema sound like

A

rice crispies

46
Q

subcutaneous emphysema

  • definition
  • plain film appearance
  • CT appearance
A

air escapes respiratory system and enters subq space

  • always bad
  • looks like spiderweb on plain film
  • CT will show air spaces
47
Q

Pneumomediastinum def

A
  • the conducting airway communicates with the mediastinum
  • tumor or trauma can cause
  • pushes the parietal pleura off the fibrous pericardium and lets air inbetween
48
Q

Radiographic signs of pneumomediastinum

A
  • 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
49
Q

4 causes of pneumothorax

A
  1. primary spontaneous pneumothorax (PSP)
  2. secondary spontaneous pneumothorax (SSP)
  3. Iatrogenic pneumothorax
  4. Traumatic pneumothorax
50
Q

Primary spontaneous pneumothorax

  • common population
  • what causes?
A
  • healthy young adults (<40)

- no underlying dz or trauma

51
Q

Secondary spontaneous pneumothorax

- cause

A

presense of underlying disease - COPD, interstitial lung disease

52
Q

Iatrogenic pneumothorax cause

A

practitioner caused!!

  • Central venous catheter placement
  • permanent pacemaker placement
53
Q

Primary spontaneous pneumothorax

  • other lung disease
  • BMI
  • black vs. white
  • male vs. female
A
  • no underlying dz
  • low BMI
  • white > black
  • male > female
54
Q

Primary spontaneous pneumothorax

- S&S

A
  • sudden onset of pleuritic chest pain, dyspnea

- tachypnea, hypoxia, asymmetric chest, decreased breath sounds

55
Q

When look at lung tissue on CXR, what should be able to see to help rule out pneumothorax

A

vasculature to within 1 cm of the edge of the chest cavity. No vasculature, no lung tissue!

56
Q

4 Characterisitcs of a simple pneumothorax

A
  1. ipsilateral decreased breath sounds
  2. respiratory distress
  3. mediastinal shift to pneumothorax side
  4. exaggerated dome of diaphragm

*things move into the space the lung vacated

57
Q

Tactile fremitus and simple pneumothorax

A

will decrease

58
Q

Tx of simple pneumothorax

A
  • depends on size and clinical stability (O2 and hemodynamic status)
  • <10% can be managed conservatively, O2 therapy
  • large or clinical instability - drainage procedure
59
Q

Three common causes of secondary spontaneous pneumothorax

A
  1. COPD: emphysema blebs
  2. interstitial lung disease
  3. infectious etiologies
60
Q

What tx is always required for secondary spontaneous pneumothorax

A

drainage procedure, regardless of size and clinical condition

61
Q

secondary spontaneous pneumothorax

  • Recurrence rate
  • what do most pts require
A
  • high recurrence rate

- hospitalization

62
Q

What must the first episode of secondary spontaneous pneumothorax receive

A

definite therapy - chest tube, CT if emphysema to look for blebs, etc.

63
Q

3 tx for pneumothorax

A
  1. drainage (large PSP and any SSP)
  2. Pleural space obliteration in recurrent PSP and any SSP
  3. video assisted thorascopic surgery (VATS) pleurodesis
64
Q

What types of substance are used as sclerosing agents in pleurodesis

A

irritative like talc, doxycycline, tetracycline, minocycline, erythromycin

65
Q

What does the injection of sclerosing agents into the pleural space cause

A

aseptic inflammation with dense adhesions, leading to pleural symphysis (visceral pleura adheres to parietal pleura)

66
Q

7 characteristics of tension pneumothorax

A
  1. ipsilateral decrease in breath sounds
  2. resp. distress
  3. mediastinal shift away from dec. breath sounds
  4. flattened hemidiaphragm
  5. falling BP, increasing pulse
  6. PEA
  7. Dead

*things are pushed away from tension side

67
Q

what is cause of tension pneumothorax

A

trauma

68
Q

What happens outside of lungs due to tension in tension pneumothorax

A

SVC compression

- decreases venous return to RA, decreases cardiac output

69
Q

Tension pneumothorax tx

A
  • needle decompression (don’t wait for films if suspect, just decompress!)
  • second intercostal space
  • needle in ABOVE third rib
70
Q

what must also be used when do needle decompression

A

chest tube

71
Q

If suspect pneumothorax but don’t see on image, what second type of image can be helpful

A

expiratory CXR

- makes pneumothorax look relatively larger

72
Q

Flail chest def

A
  • traumatic injury to chest
  • 3+ ribs broken in 2+ places each
  • when breath, chest pulls in with decrease in pressure instead of inflates out
73
Q

Flail chest tx

- field

A

pressure over segment

74
Q

Flail chest tx

- ER

A
  • Intubate immediately if respiratory compromise
  • analgesics
  • surgical stabilization of rib fragments

Pulmonology 2 (17 decks)

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