plural space / mediastinal disorders Flashcards by Melissa Ring

What is pleural effusion

accumulation of fluid in the pleural space

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What is the most common pleural disease

Pleural effusion

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What is transudative effusion

decreased oncotic or increased hydrostatic pressure

too much fluid OR too few proteins in fluid (fluid overload)

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What is exudative effusion

inflammation = increased capillary permeability

generally infectious agents or malignancy

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how will a patient present with pleural effusion

shortness of breath
orthopnea
PND
chest pain
dry cough

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What may be seen on PE with pleural effusion

dullness ot percussion (over fluid)
Diminished breath sounds
decreased tactile fremitus
E -> A egophony

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What is lymphatic fluid called

chyle

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How can you workup a pleural effusion

CXR
US (more sensitive)
Thoracentesis (dx and therapeutic)

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What sign may you see on CXR with pleural effusion

Meniscus sign

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If there is lots of fluid in the lungs, what should be your differentials

Malignancy
CHF
Ascites
TB

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If the pleural effusion is bilateral, what should be your differentials

CHF or malignancy

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How much fluid do the lungs need to have to be able to see the meniscal sign

200mL

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If pleural effusion is right sided, what should be your differentials

CHF

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If the effusion is left sided, what should be your differentials

Esophageal rupture
pancreatic
post-CABG

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What are contraindications for thoracentesis

overlying wound/skin infection
small fluid accumulation
bleeding disorders

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What are complications of thoracentesis

pneumothorax
bleeding
SOB/Cough
spleen/liver puncture
vasovagal

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What labs get run on pleural fluid

Glucose
RBC / WBC
Protein/ amylase/ triglycerides
LDH
pH
Cytology
Gram stain and culture

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What criteria is used to determine whether effusion is transudative or exudative

Lights criteria

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If pleural fluid is blood tinged, what is the likely cause

malignancy
PE
Trauma

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If pleural fluid has gross blood, what is the likely cause

hemothorax

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If pleural fluid is turbid/milky colored, what is the likely cause

chylothorax

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If pleural fluid is gross pus, what is the cause

empyema

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If pleural fluid has low glucose, what is the cause

malignancy
infection
rheumatologic

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If pleural fluid has high amylase, what is the likely cause

Pancreatitis
GI malignancy
Esophageal rupture

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If pleural fluid has a low pH, what is the likely cause

bacterial infection TB malignancy hemothorax esophageal rupture

If there are increased eosinophils in pleural fluid, what is the underlying cause

air pneumothorax hemothorax infarct **NOT TB or Cancer

What is a hemothorax

pooling of blood in the pleural space

What causes hemothorax

generally secondary to blunt trauma

How much blood volume can hide in a hemothorax

40%

What are clues for a hemothorax MOI

MVC > 35mph Fall> 15ft Ejection> 10ft LOC

How will a hemothorax present

rapid development +/- hemodynamic instability

What is the preferred imaging for hemothorax

CT *hard to differentiate between pleural effusion and hemothorax

What is the treatment for a hemothorax

IV, O2, Monitor if < 300mL and stable = observation if unstable = decompression

How often do you re-image a stable patient with a hemothorax

at 4-6 hours and again at 24 hours

How do you decompress an unstable hemothorax

needle thoracostomy chest tube +/- thoracotomy

Which patients require a thoracotomy

massive hemothorax (>1-1.5 L) Continued bleeding >300-500 in first hour >200mL for first 3+ hours >7mL/Kg/hr Inability to ventilate decompensation worsening CXR

What is a pneumothorax

Accumulation of air in the pleural space

What are the pneumothorax classification

Primary (spontaneous) Secondary (Spontaneous) traumatic iatrogenic tension

Who are at increased risk for a primary spontaneous pneumothorax

Tall, thin males (10-30y/o) +FH and Smokers

What causes secondary pneumothorax

underlying pulmonary disease (M>F)

What occurs on inspiration with traumatic pneumothorax

Air goes into pleural space

What occurs on expiration of traumatic pneumothorax

Air leaves pleural space

What may be the cause of an iatrogenic pneumothorax

thoracentesis lung biopsy central lines

What generally causes a tension pneumothorax

Penetrating trauma mechanical ventilation CPR infection

What is occuring with a tension pneumothorax

the pressure in the pleural space is greater than pressure within the lungs this causes impaired expansion and ultimately collapse *will ultimately cause mediastinal shift

What is the presentation of a tension pneumothorax

Sudden, severe, pleuritic chest pain on effected side

What will as patient have on exam with tension pneumo

Severe tachycardia hypotension reduced chest movement JVD respiratory distress

How do you treat a tension pneumothorax

Immediate decompression, no imaging

What will you see on Xray with a pneumothorax

Visible pleural edge lung markings dont extend to chest wall Increased radiolucency deep sulcus sign when supine

Which patients with a pneumothorax are stable

RR<24 Normal BP SpO2>90% HR 60-120 able to speak sentences **need all these

What is the. treatment for a pneumothorax

Bigger & stable = chest tube Respiratory distress= chest tube & ventilation

If a chest tube fails or patient is super high risk, how do you treat a pneumo

pleurodesis -tacking up the lung, abrasion, doxy/minocycline

What are the 3 main processes of mediastinal disease

mediastinal masses pneumomediastinum mediastinitis

What assess may present in the anterior mediastinum

thymoma lymphoma

What massess may present in the middle mediastinum

Vascular lymphadenopathy

What masses may present in the posterior mediastinum

neurogenic esophagus

What mediastinal masses can kiddos have

neurogenic cystic

What symptoms may occur with mediastinal masses

obstructive respiratory symptoms stridor recurrent bronchitis / PNA Chest pain, dysphagia

How do you workup mediastinal masses

Chest CT (TOC) bx for definitive dx

What is a thymoma

tumor arising from thymus # anterior mediastinal tumor

What are thymomas associated with

autoimmune paraneoplastic syndromes -myasthenia gravis -hypogammaglobinemia -red cell aplasia

IF a patient has symptoms with a thymoma, what would they be

phrenic palsy hoarsness cough SVC syndrome

What is the mainstay treatment of thymomas

surgical resection for early disease +/- chemo if more severe

Who is at greatest risk for pneumomediastinum

Young males

How does pneumomediastinum present

sudden, severe, retrosternal chest pain increased work of breathing voice changes

How do you dx pneumomediastinum

CXR *CT to confirm, assess extent, or look for cause

What is the treatment for pneumomediastinum

Most resolve on own **rarely decompress if causing tamponade

What is medistinitis

inflammation of mediastinal space

What is the cause of medistinitis

secondary to infection (m/c)

How does medistinitis present

sudden or insidious onset severe chest pain, dyspnea, and fever

How do you dx medistinitis

CXR or CT

How do you treat medistinitis

abx (clinda + ceftriaxone) *is pleural effusion or pneumothorax is also present... need surgery