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Pulmonology > Pleural Effusions > Flashcards

Pleural Effusions Flashcards

1
Q

What lines the surface of both parietal and visceral pleura?

A

mesothelial cells

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2
Q

Does visceral pleura have stomata and sensory fibers?

A

NO!!! (think about when get pleuritic pain - when the parietal pleura is irritated!!!) visceral pleura does NOT have sensory fibers, parietal pleura does!!!

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3
Q

What are three things that happens when there is abnormal accumulation of stuff in the pleural space?

A

bad news bears!!

  1. mechanical uncoupling of lung and chest wall
  2. reduction in FRC (restrictive physio)
  3. atelactasis and impaired gas exchange (shunt - i.e. lack of ventilation)
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4
Q

How much pleural fluid is normally in each hemithorax?

A

8-10 cc

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5
Q

How does a clinically significant effusion happen?

A

increased pleural fluid production and/or impaired lymphatic resorbtion (ie. either make too much and/or trouble getting rid of it)

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6
Q

Where does pleural fluid come from?

A

PLEURAL CAPILLARIES

  • parietal: intercostal and internal mammary arteries (major contributor)
  • visceral: bronchial arteries (minor - not pulling much weight :P)
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7
Q

What takes pleural fluid away (i.e. clears it away)?

A
  • parietal lymphatics (major contributor)
  • pulmonary capillaries (minor
    (looks like the parietal does most of the work with pleural fluid - bring it AND taking it away)
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8
Q

Causes of pleural effusion

A
  • increased driving pressure –> transudative pleural effusion (more watery)
  • altered permeability –> exudative pleural effusion (more proteinaceous)
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9
Q

examples of increased driving pressure

A
  • incr intravascular P (Pcap_
  • decr Ppl
  • decr plasma protein (decr COPcap)
  • incr gradient for flow from peritoneal to pleural space (Ppr >Ppl)
    TRANSUDATES!!!!!
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10
Q

examples of altered permeability

A
  • incr permeability
  • decr lymphatic clearance via stomata
  • structural disruption
    EXUDATES!!!!
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11
Q

transudate v. exudate

A

transudate - watery

exudate - high protein content

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12
Q

How much pleural fluid usu needs to acculumate before sx?

A

> 300-500cc!

often a-sx before that, keep in mind normal is 8-10 cc per hemithorax

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13
Q

Sx of pleura effusion

A
  • dyspnea (>50%),
  • cough (40%),
  • pleuritic chest pain - inflammation of the parietal pleura
  • fever - more common in infectious/inflamm disease
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14
Q

Physical findings

A
  • dullness to percussion
  • decr breath sounds
  • egophony at UPPER border (compressive actelectasis)
  • pleural friction rub
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15
Q

egophony

A
  • increased resonance of voice sounds[1] heard when auscultating the lungs, often caused by lung consolidation and fibrosis
  • E to A transition
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16
Q

thoracentesis

A

removal of xs pleural fluid

17
Q

indication for thoracentesis

A
    • fluid of unknown etio, esp important for
  • unilateral effusion (esp Lft side)
  • bilateral effusions of unequal size
  • normal cardiac silhouette on CXR
  • febrile patient
  • clinical evidence of pleurisy
  • concern for undiagnosed malignancy
    • relief of dyspnea
18
Q

Where does the needle go for thoracentesis and why?

A

ABOVE the rib

b/c the nerves and vessels that feed the rib run along the inferior aspect of that rib

19
Q

Light’s Criteria for exudate

A

exudate if ANY one of following present:

  • pleural fluid:serum protein ratio of >0.5
  • pleural fluid: serum LDH ratio of >0.6
  • pleural fluid LDH >2/3 upper limits of normal serum value
20
Q

Is the pleural usually intact in transudative pleural effusion?

A

YES!

  • normal ability to restrict movement of protein and other large molecules (normal permeability)
  • can think of transudative effusion as the more watery effusion
21
Q

What disease states most commonly lead to transudative effusion?

A

CHD, nephrotic syndrome, cirrhosis complicated by ascites

22
Q

Rare causes of pleural effusion include . . .

A
  • Pulmonary embolism
  • peritoneal dialysis
  • pericardial disease
  • hypoalbuminemia (<1.5)
  • sarcoidosis
  • SVC syndrome
  • urinothorax
  • myxedema
23
Q

What are some diseases that productive exudative effusion?

A 
infectious, inflamm, and malignant disease --> exudative effusion (proteinaceous)
these include: 
- parapneumonic effusion/empyema
- malignant effusion 
- TB
- PE (infarct)
- connective tissue disease (SLE, RA)
- absestos exposure
- pancreatitis, esophageal perforation
24
Q

chylothorax

A

a rare cause of exudative effusion w/ incr lipid content that results from obstruction or disruption of thoracic duct

25
Q

Which type of pleural effusion that can occur with CHF?

A

transudative

26
Q

Which type of pleural effusion that can occur with parapneumonic disease?

A

exudative

27
Q

Which type of pleural effusion that can occur with malignant disease?

A

exudative

28
Q

Which type of pleural effusion that can occur with pulmonary embolism?

A

either (transudative OR exudative)

29
Q

Which type of pleural effusion that can occur with viruses?

A

exudative

30
Q

Which type of pleural effusion that can occur with cirrhosis/ascites?

A

transudative

31
Q

Which type of pleural effusion that can occur post CABG?

A

exudative

32
Q

Which type of pleural effusion that can occur with TB?

A

exudative

33
Q

Which type of pleural effusion that can occur with mesothelioma?

A

exudative

34
Q

Which type of pleural effusion that can occur with asbestos exposure?

A

exudative

35
Q

Pleurodesis

A

medical procedure in which the pleural space is artificially obliterated.[1] It involves the adhesion of the two pleurae; performed to prevent recurrence of pneumothorax or recurrent pleural effusion. It can be done chemically or surgically. It is generally avoided in patients with cystic fibrosis, if possible, because lung transplantation becomes more difficult following this procedure.

36
Q 
Hemothorax
cause 
exam findings
defn
how treat
A
  • generally traumatic, rarely spontaneous
  • decreased breath sounds, dullness, tracheal deviation, HYPOtension, TACHYcardia (fast HR) on exam
  • defn usu Hct in pleural fluid >0.5 serum Hct
  • drainage needed to prevent calcific rind and restrictive physio; may need surgery for hemostasis
37
Q

Pneumothorax
possible causes
exam findings

A
  • mechanisms include:
    1. trauma, med procedure, pos pressure ventilation
    2. 2ndary to underlying disease (COPD, ILD, infection)
    3. primary (i.e. no known lung disease) with bleb rupture
  • exam: decreased breath sounds, HYPERresonance, tracheal deviation, hypotension, tachycardia
38
Q

tension pneumothorax treatment

A

MED EMERGENCY, fix ASAP, decompress before image, do needle decompression followed by chest tube placement

39
Q

non-tension pneumothorax (open pneumothorax) treatment

A

depends on size, sx, injury mech

  • observe
  • give 100% oxygen
  • tube thoracostomy

Pulmonology (1 decks)

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