Pleuromediastinal Disorders Flashcards by Jonathan Paul Ladera

Symptoms related to pleural diseases

compression
Invasion
Irritation

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Normal volume of pleural fluid

15-20ml

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Pleural effusion

Blunting of the costophrenic sulcus
200-300 ml of pleural fluid
Most dependent portion -> first to be filled

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Things to look fo if you suspect atelectasis

Trachea midline?

Interpaces narrow?

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Thing to look for if you suspect a mass

mediastinal shift

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Fluid enters the pleural space from the?

Capillaries in the parietal pleua
Interstitial spaces of the lung via the visceral pleura
Peritoneal cavity via small holes in the diaphragm

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How is pleural fluid removed?

via the lymphatics

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First step when dealing with pleural effusion

determine wether the effusion is a transudate or an exudate

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Advantage of an ultrasound

demonstrate loculation early

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Thoracentesis

Needle -> (T7/T8)

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Systemic factors affect the formation and absorption of pleural fluid are altered

transudative pleural effusion

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Local factors that influence the formation and absorption of pleural fluid are altered

Exudative pleural effusion

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Lghts’s criteria

PF protein/S protein >0.5
PF LDH/S LDH >0/6
PF LDH more than 2/3 normal upper limit for serum

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If exudative pleural effusion…

Description
Glucose level
Amylase level
DIff count
Microbiologic studies
Cytologyq

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Effusion due to heart failure

increased amount of fluids in the lung interstitial spaces exit in part across the visceral pleura.

Patient is treated with diuretics

If it persists despite the diuretics, thoracentesis

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Hepatic hydrothorax

approx. 5% of patients with cirrhosis and ascites

direct movement of peritoneal fluid through small holes in the diaphragm into the pleural space

Usually right-sided and frequently large enough to produce severe dyspnea

Liver transplant

if not candidate, insertion of a transjugular intrahepatic portal systemic shunt

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Parapneumonic effusion

associated with bacterial pneumonia, lung abscess or bronchiectasis

serous or frank pus

can be demostrated with lateral decubitus radiograph

If free fluid separates the lun from the chest wall by more than 10 mm on the decubitus radiograph, a therapeutic thoracentesis should be performed

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Factors indicating the likely need for a procedure more invasive than a thoracentesis

Loculated PF
PF pH below 7.20
PF glucose less than 60 mg/dl
(+) grams stain or culture of the pleural fluid
The presence of gross pus in the pleural space

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If the fluid recur after the secoond treatment at thoracentesis in the absence of complicating factors….

Surgical drainage

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If the fluid cannot be completely removed with the therapeutic thoracentesis, consideration should be given to…

inserting a chest tube and instilling a thrombolytic streptokinase, 250,000 units or urokinase, 100 000 units

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Stages of Parapneumonic effusion

Exduative
Fibrinopurulent (Empyema)
Organization stage

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Exudative phase

Small to moderate in size
Normal glucose level
Dependent in location
Do not show signs of loculation
Meniscus sign on chest  ray; crescent shape in CT

TREATMENT: Thoracentesis

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Fibrinopurulent stage

Increassed PMN
Decreased glucose level and pH
Fluid becomes particulate, tendency to loculate

Treatment: VATS

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organization Stage

Fibrothorax
Development of pleural peel/trapped lung

Treatment: Surgery (Decortications)

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Process of removing peel

Decortication

Effusion secondary to malignancy

patients complain of dyspnea PF is an exudate and its glucose level may be reduced if the tumor burden in the pleural space is high PF is usually serosanguinous

Three tumors that cause approximately 75% of all malignant pleural effusions

Lung Breast Lymphoma

If the patient's lifestyle is compromised by dyspnea, and if the dyspnea is relieved by thoracentesis....

Tube thoracotomy with sclerosing agent (talc, 5g or doxycycline 500mg) Outpatient insertion of a small indwelling catheter Thoracoscopy with pleural abrasio or the insufflation of talc

PRimary tumors that arise from the mesothelial cells that line the pleural cavitiesm most are related to asbestos exposure

Mesothelioma -chest pain, chortness of breath

CXR finding in mesothelioma

Pleural effusion, generalized pleural thickening and shrunken hemithorax

Diagnosis of Mesotheloma

Thoracoscopy or open pleural biopsy

Treatment for MEsothelioma

symptomatic

EFfusion secondary to pulmonary embolizatio

More often exudative Westermark sign : wedge spaced opacity on CT

Tuberculous pleuritis

Hypersensitivity reaction to tuberculous protein in the pleural space Exudate with predominantly smally lymphocyte

Diagnosis of TB pleuritis

High levels of TB markers (ADA>45 IU/L. gamma interferon >140pg.ml) Positive PCR for TB Culture of the PF, needle biopsy of the pleura or thoracoscopy AFB smear

Chylothorax

Thoracic duct is disrupted and chyle accumulates in the pleural space Most common cause: TRAUMA

Thoracentesis of chylothorax

milky flid, and biochemical analysis revelas a TG level > 110mg/dl presence of chylomicrons Sudan Blue staim

Treatment for chylothorax

Pleuroperitoneal shunt Should not undergo prolonged tube thoracotomy with chest tube drainage because this will lead to manutrition and immunologic incompetence

Hemothorax

Bloody pleural fluid, Hematocrit should be obtained. If HCT is >50% that of the peripheral blood, the patient has hemothorax If pleural hemorrhage exceeds 200ml/hr consider thoracotomy

Transudative PF

``` CHF Cirrhosis Pulmonary emolization Nephrotic syndrome Peritoneal dialysis SVC obstruction Myxedema Urinothorax ```

Presence of gas in the pleural space

Pneumothorax

Spontaneous pneumothorax

Occurs without antecedent trauma

Traumatic pneumothorax

Results from penetrating or non-penetrating chest injuries treated with tube thoracotomy unless they are very small

If a hemopneumothorax is present

one chest tbe should be placed in the superior part of the hemithorax, and another should be placed in the inferior part of the hemithorax.

Iatrogenic pneumothorax

type of traumatic pneumothorax

Pneumothorax in which the pressure in the pleural space is positive throughout the Respiratory cycle

Tension Pneumothorax

Why is (+)pleural pressure life threatening

Ventilation is severly compromised (+) pressure is transmitted to the mediastinum which result in decreased venous return to the heart and reduced cardiac output

How to relieve pressure for pneumothorax

A large bore needle should be inserted as a medical emergency

Primary SPontaneous Pneumothorax

due to rupture apical pleural blebs, small cystic spaces that lie within or immediately under the visceral pleura Most are due to chronic obstructive pulmonary disease

Secondary spontaneous pnumothorax

TReated with tube thoracotomy and the instillation of a sclerosing agent such as doxycycline or talc

Disorders of the Mediastunum

Anterior Middle - congenital Posterior - neurogenic

extends from the sternum anteriorly to the pericardium and brachiocephalic vessels posteriorly

Anterior Mediastinum

Lies between the anterior and posterior mediastinum, Contains the heart; the ascending and transverse arches of the aorta, the VC, the brachiocephalic arteries and veins

middle mediastinum

Bounded by the pericardium and trachea anteriorly and ther vertebral column posteriorly, COntains the descending thoracic aorta; esophagusl thoracic duct; azygos and hemiazygos beins. and the posterior group of mediastinal lymph nodes

Posterior Mediastinum

FIrst step in evaluating mediastinal masses

Place it one of the three compartments

Most valuable imaging tchnique for evaluating mediastinal masses and is the only imaging technique that should be done in most instances

Mediastinal Masses

Difficult to diagnose - in biopsy, middle of mass is mostly necrotic tissue

Mediastinal Masses

Principles of management

assess resectability

Anterior Mediastinal Tumor

Lymphoma | Thymoma

Posterior MEdiastinal Tumor

Predominantly neurogenic

Most cases are either due to esophageal perforation or occur after median sterntomy for cardiac surgery

Acute Mediastinitis

Acutely ill with chest pain and dyspnea due to the mediastinal infection. Spontaneously or as a complication of esophagoscopy. Treatment is exploration of the mediastinum with primary repair of the esophageal tear and drainage

Esophageal Rupture

Performed in cardiac surgeries like CABG. Commonly present with wound drainage. Other presentations include sepsis or a widened mediatinum

Median Sternotomy

Gas in the interstices of the mediastinum

Pneumomediastnum

Three main causes of Pneumomediastinum

Alveolar rupture with dissection of air into the mediastinum Perforation or rupture of the esophagus, trachea or main bronchi Dissection of air from the neck or the abdomen into the mediastinum

PE of pneumomediastinum

reveals subcutaneous emphysema in the supresternal notch and Hamman's sign