Pneumonthorax/Pleural Effusion Flashcards
A pneumothorax by definition is:
air in the pleural space
The major structural changes associated with pneumothorax are:
- Lung collapse
- Atelectasis (from compressed alveoli)
- chest wall expansion (in tension pneumo)
- compression of the great veins and decreased cardiac venous return
Etiology- how does gas get into the pleural space?
- from the lungs through perforation of the visceral pleura
- from the atmosphere via perforation of the chest wall/parietal pleural
- (rarely) through an esophageal fistula or perforated abdominal viscus
- (rare) from gas forming microorganisms in an empyema in the pleural space
What is the difference between an open and closed pneumothorax?
Open- gas is in direct contact with atmosphere and can move freely in/out
Closed- gas not in direct contact with atmosphere
A tension pneumothorax is defined (pressure wise) as:
pneumothorax in which the INTRApleural pressure is greater than the intraALVEOLAR or atmospheric pressure
T/F All traumatic (piercing) chest wounds are classified as open pneumothorax
False-
Sucking chest wounds are open. However, sometimes traumatic injury causes formation of a valvular mechanism in the parietal pleura resulting in a closed pneumothorax. Gas enters during inspiration but can’t leave during expiration (aka TENSION pneumo)
Spontaneous pneumothorax can be caused by ruptures of ____ or ____ on the surface of the lung and most often occur in (body type) (age)
blebs or bulla
tall, thin
15-35 years
An iatrogenic pneumothorax is caused by:
complication of medical procedures (diagnostic or therapeutic
T/F Pneumothorax is a common complication of positive pressure ventilation
true
T/F Clinical manifestations of pneumothorax are caused by atelectasis
true
Pneumothorax causes a shift (toward)(away) from the affected area
AWAY from the affected area and toward the unaffected side (intrapleural pressure is lower in the uninjured area- shift from high to low)
The paradoxic movement of gas within the lungs caused by shifting pressures is called
pendelluft. patients with this will hyperventilate
T/F Pendelluft increases alveolar ventilation
FALSE- it further decreases alveolar ventilation due to lung collapse and atelectasis
Reduced alveolar ventilation causes V/Q ratio to (increase) (decrease)
decrease
Shunting and venous admixture is a result of
decreased V/Q
What effect does pneumothorax have on compliance and resistance?
compliance is decreased
resistance is increased to overcome changes in compliance
Chest assessment finding in pneumothorax are:
hyperresonant percussion
diminished/absent breath sounds over pneumo
tracheal shift
displaced heart sounds
increased thoracic volume on affected side
The most serious type of pneumothorax is ___.
tension pneumothorax
ABG values in small pneumothorax:
consistant with acute alveolar hyperventilation with hypoxemia (acute respiratory alkalosis) – pH elevated, PaCo2, decreased, HCO3 decreased slightly, PaO2 decreased
ABG values in large pneumothorax:
consistant with acute ventilatory failure with hypoxemia (acute respiratory acidosis) – pH and PaO2 decreased, PaCO2 and HCO3 elevated
In pneumothorax, tidal volume and RV/TLC ratio are:
tidal volume normal or decreased
RV/TLC normal
Oxygenation indices in pneumothorax:
Qs/Qt ; Do2 , Vo2 ; C(a-v)O2 ; O2ER ; SvO2
Qs/Qt - increased Do2 - decreased Vo2 - Normal C(a-v)O2 - elevated (severely) O2ER - increased SvO2 - decreased
CXR findings in pneumothorax
increased translucenchy (darker lung fields) on the affected side mediastinal shift to the unaffected side depressed diaphragm lung collapse atelectasis
Pneumothorax greater than ___% requires evacuation.
20%
What are the respiratory care treatment protocols for pneumothorax?
oxygen therapy protocols
lung expansion therapy protocols
mechanical vent w/ PEEP protocols
The anatomic alteration caused by a pleural effusion is:
A.) pulmonary fibrosis
B.) seperation of the visceral and parietal pleura
C.) adhesion of the visceral and parietal pleura
D.) pulmonary edema
B.) separation of the visceral and parietal pleura
The major pathologic and structural changes associated with a significant pleural effusion include all of the following EXCEPT: A) diaphragm elevation. B) atelectasis. C) compression of the great vessels. D) lung compression.
A) diaphragm elevation.
Pleural effusion is classified as what type of lung disorder? (obstructive, restrictive, combination)
restrictive
Which of the following are associated with a transudative pleural effusion? 1. Thin and watery fluid 2. Fluid has a lot of cellular debris 3. Fluid has high protein count 4. Few blood cells A) 2, 3 B) 1, 4 C) 1, 2, 3 D) 1, 3, 4
B) 1, 4
What are the symptoms of pleural effusion?
early s/s include:
pleuritic chest pain
chest pressure
dyspnea (rarely in small effusions)
and cough (related to degree of atelectasis)
chest pain can occur early when there is intense inflammation of the pleural surface
What is the difference between transudative and exudative pleural effusion?
transudative is a result of fluid from the pulmonary capillaries moving into the pleural spaces- the fluid is thin and watery with few blood cells and little protein.
EXUDATE develops when the pleural surfaces are diseased and the fluid has a high protein content and lots of cellular debris - caused by inflammation, infection or malignancy
To be exudative, pleural fluid protein levels must be what?
greater than 2.9 g/dL (29 g/L)
To be exudative, pleural fluid cholesterol levels must be what?
greater than 45 mg/dL (1.16 mmol/L
To be exudative, pleural fluid LDH levels must be what?
greater than 60 % of the upper limit for serum
Which of the following are associated with a transudative pleural effusion? 1. Thin and watery fluid 2. Fluid has a lot of cellular debris 3. Fluid has high protein count 4. Few blood cells A) 2, 3 B) 1, 4 C) 1, 2, 3 D) 1, 3, 4
B. 1, 4
The most common cause of pleural effusion is what?
Congestive heart failure -
(both left and right sided heart failure can cause pleural effusion, but left sided is more likely to produce plueral effusion)
In _____sided heart failure, an increase in the hydrostatic pressure in the systemic circulation increases the rate of pleural fluid formation and decreases lymphatic drainage from the pleural space because of the elevated systemic venous pressure
right sided heart failure (cor pulmonale)
In _____sided heart failure, an increase in the hydrostatic pressure in the pulmonary circulation increases the rate of pleural fluid absorbed through the visceral pleura and causes fluid movement through the visceral pleura into the pleural space
left-sided heart failure
Major causes of transudative pleural effusion are:
- congestive heart failure (cardiogenic pulmonary -edema)
- liver disease
- kidney disease
- pulmonary embolus
Major causes of exudative pleural effusion are:
- cancer
- pneumonias
- fungal diseases
- diseases of the GI system
The accumulation of pus in the pleural cavity is called ___ and is the result of infection and inflammation
empyema- confirmed by thoracentesis
Chylothorax (chyle [fatty particles in stable emulsion/milky liquid produced from food] in the pleural cavity results from what mechanism?
transported from the intestinal lymphatics thru the thoracic duct in the neck into venous circulation- its presence in the pleural cavity is usually due to trauma in the neck/thorax or a tumor occluding the thoracic duct
List common causes of hemothorax
Trauma- either penetrating or blunt chest trauma rupture small blood vessels
Iatrogenic hemothorax is complication from insertion of a central venous catheter
Chest assessment findings in plural effusion
chest pain decreased chest expansion dry, non-productive cough tracheal shift decreased tactile and vocal fremitus dull percussion diminished breath sounds displaced heart sounds occasional pleural friction rub
Pleural effusion is (obstructive/restrictive/combination) and effects compliance and resistance in what way?
restrictive
decreased lung compliance and resistance
Chest xray findings in pleural effusion
- liquid filled areas show up as opacities (white)
- blunting of the costophrenic angle
- depressed diaphragm
- possible mediastinal shiff to UNaffected side
- atelectasis in bad lung
remember fluid fills dependent spaces first-
weight of fluid may cause diaphragm to become inverted (concave)
Treatment of pleural effusion includes
- thoracentesis (removal of fluid w/needle in a 1 time procedure)
- insertion of chest tube
- oxygen therapy
- hyperinflatoin therapy after fluid removal to reinflate the compressed lung
Which of the following are associated with exudative effusion?
- few blood cells
- inflammation
- thin and watery fluid
- disease of the pleural surfaces
2 and 4 only
inflammation and disease
Which of the following is the most common cause of a transudative pleural effusion 1. pulmonary embolus 2 congestive heart failure 3. Hepatic hydrothorax 4 nephrotic syndrome
2- congestive heart failure
A hemothorax is said to be present when the hematocrit of the pleural fluid is at least what? A. 20% B. 30% C. 40% D. 50%
d 50%
Approximately what percentage of patients with pulmonary emboli develop pleural effusion? A. 0-20 % B 20-30% C. 30-50% D 50-60%
c- 30-50%
Which of the following are associated with pleural effusion? 1. increased RV 2 decreased FRC 3 increased VT 4 Decreased VC
2 and 4 only
decreased FRC and decreased VC
The causes of a transudative pleural effusion include: 1. congestive heart failure. 2. fungal pneumonia. 3. pulmonary embolism. 4. hemothorax. A) 1, 3 B) 2, 4 C) 1, 3, 4 D) 1, 2, 3, 4
A) 1, 3
A: 1, 3
Your patient has cancer related to his chronic asbestos exposure. What is his pleural effusion fluid likely to show on laboratory analysis? 1. Erythrocytes 2. Lymphocytes 3. Normal mesothelial cells 4. Malignant mesothelial cells A) 1, 4 B) 2, 3 C) 2, 3, 4 D) 1, 2, 3, 4
C: 2, 3, 4
Which of the following are major causes of an exudative pleural effusion? 1. Empyema 2. Chylothorax 3. Pancreatitis 4. Peritoneal dialysis A) 1, 4 B) 2, 3 C) 1, 2, 3 D) 1, 2, 3, 4
C: 1, 2, 3
Your patient with a large pleural effusion will have a chest tube inserted. Which of the following statements are true of this procedure?
1. Tube placement in the 2nd to 3rd intercostal space
2. Tube placement in the 4th to 5th intercostal space
3. Tube placement in the midclavicular line
4. Tube placement in the midaxillary line
A) 1, 4
B) 2, 3
C) 1, 3
D) 2, 4
D 2, 4
Treatment of an empyema usually includes: 1. antibiotics for bacterial infection. 2. thoracentesis. 3. lung removal (pneumonectomy). 4. lung transplant. A) 1 B) 2 C) 2, 3 D) 1, 2
D. 1, 2
Your patient has a pleural effusion from an unknown cause. A fluid sample has been taken for analysis. To help identify the cause of the effusion, all of the following tests should be performed EXCEPT: A) specific gravity. B) biochemical makeup. C) cytologic examination. D) check for bacteria.
A. specific gravity
A large pleural effusion commonly demonstrates which of the following findings during a chest assessment? 1. Increased tactile and vocal fremitus 2. Hyperresonant percussion note 3. Diminished breath sounds 4. Tracheal shift A) 1 B) 2, 3 C) 3, 4 D) 1, 3, 4
C) 3, 4
While reviewing the upright chest radiograph of your patient, you see a fluid density in the right lung area that extends upward around the anterior, lateral, and posterior thoracic walls. What is this sign of a pleural effusion called? A) Meniscus sign B) Scarf sign C) Transudate sign D) Kerley B lines
A meniscus sign
Usual chest radiograph findings on a patient with a large pleural effusion include:
1. blunting of the costophrenic angle.
2. fluid level on the affected side.
3. mediastinal shift to the unaffected side.
4. mediastinal shift to the affected side.
A) 1, 3
B) 2, 4
C) 1, 2, 4
D) 1, 2, 3
D 1, 2, 3
Your patient is complaining of great chest pressure and shortness of breath. A chest radiograph shows a large pleural effusion. What is the best way to manage the effusion A. Thoracentesis B Supplemental O2 C Lung expansion therapy D Antibiotics
A. Thoracentesis
If a person has a transudate type pleural effusion, and changes from an upright to a lateral position for a chest x-ray, the effusion will:
A stay as it was originally positioned
B shift its position to be more horizontal
C become more viscous
D flow into a bronchus to be coughed or suctioned out
B. shift position to be more horizontal
Clinical manifestations associated with a pleural effusion include: 1. tracheal shift away from the effusion 2. increased lung compliance 3. decreased breath sounds over the affected area 4. decreased vital capacity A 2 and 4 B 3, and 4 C 1 and 3 D 1, 3 and 4
D- 1, 3, and 4
