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Clinical Medicine PA 581: Pulmonary > Pleural Effusion/Pneumothorax > Flashcards

Pleural Effusion/Pneumothorax Flashcards

Objectives

1
Q

Pleuritis/Pleurisy

A
  • Pain caused by inflammation of the pleura (specifically irritation of parietal pleura)
  • Lung parenchyma has NO nerve fibers!
    • All nerves are located on pleura so any inflammation is VERY painful
  • Localized chest pain, worsens with cough/inspiration, movement, deep breaths
  • Described as stabbing and sharp “pleuritic chest pain”
    • Pleuritic CP: pain with deep inspiration
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2
Q

Causes of Pleuritis

A
  • Inflammation: malignancy or Rheumatologic disorders (RA, SLE)
  • Infection
  • Radiation
  • Pulmonary Embolism
  • Pneumothorax
  • Trauma
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3
Q

Pleuritis Tx

A
  • Typically, self-limiting; tx underlying cause; consider NSAIDS
  • Often associated w/ Pleural Effusions (CXR helpful)
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4
Q

Pleuritis Physical Exam Findings

A
  • Patient “splints” during inspiration
  • Can have musculoskeletal pain
  • Tachypnea due to painful respirations
  • Possible pleural friction rub: squeaking sound of pleural/visceral pleura rubbing together
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5
Q

Pleural Effusion

A
  • Collection of fluid in the pleural cavity between the parietal and visceral pleura
    • 3-20 ml is normally present to provide lubrication b/ pleural surfaces
  • Amt of fluid remains constant by balance of hydrostatic and oncotic pressures & permeability of both pleural capillary and lymphatic systems
  • Types
    • Transudate
    • Exudate
    • Empyema (“pus” thorax)
    • Hemorrhagic/hemothorax
    • Chylous/chylothorax (lymph)
    • Transudate Effusion
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6
Q

Transudate Effusion

A
  • Most Common!
  • Caused by ↑ pulmonary venous pressure or hypoproteinemia
    • Increased hydrostatic pressure
    • Decreased colloidal osmotic pressure
  • LOW protein concentration < 3.0 g/100ml
    • BUT Total Protein may be elevated in pts taking diuretics “pseudoexudative” (think of pts with decompensated acute HF)
  • Clear, yellow/straw colored
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7
Q

Exudate Effusion

A
  • Caused by inflammation
  • HIGH protein concentration
  • Deeper color, turbid
  • Can appear loculated on CXR
  • Complicated Parapneumonic (from underlying PNA) Effusion
    • Can develop into empyema
    • Thoracentesis or insertion of larger chest tube for drainage
    • Consider intrapleural thrombolytic agents (like streptokinase)
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8
Q

Exudative effusion: “two test rule” and “three test rule”

A
  • Two Test Rule
    • Pleural fluid cholesterol > 45 mg/dL
    • Pleura fluid LDH > 0.45 x the upper limits of normal for serum LDH
  • Three Test Rule
    • Pleural fluid protein > 2.9 g/dL
    • Pleural fluid cholesterol > 45 mg/dL
    • Pleura fluid LDH > 0.45 x the upper limits of normal for serum LDH
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9
Q

Light’s Criteria

A
  • exudate effusion has one or more of the following:
    • Pleural fluid protein to serum protein ratio >0.5
    • Pleural fluid LDH to serum LDH ratio >0.6
    • Pleural fluid LDH > 2/3 upper limits of normal serum LDH
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10
Q

Transudate associated with…

A
  • CHF (40%)
  • Nephrotic Syndrome
  • Cirrhosis with ascites
  • Pulmonary Emboli
  • Peritoneal Dialysis
  • Pancreatitis
  • s/p CABG
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11
Q

Exudate associated with…

A
  • Parapneumonic (underlying PNA) (25%)
  • Malignancy (15%)
  • Pulmonary Emboli (10%)
  • TB
  • Traumatic
  • Connective Tissue Dz
  • Chylothorax
  • Sarcoidosis
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12
Q

Hemothorax

A
  • Gross blood in pleural space
  • Hct of Pleural fluid is =/> 50% of Hct of peripheral blood
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13
Q

Hemothorax cause

A
  • Coagulopathy, Aortic dissection
  • Trauma: Penetrating injury OR Non-penetrating injury
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14
Q

Hemothorax Tx

A
  • Chest Tube or Thoracotomy
  • Remove blood ASAP to avoid stasis of blood and possible resulting fibrosis!
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15
Q

Chylous/Chylothorax Effusion

A
  • Results from disruption of thoracic duct causing lymph in pleural space
  • Triglyceride level > 110 mg/ml
  • Milky white color
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16
Q

Chylous/Chylothorax Effusion Causes

A
  • Lymphoma
  • Tumor invading thoracic duct
  • Trauma
  • Complication from surgery
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17
Q

Chylous/Chylothorax Effusion Tx

A
  • Tx underlying cause
  • Intermittent thoracentesis/pleurx catheter
    • Pleurx catheter: small chest tube to allow for pt to drain on their own
      • High rate of infection
  • Diet Modifications:
    • TPN/NPO, Fat Free diet, Clear liquids
    • To allow time for spontaneous closure of leak
  • Pleurodesis: procedure indicated for recurrent pleural effusions; creates inflammation & scar tissue b/ pleural layers to prevent fluid build-up (inject talc powder)
  • Thoracic duct ligation (with large effusions)
  • Octreotide (IV or SQ for several weeks to reduce production)
  • Shunt from pleural space to peritoneal cavity
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18
Q

Empyema

A
  • Exudative effusion (pus) caused by infection
    • Increase in fibrin; loculated effusion
  • Fluid is turbid, purulent, pus in pleural space
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19
Q

Empyema Causes

A
  • MCC = Strep pneumoniae
  • pH, elevated LDH & Glucose, Gram stain, cytology
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20
Q

Empyema Tx

A
  • CT, decortication, IV abx 4-6 weeks), Fibrinolytic agents (TPA)
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21
Q

Pleural Effusion signs and symptoms

A
  • Dyspnea, SOB
  • Pleuritic CP
  • Dry cough
  • Diminished Breath sounds
  • Dullness to percussion, decrease TF (tactile fremitus)
  • Fever, chills, productive cough w/ parapneumonic effusions
  • Massive effusion can cause shift of trachea to contralateral side
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22
Q

Pleural Effusion dx tests

A
  • CXR: Bilateral decub films >1 cm layering = thoracentesis
  • CT scan of chest
  • Thoracentesis
    • US guided vs. Bedside
    • Risks
23
Q

Indications for Thoracentesis

A
  • Unilateral effusions/new effusion
  • Parapneumonic effusions ASAP
    • Observation of effusion if uncomplicated heart failure is suspected
24
Q

Thoracentesis possible complications

A
  • Pneumothorax (5-10%)
  • Bleeding/hemothorax
  • Re-expansion pulmonary edema
    • Body compensates for rapid fluid loss by increasing production of pleural fluid
  • Splenic/liver laceration
25
Q

Conditions Diagnosed via Thoracentesis

A
  • Malignancy (cyto)
  • Empyema (gram stain, LDH >1000)
  • Tuberculous pleurisy (total protein >4)
  • Fungal infection of pleural space (gram & fungal stain)
  • Chylothorax (triglycerides >110)
  • Cholesterol effusion (cholesterol > 250)
  • Urinothorax: fistula in pleural space from urinary tract
  • Esophageal rupture (elevated amylase)
  • Hemothorax
26
Q

Pleural Fluid and Dx via Gross appearance

A
  • Pale yellow/straw colored = Transudative
  • Red/Bloody = Malignant / asbestos / exudative
  • Pus appearing = Empyema
  • Milky = Chylothorax/cholesterol effusion
27
Q

Pleural Fluid and Dx via labs

A
  • Send Pleural Fluid for:
    • Cell count/cytology
      • Nucleated cells >50 k = complicated parapneumonic effusion/empyema
      • Lymphocytes 85-95% = TB, chlyothorax, lymphoma, sarcoidosis, RA, malignancy (50-70%)
      • Eosinophilla >10% = PTX, hemothorax, pulm infarction, fungal, malignancy
    • Total Protein
      • Transudative < 3.0
      • Exudative > 3.0
    • LDH >1000 = empyema
    • Glucose: LOW glucose with exudative effusion:
      • Rheumatoid pleursity, complicated parapneumonic effusion/empyema
      • Malignant, TB, lupus, esophageal rupture
    • pH
      • pH < 7.3 = empyema/malignancy
        • Low pH associated with malignant effusion -> shorter life expectacy
      • pH < 7.15 = needs drainage /evacuation
    • Amylase
      • Elevated // Ddx: acute or chronic pancreatitis, esophageal rupture, malignancy
    • Cholesterol
      • >250 = cholesterol effusion
    • Triglycerides
      • >110 = chylothorax
    • Gram stain, Fungi
    • AFB (acid-fast bacilli) for TB screening
    • Hct for Hemothorax
28
Q

Pneumothorax (PTX)

A
  • Defined as air in the pleural space
  • Types
    • Spontaneous/Primary
    • Traumatic/Iatrogenic
    • Tension PTX
    • Secondary
29
Q

Spontaneous PTX

A
  • Sudden onset unilateral pleuritic CP & dyspnea
  • Male > Female
  • Age 20-40
  • Smoking increases risk
  • Family Hx
  • Recurrence is common
30
Q

Traumatic/Iatrogenic PTX = MCC!

A
  • Iatrogenic
    • Central lines, Lung biopsy
    • Mechanical ventilation
  • Traumatic
    • Penetrating chest trauma
    • Rib fractures
31
Q

Tension PTX

A
  • One-way value develops where air can enter pleural space but not exit; dangerous, potentially fatal if untreated
32
Q

Tension PTX signs and symptoms

A
  • Acute resp failure
  • Hypoxemia
  • Dyspnea, tachypnea, tachycardia
  • Diaphoresis, cyanosis
  • Tracheal deviation to opposite side of PTX
    • Shifting of mediastinum can cause compression of bv → DEATH
  • Hypotension, distended neck veins
33
Q

Tension PTX Tx

A
  • Dx w/ CXR if able
  • High Flow oxygen
  • Needle inserted into 2nd ICS
    • Then prep pt for needle thoracostomy
34
Q

Secondary PTX

A
  • Pneumothorax caused by underlying disease; spontaneous in nature
    • COPD
    • Cystic fibrosis
    • Sarcoidosis
    • TB
    • AIDS – PCP or PJP
35
Q

Secondary PTX signs and symptoms

A
  • Pleuritic CP
  • Dyspnea
  • Acute onset
  • Localized chest pain to affected side
  • Hemoptysis
  • Hypoxia
36
Q

Physical Exam: finding of PTX

A
  • Diminished breath sounds on affected side
  • Decreased TF (tactile fremitus)
  • Hyper-resonance to percussion
  • Mediastinal shift to contralateral side with tension PTX
37
Q

Lab findings and imaging: finding of PTX

A
  • ABG
  • CXR or CT scan of chest
  • EKG and Cardiac enzymes to r/o cardiac origin
38
Q

PTX Treatment

A
  • Depends on the size and etiology:
    • Primary Spontaneous PTX:
      • Observation & oxygenation if size < 2-3 cm in stable pt
      • Chest tube if ≥ 3 cm in unstable pt
      • Unstable or recurrent = Chest tube!
    • Role of Oxygen: ↑ rate of reabsorption of air in pleural space
  • Chest tube Placement:
    • 22 Fr (small chest tube) or 14 Fr (large chest tube)
    • Place to Suction: water seal device, watch for air leak
      • Once PTX resolves by suction, can remove chest tube if no air leak
      • If persists, do VATS/pleuradesis!
39
Q

PTX Recurrence rate

A
  • After 1st Primary Spontaneous PTX:
    • 23-50% (over 1-5 years)
    • ↑ pts with blebs/bullae (can remove bleb; remove diseased lung to allow healthy lung to expand)
    • If recurrent, recommend pleuradesis
40
Q

PTX pt education

A
  • NO air travel with PTX!
  • Healthy lungs = can travel after 2 weeks
  • Unhealthy lungs = wait up to one year
    • Must check pre-flight CXR / CT prior to clearance
41
Q

Pleurx Cath

A
  • self-drainage of pleural fluid
42
Q

Trapped Lung Syndrome

A
  • Unexpandable lung: when lung does NOT expand to chest wall, creating adherence of visceral and parietal pleural layers
  • Seen when pleural fluid is removed and lung does NOT fully re-expand // post procedure pneumothorax
43
Q

Trapped Lung Syndrome Causes

A
  • malignancy
  • infection
  • inflammation
44
Q

Trapped Lung Syndrome Tx

A
  • pleurodesis
  • indwelling pleural catheter
45
Q

Costochondritis

A
  • “It hurts when you touch it”
  • Inflammation of the costochondral joints of the chest, which can cause chest pain. The pain of costochondritis can sometimes be distinguished from other, more serious forms of chest pain by its reproducibility on palpation of the involved joints and the absence of abnormalities on chest x-ray examinations, electrocardiograms, and blood tests.
46
Q

Costochondritis symptoms

A
  • Symptoms include pain and tenderness over the joints lateral to the sternum
47
Q

Costochondritis Tx

A
  • Nonsteroidal anti-inflammatory agents often help reduce the discomfort, which normally resolves spontaneously over time.
48
Q

Pleurisy

A
  • a condition in which the pleura — a membrane consisting of a layer of tissue that lines the inner side of the chest cavity and a layer of tissue that surrounds the lungs — becomes inflamed. Also called pleuritis, pleurisy causes sharp chest pain (pleuritic pain) that worsens during breathing
49
Q

pleural fibrosis

A
  • Pleural fibrosis and calcification are thickening and stiffening of the pleura (the thin, transparent, two-layered membrane that covers the lungs) that occurs as a result of pleural inflammation or exposure to asbestos.
50
Q

Chest Ultrasound : A-lines

A
  • A-lines – occur when sound waves cross the pleural line and encounter air
  • typically NORMAL
  • A lines are reverberation artifacts due to the pleura acting as a very strong reflector. Ultrasound pulses continue to travel several times between the probe and the pleura and are displayed as horizontal lines equidistant from one another, repetition of the distance between the pleural line and ultrasound transducer.
51
Q

Chest Ultrasound : B-lines

A
  • B lines have been explained as reverberation artifacts or due to resonance phenomena.
  • They are etiology a-specific and associate with every condition that causes changes in lung density:
    • Increased lung weight (i.e., water, blood, proteins, connective tissue, cells)
    • Lung deflation (atelectasis)
      • Assess w/a curved or phased array probe with the probe depth set round15 cm.
  • B lines have also been called: lung Rockets or comet tails.
  • Comet tail artifacts - single incomplete artifacts originating from the pleural line and propagating for a short distance distally. They are of no clinical significance but can be used to exclude a pneumothorax.
52
Q

Pleural effusion Dx via detailed hx

A
  • Comorbid conditions/disorders
    • SLE, hypothyroidism, amyloidosis, yellow nail syndrome
    • Hepatic/pancreatic diseases
  • Risk factors for pulmonary embolism/tuberculosis
  • Chronic hepatitis or alcoholism (cirrhosis)
  • Recent trauma or surgery to the thoracic spine
  • History of cancer, post-cardiac surgery
  • Occupational history
    • Asbestos exposure mesothelioma
      • Unilateral, exudative
      • Pleural eosinophil count
  • Medications
53
Q

Pleural effusion dx via Medications

A
  • Nitrofurantoin
  • Amiodarone
  • Ovarian stimulation therapy meds
  • Drug which induces lupus-like syndrome
54
Q

Pleural effusion CXR

A
  • X-Ray Frontal
  • PA-usually sufficient
  • Lateral decubitus view can show layering out of pleural fluid
    • Appeared as a site affected area or appears at decubitus
  • Due to gravity-liquid accumulation in subpulmonic location
    • Inferior surface of lower lobes/ the diaphragmatic leaflets (75 mL)
    • Costophrenic sulcus posteriorly, anteriorly, and laterally (175ml)
    • Obscure the diaphragmatic contour (500ml)
    • Effusion at fourth anterior rib level (1000ml)
  • Blunting of costophrenic angle:
    • On lateral-200mL fluid
    • On PA-75mL
    • Decub film can detect very small amounts: 5-10mL

Clinical Medicine PA 581: Pulmonary (9 decks)

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