Pleuromediastinal Disorders Flashcards
Symptoms related to pleural diseases
compression
Invasion
Irritation
Normal volume of pleural fluid
15-20ml
Pleural effusion
Blunting of the costophrenic sulcus
200-300 ml of pleural fluid
Most dependent portion -> first to be filled
Things to look fo if you suspect atelectasis
Trachea midline?
Interpaces narrow?
Thing to look for if you suspect a mass
mediastinal shift
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
How is pleural fluid removed?
via the lymphatics
First step when dealing with pleural effusion
determine wether the effusion is a transudate or an exudate
Advantage of an ultrasound
demonstrate loculation early
Thoracentesis
Needle -> (T7/T8)
Systemic factors affect the formation and absorption of pleural fluid are altered
transudative pleural effusion
Local factors that influence the formation and absorption of pleural fluid are altered
Exudative pleural effusion
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
If exudative pleural effusion…
Description Glucose level Amylase level DIff count Microbiologic studies Cytologyq
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
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
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
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
If the fluid recur after the secoond treatment at thoracentesis in the absence of complicating factors….
Surgical drainage
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
Stages of Parapneumonic effusion
Exduative
Fibrinopurulent (Empyema)
Organization stage
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
Fibrinopurulent stage
Increassed PMN
Decreased glucose level and pH
Fluid becomes particulate, tendency to loculate
Treatment: VATS
organization Stage
Fibrothorax
Development of pleural peel/trapped lung
Treatment: Surgery (Decortications)
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
