Pleural space disease Flashcards by Jessica Ernst

parietal pleura cover what? where does blood flow come from?

covers mediastinum, diaphragm and chest wall

blood flow from systemic circulation

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Visceral pleura covers what? Where does the blood come from?

covers lungs

blood flow from pulmonary circulation

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pressure gradients of pleural space

net pressure at the level of parietal pleura drives fluid into pleural space.

a net pressure move fuid from pleural space into visceral pleura

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Causes of pleural fluid accumulation

increased capillary hydrostatic pressure

increased capillary permeability/vasculitis

decreased capillary oncotic pressure-hypoalbuminemia

increased oncotic pressure of pleural cavity

lymphatic obstruction and/or interference with lymphatic drainage

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What can alter net filtration and lead to pleural effusion?

vasculitis

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types of pleural fluid

hemothorax-blood

pyothorax-pus

transudate-serum

chylothorax-chyle

malignant effusion

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diseases associated with pleural effusion

CHF

neoplasia

chylothorax

FIP

pyothorax

diaphragmatic hernia

lung lobe torsion

trauma

hemorrhage

pancreatitis

others: hypoalb, PTE, parasitic

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Pleural effusion: clinical presentation

dyspnea, inability of lungs to expiration-restrictive

exercise intolerance

cough

anorexia, lethargy, weight loss

fever

dehydration, shock

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Pleural effusion: PE findings

muffled heart sounds

decreased lung sounds ventrally

dyspnea

jugular venous distension (CHF)

other cardiac abn (murmur, gallop)

ascites

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Pleural effusion: Dx work up

Chest rads

thoracocentesis

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Pleural effusion: dx work up-Chest rads

only a stable patient

thoracocentesis often done prior to rads

obscured cardiac silhouette

interlobar fissure lines

rounding of lung margins

fluid density surrounding lung lobes

scalloping of lung margins dorsal to the sternum

widening of mediastinum

dorsla elevation of trachea

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Pleural effusion: location

usually bilateral

unilateral if adhesions or compartalization-pyothorax, chylothorax, lung lobe torsion, neoplasia, hemorrhage, hernia

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Pleural effusion: diagnostic work up-thoracocentesis Procedure

for therapeutic and dx purpose

clip and prep site

sternal recumbency or standing

proper restraint req

mild sedation

butterfly needle, extension set, three way stopcock, syringe

between 7th & 9th rib space

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Pleural effusion: dx work up-Thoracocentesis-fluid analysis

color, clarity, odor, clots/fibrin

PCV/TP (TP<1.5 mg/dl)

specific gravity

nucleated cell type (<500 cell/ul)

cytology

triglycerides & chol

others

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Fluid characterization: transudate

sp <1.017

TP<2.5

nuc cell <1000

predominant cell type: mononuclear, mesothelial

bacteria absent

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fluid characterization: modified transudate

sp grav: 1.017 to 1.025

TP: 2.5-5

nuc cells: 500-10,000

predominant cell type: lymphocytes, monocytes, mesothelial, RBCs

bacteria absent

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fluid characterization: exudate

sp grav: >1.025

TP >3.0

Nuc cell >5000

predominant cell type: neutrophils, mononuclear, RBCs

bacteria: present or absent

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Disease associations:; transudate

Hypoalbuminemia

Protein losing enteropathy

protein losing nephropathy

liver failure

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Disease associations: modified transudate

heart failure

malignant effusions

diaphragmatic hernia

PTE

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Disease associations: exudate

pyothorax

FIP

neoplasia

diaphragmatic hernia

lung lobe torsion

PTE

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Disease Associations: Chyle

lymphangiectasia

CHF

neoplasia

heartworm disease

hernia

trauma

tornsion

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disease associations: hemorrhage

trauma

coagulopathy

neoplasia

lung lobe torsion

PTE

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Fluid from thoracocentesis

Color-cloudy

TP: 4.5 mg/dl

cell count: 15,000

predominant cell type: neutrophils

classification?

exudate

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pyothorax

infection in the pleural space

hematogenous spread/sepsis, direct innoculation, spread from adjacent tissue

aspiration of plant material

pyothorax: etiology

actinomyces nocardia bacteriodes fragillis-cats pasteurella, clostridium-cats

pyothorax: clinical presentation

hunting dogs outdoor cat, multi cat household poss penetrsting wound anoxeria exercise intolerance fever dyspnea weight loss cyanosis tachypnea orthopnea muffed heart and lung sounds

pyothorax: dx

CBC-leukocytosis & left shift chem: poss hypoalb chest rads: pleural effusion, uni or bilateral thoracocentesis: culture

pyothorax-tx: drainage of chest

chest tube placement is preferred cotinuous or intermittent suction lavage of pleural space with sterile saline

pyothorax tx

chest tube abx based on C&S parenteral abx initially tx at least 2 months after resolution of clin sxs supportive care

pyothorax-patient monitoring

volume of fluid recovered daily microscopic exam of effusion dail rads-EOD initially then 1 week after chest tube removal, repeat 1-2 weeks after stopping abx chest tube remove: once fluid resolved on rads and cytology shows no infectious agents, low quantity of fluid retrieve

pyothorax: px

good with aggressive therapy adhesions may form

pyothorax: surgical indications

if fluid is localized and not improving after 2-3 days consider CT scan for removal of foreign body for removal of nidus of inf to break down adhesions

pleural effusion

thoracocentesis

9 yo MC DSH dyspnic cat started last night, indoor/outdoor cat, no coughing, otherwise healthy PE: weak, sternal recumbency, mildly cyanotic, intermittently open mouth breathing, shallow, rapid respirations, unable to hear lung or heart sound billaterally thoracocentesis done, fluid is clear, cat is breathing more comfortably repeated chest ausculations: lung sounds audible bilaterally, heart murmur, poss gallop diagnostics?

chest rads, fluid analysis, bloodwork

modified transudate

Chylothorax

collection of chyle in pleural space fluid leakage from dilated thoracic lymphatic vessels form in response to increased lymphatic flow

Chylothorax etiology

idiopathic-most otr mediastinal mass CHF-cats HW disease-cats lymphangiectasia venous thrombi trauma diaphragmatic hernia congenital lung lobe torsion

Chylothorax clinical presentations

cough dyspnea

chylothorax dx

chest rads thoracocentesis

Chylothorax: dx-chest rads

pleural fluid compartmentalization of fluid fibrinous pleuritis

Chylothorax: cytology

milky white fluid opaque protein usually \>2.5 500 to 200,000 cells/ul lymphocytes chylomicrons triglyceride and cholesterol

chylothorax tx

if idiopathic, can't do anything dietary fat restriction Medium chain triglyceride oild pred periodic thoracocentesis rutin sx: subtotal pericardectomy with thoracic duct ligation

chylothorax: px

poor spontaneous/prolonged remission poss

hemothorax

trauma coagulopathy-rodenticide toxicity, DIC neoplasia-primary or metastatic

hemothorax: dx

fluid characteristics to support: PCV fo chest fluid is =\> than peripheral blood, chest fluid does not clot after removal, no plt, erythrophagocytosis cytology: neoplastic cells coag panel toxicology screen

hemothorax: tx

poss autotransfusion blood transfusion stop the bleeding-plasma, Vit K, Sx if neoplastic

pleural effusion

4 yo M beagle, dyspnic, acute onset, risk of trauma, coughing, on HW preventative, vomited yesterday ## Footnote PE: shallow, rapid respirations, pale mucous membranes, unable to stand, no signs of trauma, decreased heart and lung sounds bilaterally poss pleural fluid, pneumothorax, shock and/or anemia, critical status plan?

PCV/TP IV catheter placement thoracocentesis

4 yo M beagle, dyspnic, acute onset, risk of trauma, coughing, on HW preventative, vomited yesterday PE: shallow, rapid respirations, pale mucous membranes, unable to stand, no signs of trauma, decreased heart and lung sounds bilaterally poss pleural fluid, pneumothorax, shock and/or anemia, critical status Blood from chest does not clot, PCV of fluid: 16%, PCV of serum: 17%, no plt seen other dx?

ACT CBC Coag panel chest rads rodenticide screen

suspect rodenticide toxicity young dog with chance of exposure, no previous medical problems, acute clin sxs, V

Thoracocentesis transfusion Vit K therapy ICU monitoring

pneumothorax

accumulation of air within the pleural space caused by trauma to chest wall, iatrogenic, spontaneous

spontanoeus pneumothorax

primary: rupture of bullae or bleb in absence of underlying respiratory dz, rads normal except for pneumothorax secondary-neoplasia, parasitism, inflammatory airway disease, pneumonia, abscess, foreign body

pneumothorax-presentation

hx of trauma tachypnea, dyspnea abdominal component to breathing poss cyanosis decreased lung sounds hyperresonance

pneumothorax-chest rads

perform thoracocentesis first air within pleural space retraction of lung lobe from thoracic wall and diaphragm displacement of heart away from sternum

pneumothorax: dx

chest rads endoscopy/bronchoscopy HWT fecal float FNA, cytology of masses CT scan exploratory thoracotomy

pneumothorax-tx

none if asymptomatic evacuate the chest or air chest tube placement supportive care sx