Pleural space disease Flashcards
parietal pleura cover what? where does blood flow come from?
covers mediastinum, diaphragm and chest wall
blood flow from systemic circulation
Visceral pleura covers what? Where does the blood come from?
covers lungs
blood flow from pulmonary circulation
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
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
What can alter net filtration and lead to pleural effusion?
vasculitis
types of pleural fluid
hemothorax-blood
pyothorax-pus
transudate-serum
chylothorax-chyle
malignant effusion
diseases associated with pleural effusion
CHF
neoplasia
chylothorax
FIP
pyothorax
diaphragmatic hernia
lung lobe torsion
trauma
hemorrhage
pancreatitis
others: hypoalb, PTE, parasitic
Pleural effusion: clinical presentation
dyspnea, inability of lungs to expiration-restrictive
exercise intolerance
cough
anorexia, lethargy, weight loss
fever
dehydration, shock
Pleural effusion: PE findings
muffled heart sounds
decreased lung sounds ventrally
dyspnea
jugular venous distension (CHF)
other cardiac abn (murmur, gallop)
ascites
Pleural effusion: Dx work up
Chest rads
thoracocentesis
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
Pleural effusion: location
usually bilateral
unilateral if adhesions or compartalization-pyothorax, chylothorax, lung lobe torsion, neoplasia, hemorrhage, hernia
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
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
Fluid characterization: transudate
sp <1.017
TP<2.5
nuc cell <1000
predominant cell type: mononuclear, mesothelial
bacteria absent
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
fluid characterization: exudate
sp grav: >1.025
TP >3.0
Nuc cell >5000
predominant cell type: neutrophils, mononuclear, RBCs
bacteria: present or absent
Disease associations:; transudate
Hypoalbuminemia
Protein losing enteropathy
protein losing nephropathy
liver failure
Disease associations: modified transudate
heart failure
malignant effusions
diaphragmatic hernia
PTE
Disease associations: exudate
pyothorax
FIP
neoplasia
diaphragmatic hernia
lung lobe torsion
PTE
Disease Associations: Chyle
lymphangiectasia
CHF
neoplasia
heartworm disease
hernia
trauma
tornsion
disease associations: hemorrhage
trauma
coagulopathy
neoplasia
lung lobe torsion
PTE
Fluid from thoracocentesis
Color-cloudy
TP: 4.5 mg/dl
cell count: 15,000
predominant cell type: neutrophils
classification?
exudate
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
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
what could be causing these signs?
pleural effusion
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
next best step?
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
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
Fluid analysis: clear, colorless, odorless, TP: 3.0, SpGr: 1.018, cellularity: 1500 mononuclear, no organisms
Classify fluid?
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
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 bilateraly
most likely cause?
pleural effusion
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
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
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
very prolonged ACT, mild thrombocytopenia, prolonged PT/PTT, Chest rad-pleural fluid/infiltrate?
Case assessment?
suspect rodenticide toxicity
young dog with chance of exposure, no previous medical problems, acute clin sxs, V
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
very prolonged ACT, mild thrombocytopenia, prolonged PT/PTT, Chest rad-pleural fluid/infiltrate?
suspect rodenticide toxicity
Treatment plan?
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
