pleural effusions + pneumothorax Flashcards

1
Q

pleural effusion def and list the four pathophysiologic processes

A

Definition: Abnormal accumulation of fluid in the pleural space (5-15 mL of fluid in pleural space)

1) Transudates: normal capillary function
2) exudtes: abnormal capillary permeability
3) empyema: infection in pleural space
4) hemothorax: blood in pleural space

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

transudate pathophys + causes

A
  • Normal Capillary Function
    Due to:
    -increased HYDROSTATIC pressure (pushes fluid out) OR
  • decreased ONCOTIC (cannot hold onto fluid)

Causes:
- CHF: (MC) - bilateral
- Cirrhosis: low protein
- Nephrotic Syndrome: low proteins -> spills out

others:
-Acute atelectasis
-Constrictive pericarditis
-PE
-Superior vena cava obs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

exudate causes

A

Due to ABNORMAL capillary permeability
- Decreased lymphatic clearance = fluid accumulation

Causes
- Pneumonia *
- Cancer *
- PE
- infection

Others:
-Post MI
-Chronic atelectasis
-Asbestos
-Sarcoid-rare

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

PE of pleural effusion: small vs large vs massive

A

-Dyspnea, cough, or chest pain- Small less symptomatic

PE:
Small: none

Larger:
- dullness to percussion
- diminished or absent breath sounds over effusion

Massive:
- may have contralateral shift of trachea (ddx tension pneumothorax)
- bulging of the intercostal spaces**

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what is the gold standard diagnostic test for pleural effusions?

A

Gold Standard = Diagnostic Thoracentesis
- Indicated with new pleural effusion of no known cause
- Can collect sample for laboratory analysis: Transudative vs Exudative

-1. Visualization of fluid
-2. Send to lab:
-Cell count and cell differential, pH, protein, LDH, glucose -> determines Transudate vs exudate

-Additional tests in selected patients: amylase, cholesterol, triglycerides, N-terminal pro-brain natriuretic peptide (NT-proBNP), creatinine, adenosine deaminase (ADA), gram and acid-fast bacillus (AFB) stain, bacterial and AFB culture, and cytology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

pleural fluid analysis

A

Malignancy= positive cytology
Empyema= Pus, positive culture
Chylothorax= triglycerides
Tuberculous- Positive AFB stain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

hemorrhagic vs hemothorax

A

Hemorrhagic: MIX of blood and pleural fluid
-10,000 rbc/ml to create blood-tinged fluid (dont need to know #)

Hemothorax: GROSSLY blood in pleural space
- 100,000 rbc /ml create grossly bloody pleural fluid
-straw colored
-blood stained
-purulent
-chylous

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

hemothorax ratio

A

Gross blood in pleural space:
- [Pleural Fluid Hct] : [Serum Hct] > 1:2

Appearance:
-straw colored
-blood stained
-purulent
-chylous

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

exudate lights criteria rule***

A

-Effusion that has ONE OR MORE of the following is exudate:

*Pleural fluid protein/serum protein ratio greater than 0.5

*Pleural fluid LDH/serum LDH ratio greater than 0.6

*Pleural fluid LDH greater than two-thirds the upper limits of the laboratory’s normal serum LDH

“these are saying that there is:
HIGH proteins - capilllary permeability increased
HIGH LDH - indicates exudative”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

transudates def

A

-Transudates have NONE of mentioned exudate features/criteria
-Occur in setting of NORMAL CAPILLARY integrity and ABSENCE of local pleural disease

Distinguishing laboratory findings include:
-Glucose = serum glucose
-pH between 7.40 -7.55 (nl 7.6)
-< 1,000 wbc/mcL with a predominance of MONONUCLEAR cells

“basically this is a systemic issue that causes altered hydrostatic and oncotic pressures and NOT FROM INFECTION (exudates)”

Exudates:
- lower glucose: bacteria is consuming glucose
- ph is LOWER due to infection
- HIGH WBC = infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Elevated pleural amylase: evidence of what

A

Elevated pleural amylase:
-Pancreatitis, pancreatic pseudocyst
-Adenocarcinoma of pancreas
-Esophageal rupture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Other features of pleural effusion- cytology

A

can use cytology: assess for malignancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

imaging: effusion

A

Standard upright CXR:
-must have 75–200 mL to be visible in costophrenic angle

May appear loculated (~mass/pseudotumor) if there are pleural adhesions:
-Round/oval fluid collections in fissures resembling intraparenchymal masses (pseudotumors)

Chest CT scans: more sensitive!!
- Can identify pleural effusions >15 mL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

transudative treatment

A

1: treat underlying condition - will just fill again if not
2: Therapeutic thoracentesis for significant dyspnea
-Repeat again and reassess dx
3: if refractory after repeat
-Pleurodesis- irritant into the space- obliterates the space so no fluid can fill
-Indwelling pleural catheter- drain at home

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

exudate malignant treatment: what are the MC cancers, acute tx vs long term

A

Malignant Pleural Effusion:
-Most common: lung and breast cancer

Acute tx:
- repeated thoracocentesis
- chest tube

Long-term if needed:
-Pleurodesis
-Indwelling pleural catheter (eg, Pleurex) for home drainage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

parapneumonic pleural effusion categories

A

Divided into 3 categories:
-Simple or uncomplicated
-Complicated
-Empyema

+/- loculation often in empyema or complicated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Exudates accompany approximately ___% of bacterial pneumonias. Parapneumonic pleural effusions

A

40%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

uncomplicated parapneumonic effusions tx

A

-Free-flowing sterile exudates of modest size that resolve quickly with antibiotic treatment of pneumonia

Tx: NONE
- no drainage
- just do normal abx for pneumonia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

empyema

A

Gross infection of pleural space indicated by positive Gram stain or culture

Tx:
- ALWAYS DO drainage
- antibiotics for effusion

20
Q

complicated parapneumonic effusions tx

A

Requires difficult management decisions
-Larger than simple parapneumonic effusions and show more evidence of inflammatory stimuli
- Demonstrate inflammatory processes: Low glucose level, low pH, or evidence of loculation

Tx - Tube thoracostomy (chest tube for drainage) if:
- glu is < 60 mg/dL
- pH is < 7.3
-clinical decision based on provider

21
Q

Loculation: what type of effusions is this a complication and what is tx

A

Empyema or complicated parapneumonic effusions

Tx:
-Intrapleural injection of fibrinolytic agents: (-kinase)
-Streptokinase, 250,000 units
-Urokinase, 100,000 units
-break up the loculation

Definition:
-fomration of compartmentalization within the pleural space due to ahdesions

22
Q

hemothorax tx

A

Small: close observation

ALL other cases: IMMEDIATE insertion of a large chest tube (tube thoracostomy )
-Controls hemorrhage
-Removes clot
-Treats complications
-drained

23
Q

pneumothorax classification

A

(Non-Traumatic) Spontaneous pneumothorax:
-Primary: Occurs in absence of underlying lung disease
-Secondary: Complication of preexisting pulmonary disease (COPD bulla)

Traumatic pneumothorax:
-Results from penetrating or blunt trauma
-iatrogenic

Tension:
- one way valve into pleural space

24
Q

primary pneumothorax causes

A

Occurs without a known cause:
- often tall, thin, young males -> usually result from the rupture of small, air-filled sacs on the lung surface (BLEBS or bullae).

-drug use
-increased transpulmonary pressure -> valsava maneuver, diving, military, flying

25
Q

secondary pneumothorax causes

A

Occurs in ppl with existing lung ds: makes lung more prone to collapse
- Obstructive Airway Ds (COPD, asthma, cystic fibrosis)
- Infection (Tuberculosis, Pneumocystis pneumonia)
- ILD (Sarcoidosis)
- connective tissue disease
- Malignancy

26
Q

tension pneumothorax

A

-A check-valve mechanism/one way valve
- air entering the pleural space on inhalation cannot escape on exhalation-> pressure builds
-medical emergency!!

27
Q

pneumothorax symptoms

A

SUDDEN onset of dyspnea and PLEURITIC chest pain
-Chest pain: on affected side
-May present with life-threatening respiratory failure

28
Q

pneumothorax signs: small vs large pneumothorax

A

Small pneumothorax (<15% of a hemithorax):
- Mild tachycardia

Large pneumothorax:
-Decreased movement of chest on affected side**
-Diminished breath sounds
-Decreased tactile fremitus
-Hyperresonance

“-Decreased tactile fremitus: air in the pleural space dampens the transmission of these vibrations
- hyperresonance: sounds more hollow from air on percussion
- Decreased movement of chest on affected side: air prevents full expansion”

29
Q

Tension pneumothorax: signs

A

-Marked tachycardia
- hypotension ***
- labored breathing
- mediastinal or tracheal shift -> pushed towards opposite side

30
Q

pneumothorax EKG

A

EKG:
- Left-sided primary pneumothorax may produce QRS, axis and precordial T wave changes
- misinterpreted as acute MI

31
Q

ABG: pneumothorax

A

Hypoxemic
Respiratory Alkalosis- hyperventilation

32
Q

pneumothorax CXR:

A

Dx in Chest xray = VISCERAL PLEURAL LINE

Supine patients: deep sulcus sign

Tension pneumothorax:
-Large amount of air in the affected hemithorax and CONTRALATERAL shift of the mediastinum
- could have widened intercostal space on the affected side

image: white visceral pleural lines

33
Q

Deep sulcus sign

A

Supine pts with pneumothorax:
– abnormally radiolucent costophrenic sulcus (the “deep sulcus” sign)
- when laying down -> air will accuulate in costophrenic sulcus and make it look darker

34
Q

?

A

deep sulcus sign and contralateral shift of the mediastinum!

tension pnuemothorax

35
Q

Helpful for visceral pleural lines

A

DX sign of pneumothorax: visceral pleural lines

36
Q

pneumothorax US

A

Ultrasound:
-no lung sliding

In a healthy lung, the visceral and parietal pleura move against each other -> NONE indicates air b/w the pleura

recognizing it:
- lung sliding appears as a shimmering or twinkling motion at the pleural line (the interface between the chest wall and lung).
- real-time on US: horizontal movement along the pleural line

37
Q

Would there be lung sliding with pneumothorax?

A

NO -> no sliding with pneumothorax

38
Q

pneumothorax diff dx

A

-Emphysematous bleb
-Myocardial infarction
-Pulmonary embolization
-Pneumonia

39
Q

pneumothorax complications

A

-Tension pneomothorax: life threatening
-Pneumomediastinum
-Subcutaneous emphysema

Tension pneumothorax:
- characterized by the progressive accumulation of air in the pleural space

Pneumomediastinum:
- Presence of air in the mediastinum (the central compartment - heart, great vessels, trachea, esophagus)

Subcutaneous emphysema:
- Air gets trapped in the tissue layers beneath the skin, commonly in the neck, chest wall, or face
- Characteristic crackling sensation upon palpation

40
Q

pneumothorax tx: small spontaneous

A

Small (< 15% of a hemithorax) in reliable stable patient:
-OBSERVATION -> many resolve spontaneously
-Supplemental O2

41
Q

spontaneous primary pneumothorax tx - large

A

Large or progressive = 3cm+ of air
-SMALL-BORE chest tube **
-Needle decompression with small-bore catheter
-Treated symptomatically for cough and chest pain
-Chest x-ray every 24 hours -> make sure air is reabsorbed

42
Q

secondary pneumothorax, large pneumothorax, tension pneumothorax, severe symptoms or those who have a pneumothorax on mechanical ventilation TREATMENT

A
  • needle decompression AND
  • large chest tube (tube thoracostomy)
43
Q
  • needle decompression AND
  • large chest tube (tube thoracostomy)

Who gets this treatment for pneumothorax pts?

A
  • secondary pneumothorax
  • large pneumothorax
  • tension pneumothorax
    -severe sx
  • pts on mechanical ventilation with pneumothorax
44
Q

When would a thoracscopy/ open thoracotomy be warrented with a pneumothorax?

A

Generally not needed

would be done if:
- recurrences
- bilateral pneumothorax
- Failure of tube thoracostomy for the first episode (failure of lung to reexpand or persistent air leak)
-Surgery permits resection of blebs responsible for the pneumothorax and pleurodesis

45
Q

pneumothorax recurrence frequency and who is specifically at risk

A

-occurs with 30% with spontaneous pneumothorax
-50% are smokers!!!!

46
Q

Risk factors to avoid to stop recurrent pneumothorax:

A

-High altitudes
-Flying in unpressurized aircrafts
-Scuba diving