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Symptoms of respiratory system > PLEURAL SYNDROMES > Flashcards

PLEURAL SYNDROMES Flashcards

1
Q

CLASSIFICATION

A
  1. Pleural effusion
  2. Pleuritic syndrome (“dry”)
  3. Pleural fibrosis/ Pachypleuritis
  4. Pneumothorax
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2
Q

Pleura=

A

a thin membrane that covers the inner surfaces of the
thoracic cavity. It consists of a layer of mesothelial cells
supported by a network of connective and fibroelastic tissue.
1.Parietal pleura
2.Visceral pleura

Anatomy

  1. Pleural space
  2. Pleural fluid: 5 -20 ml
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3
Q

Parietal + Visceral Pleura

A

Parietal pleurae
• cover the inner surface of the thoracic cavity
Visceral pleurae
• cover all surfaces of the lungs

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4
Q

PLEURAL FLUID

A

Acts as a lubricant to minimize friction between the chest wall and
lung as they move against each other during inspiration and expiration

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5
Q

FUNCTIONS OF PLEURAL FLUID ( total 7 functions)

A
  • spreads into interpleural space
  • facilitate movement between the lung and chest wall
  • enters from systemic capillaries -> parietal pleurae
  • exits via parietal pleural stomas and lymphatic
  • depends on the oncotic and hydrostatic pressures within the parietal and visceral pleura as well as the pressure within the pleural space itself
  • Hydrostatic pressure in the parietal pleura is similar to systemic circulation (30 cm H2O), whereas that of the
  • visceral pleura is similar to the pulmonary circulation (10 cm H2O)
  • composition ≈ plasma, but lower in protein (< 1.5 g/dL)
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6
Q

Characteristics of

Normal pleural fluid ( total 6 characteristics)

A
  • clear plasma ultra filtrate
  • pH 7.60-7.64
  • protein content less than 2% (1-2 g/dL)
  • fewer than 1000 WBCs /cmm
  • glucose content similar to that of plasma
  • LDH level less than 50% of plasma
  • Na, K, Ca concentration similar to interstitial fluid
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7
Q

Analysis

A
  1. Macroscopic Appearance
  2. Biochemistry
  3. Cytology
  4. Cellularity
  5. Cultures
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8
Q

Symptoms + signs

A

Symptoms:

  • Pleuritic chest pain
  • Dry cough
  • Dyspnea

Signs:

  • Pleural friction rub
  • Particular signs - Pleural effusion syndrome
  • Pleural fibrosis syndrome
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9
Q

PLEURITIC CHEST PAIN

A

Character : a vague discomfort OR sharp pain
Worsens by deep inhalation, chest expansion
Location: depending on affected pleura
• indicates inflammation of the parietal pleura
• usually felt over the inflamed site E.g. or on radiation area
 Diaphragmatic pleura → shoulder
 Central pleura radiates → back, neck, shoulder
 intra-abdominal referred from irritation of 6th intercostal nerve

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10
Q

Special situations:PLEURITIC CHEST PAIN

A

Missing in interlobar effusion, some chronic effusion
• Continuous, not influenced by respiration in:
• Pleural tumor
• Empyema
• Massive Pleural effusion

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11
Q

PLEURITIC CHEST PAIN : DIFFERENTIAL DIAGNOSIS

A

Rib fracture = Fixed location+ bone crepitation
• Costochondritis
• Herpes zoster = pain on nerves + vesicles
• Tracheobronchitis - burning over trachea + sputum
• Angina pectoris
• Pericarditis

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12
Q

PLEURITIC COUGH

A
  • “dry”, without sputum production
  • Irritative
  • Associated usually with pleuritic chest pain
  • DETERMINED by: Pleural irritation
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13
Q

DYSPNEA in pleural syndromes

A

Progressive
• Generated by pain
• Associated tachypnea ±
• Indicates a large effusion (usually > 500 ml)
• In pleural effusions: depends on pleural elasticity, time to accumulation (duration), quantity of the fluid and preexistent underlying pulmonary disease

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14
Q

DYSPNEA in pleural syndromes , Mechanism

A

Rapid installation of large effusion
• Compression of the lung when large eff.
• Displacement of mediastinum, if exceeds 2000 ml
• Interferences with diaphragmatic musculature activity
• ↓ Vital capacity (VC)
• + Hypoxemia that do not respond to oxygen administration

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15
Q

Pleural friction rub (Auscultation)

A

Corresponding to the pain location
• Maximum intensity on posterior axillary line
• Present throughout respiratory cycle
• Loudest at end inspiration and early expiration
• Great variability, Seldom present
• Best heard over the area of pleural inflammation
• Described as a
• Rubbing or grating (eg. leather rubbing on leather)
• Harsh
• Dry
• Scratchy sound
• Disappears with breath holding

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16
Q

Pleural effusion

A

an abnormal accumulation of fluid in the pleural space

Excess fluid results from the disruption of the equilibrium that exists across pleural membranes.

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17
Q

Intrapleural fluid

A

approximately 0.3 mL/kg of hypooncotic fluid (approximately 1 g/dL protein)
 turnover 0.15 mL/kg/hour

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18
Q

When filtration exceeds maximum pleural lymphatic flow

A

pleural effusion occurs
 estimated maximum pleural lymph flow in man could attain 30 mL/h,
equivalent to approximately 700 mL/day

19
Q

MECHANISMS OF PLEURAL EFFUSION

A
  1. Altered permeability of the pleural membranes
  2. Reduction in intravascular oncotic pressure
  3. ↑ capillary permeability or vascular disruption
  4. ↑ capillary hydrostatic pressure in the systemic and/or pulmonary circulation
  5. ↓ pressure in pleural space; lung unable to expand
  6. Inability of the lung to expand (e.g., extensive atelectasis, mesothelioma)
  7. ↓ lymphatic drainage or complete blockage, including thoracic
    duct obstruction or rupture
  8. ↑ fluid in peritoneal cavity, with migration across the diaphragm
    via the lymphatics
  9. Movement of fluid from pulmonary edema across the visceral pleura
  10. Persistent increase in pleural fluid oncotic pressure from an existing
    pleural effusion, causing accumulation of further fluid
  11. Iatrogenic causes
20
Q

TRANSUDATIVE AND EXUDATIVE PLEURAL EFFUSIONS

A

are distinguished

by measuring the LDH & Protein levels in the pleural fluid

21
Q

Pleural effusions : clinical spect

A
  1. Manifestations related to the underlying disease process
  2. Dyspnea
    • Most common clinical symptom at presentation
    • Can be determined by other underlying lung disease
  3. Chest pain
    • Intensity: mild → severe
    • Character: sharp or stabbing (typically)
    • Localized to the chest wall or referred to the ipsilateral
    shoulder or upper abdomen because of diaphragmatic involvement
    • Exacerbated by deep inspiration
    • Diminishes in intensity as the effusion increases in size
    → Offers etiological clue
22
Q

PLEURAL EFFUSION LARGER THAN 300 ML

A
  1. INSPECTION: Asymmetric expansion of thoracic cage, with lagging
    expansion on the affected side (i.e., Hoover sign)
  2. PALPATION:↓ tactile fremitus
  3. PERCUTION: Dullness or ↓ resonance to percussion
  4. AUSCULTATION: Diminished or inaudible breath sounds
  5. AUSCULTATION: Pleural friction rub
  6. If compression of adiacent parenchyma (its condensation) at the upper
    edge of the fluid may occur:
     Egophony
     Bronchophony
     Aphonic pectoriloquy
     Pleuretic murmur (expiration)
    Mediastinal shift >1000ml
23
Q

For small pleural effusion (< 500 ml)

A 
DULL AREA
• Posterior only (usual)
• Basal
• 3- 4 cm high
• dullness upper limit = Horizontal line
• Not mobile with respiration
Diferential diagnosis with:
• Ascended diaphragm ( perform Hirtz maneuver)
• Atelectasis (dullness with increased tactile fremitus)
24
Q

Medium pleural effusion (800- 1200 ml)

A 
DULL AREA
• Posterior
Upper limit :
 the tip of scapula,
 “Damoiseau line” = parabolic line of which the highest point is on the middle axillary line

• Anterior:
 Dullness up to the 5th rib
 With every 500 ml accumulation

→ dullness ↑ with 1 intercostal sp.
 When dullness is up to the 1st rib = 3000 ml fluid
Traube area disappears when fluid reaches 800 ml
Mediastinal shift (usually >1000 mL)
25
Q

IN LARGE PLEURAL EFFUSION (2000 ML)

A

Inspection: thoracic asymmetry, bulging of the affected chest, deviation of the sternum on the same side as the pleural fluidl (Pitres sign)
• Palpation: Tactile fremitus- absent
• Percution: Dull area greater then previous, compensatory hipersonority abo matite dull area,
• Auscultation: Vesicular sound Absent
• Infraclavicular tympanism; skodism= timpanic sound
• Mediastinal shift
• with massive effusions only (usually >1000 mL)
• displacement of trachea and mediastinum to the contralateral side of the pleural effusion (on Chest Xray)
(In contrast with complete atelectasis of the ipsilateral lung, when the trachea deviates toward the affected side and is most commonly seen with complete
obstruction of ipsilateral mainstem bronchus caused by bronchogenic carcinoma.)

26
Q

Pleural effusion diagnosis

A

1.Clinical suspicion- anamnesis
2.Physical examination
3.Chest x-ray
4.Ultrasonography
can be used to detect as little as 5-50 mL of pleural fluid,
with 100% sensitivity for effusions of 100 mL or more.
1.Chest CT scanning
2.Thoracentesis
3.Evaluation of pleural fluid to determine cause

27
Q

Parietal collection

A
  • Diminished respiratory movement

* Diminished tactile fremitus

28
Q

Interlobar collection

A
  • Suspended dullness in medium part of axila

* Without pain

29
Q

Diaphragmatic collection

A

• Pain by phrenic nerve irritation

30
Q

Empyema

A

purulent pleural effusions

 present on X-ray of 20-60% of patients with bacterial pneumonia

31
Q

Empyema Stages

A
  1. Exudative stage: free flowing pleural fluid, very amenable to treatment with closed tube drainage
  2. Fibrinopurulent stage: formation of fibrin strands through the pleural fluid resulting in loculations, makes adequate drainage with single chest tube unlikely
  3. Organizational stage: fibrosis is much more extensive forming a pleural peel that restricts expansion even if fluid can be evacuated
32
Q

Empyema

Diagnosis

A 
 Clinical (anamnesis + Physical ex)
 Decubitus Xray
 fluid is loculated
 Pleural fluid
 gross pus with
 positive cultures or gram stain
 pH<7.1
 glucose<40 mg/dl
 LDH>1000 iu/L
33
Q

Empyema

Treatment:

A
  • drainage of pus by chest tube
  • eradication of the infection
  • surgical intervention with removal of the fibrous peel
34
Q

Pleural involvement without effusions

Dry pleuritic syndrome

A

Pleuritic chest pain
• Cough: not productive, irritative
• Pleural friction rub
• RX: + / - diminished diaphragmatic movement

35
Q

Pleural fibrosis and calcification

Pachypleuritis ; Definition + types

A

destruction of normal pleural tissue architecture due to an excessive deposition of matrix components → compromised pleural function
Type :
• pleural plaques (discrete localised lesions)
• diffuse pleural thickening

36
Q

Pachypleuritis : Etiology + Diagnosis

A

Etiology:
1. Postinflammatory (pleural infection, tuberculous pleurisy, drug-
induced pleuritis, rheumatoid pleurisy, uraemic pleurisy, haemothorax)

  1. Asbestos exposure
    Diagnosis:
    • By chance on chest x-ray
    • Rarely: breathlessness, chest pain or both, rarely cianosis
37
Q

Pachypleuritis

Physical exam

A

Inspection: retraction of the intercostal spaces, reduction of the amplitude of respiratory movements
Palpation: reduced tactile fremitus
Percution: dullness (less than completely dull)
Auscultation:
 Diminished vesicular sounds
 Sometimes pleural rub
Diagnostic: radiology

38
Q

Pneumothorax

A

Pneumothorax refers to the accumulation of air in the pleural space between the parietal pleura lining the rib cage and visceral pleura lining the lung
- the presence of air within the pleural space results in collapse of the lung on the affected side

39
Q

Pneumothorax classification

A 
1. Spontaneous pneumothorax
• Primary
• Secondary
2. Traumatic pneumothorax
3. Iatrogenic pneumothorax (biopsy/herapeutic procedure)
4. Catamenial pneumothorax
5. Pneumothorax in AIDS
6. Other: tension PNX, ex vacuum PNX
40
Q

Pneumothorax

History

A

• CHEST PAIN with Acute (sudden) onset
• intensity: severe and/or stabbing character
• radiating to ipsilateral shoulder
• increasing with inspiration (pleuritic)
• DYSPNEA: Sudden
• ± Dry cough, Cianosis
# Anxiety, cough, and vague presenting symptoms (e.g., general malaise, fatigue) are less
commonly observed.
# Dyspnea tends to be more severe with secondary spontaneous pneumothoraces because of
decreased lung reserve.

41
Q

Pneumothorax Pulmonary Signs

A

MILD pneumothotax → no obvious signs
VOLUMINOUS pneumothotax→ on the affected →
INSPECTION:
• Fullness of the chest, bulged, immobile hemithorax
• Wide intercostal spaces
• Diminished respiratory movement
PALPATION: Diminished or no vocal fremitus or resonance
PERCUTION: Tympanic sound on percussion
AUSCULTATION: Breath sound: diminished/ disappeared
 Coin sign is positive
 Trachea and heart displace toward the healthy side
 Liver dullness edge displaces downward when pnx is on the right side
 Respiratory failure with contralateral lung compression

42
Q

Coin sign ( pneumothorax )

A

a coin held against the chest is tapped by another coin on the side where the puncture is suspected. A stethoscope is placed on the
back to listen to breath sounds and the sound of the coins. If a tinkling sound is heard, it is likely that air or fluid has found its way into the pleural cavity

43
Q

Massive Pneumothorax

A

General appearance/ Inspection with tension pneumothoraxes
• Diaphoretic
• Splinting chest wall to relieve pleuritic pain
• Cyanotic
Vital signs are altered
• Tachypnea
• Tachycardia (most common finding)
- If > 135 (bpm), tension pneumothorax is likely.
• Pulsus paradoxus
• Hypotension (often with tension pneumothorax) by inferior cava vein ICV compression

44
Q

Massive Pneumothorax
Respiratory Physical exam
( sign + symptoms )

A

Asymmetric lung expansion - Mediastinal and
tracheal shift to the contralateral side with a large
tension pneumothorax
 Decreased/ Absent tactile fremitus
 Hyper resonance on percussion with timpany
 vesicular sounds: distant or absent, amphoric
murmur on auscultation
• Cardiovascular - Jugular venous distension (tension
pneumothorax)
• Neurologic - Altered mental status

Symptoms of respiratory system (8 decks)

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