plural space / mediastinal disorders Flashcards
What is pleural effusion
accumulation of fluid in the pleural space
What is the most common pleural disease
Pleural effusion
What is transudative effusion
decreased oncotic or increased hydrostatic pressure
too much fluid OR too few proteins in fluid (fluid overload)
What is exudative effusion
inflammation = increased capillary permeability
generally infectious agents or malignancy
how will a patient present with pleural effusion
shortness of breath
orthopnea
PND
chest pain
dry cough
What may be seen on PE with pleural effusion
dullness ot percussion (over fluid)
Diminished breath sounds
decreased tactile fremitus
E -> A egophony
What is lymphatic fluid called
chyle
How can you workup a pleural effusion
CXR
US (more sensitive)
Thoracentesis (dx and therapeutic)
What sign may you see on CXR with pleural effusion
Meniscus sign
If there is lots of fluid in the lungs, what should be your differentials
Malignancy
CHF
Ascites
TB
If the pleural effusion is bilateral, what should be your differentials
CHF or malignancy
How much fluid do the lungs need to have to be able to see the meniscal sign
200mL
If pleural effusion is right sided, what should be your differentials
CHF
If the effusion is left sided, what should be your differentials
Esophageal rupture
pancreatic
post-CABG
What are contraindications for thoracentesis
overlying wound/skin infection
small fluid accumulation
bleeding disorders
What are complications of thoracentesis
pneumothorax
bleeding
SOB/Cough
spleen/liver puncture
vasovagal
What labs get run on pleural fluid
Glucose
RBC / WBC
Protein/ amylase/ triglycerides
LDH
pH
Cytology
Gram stain and culture
What criteria is used to determine whether effusion is transudative or exudative
Lights criteria
If pleural fluid is blood tinged, what is the likely cause
malignancy
PE
Trauma
If pleural fluid has gross blood, what is the likely cause
hemothorax
If pleural fluid is turbid/milky colored, what is the likely cause
chylothorax
If pleural fluid is gross pus, what is the cause
empyema
If pleural fluid has low glucose, what is the cause
malignancy
infection
rheumatologic
If pleural fluid has high amylase, what is the likely cause
Pancreatitis
GI malignancy
Esophageal rupture
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
