Pneumothorax, effusion + acute resp failure Flashcards
What is:
Sharp, localized, fleeting pain exacerbated by coughing, deep breathing, movement, sneezing
Radiation to ipsilateral shoulder
pleuritis
What does this cause:
Acute inflammation of parietal pleura: bacterial, viral, or fungal infection/pneumonia
PE/ lung cancer
Lupus, metastatic cancer, mesothelioma
pleuritis
How do you Dx pleuritis?
CXR - rule out other causes
How do you treat pleuritis?
NSAIDs, codeine, other opioids
Sudden onset of chest pain, dyspnea, cough, life-threatening or respiratory failure
pneumothorax
What are risk factors for pneumothorax?
Drug use, increased pressure (diving, flying), airway disease, infection, lung disease
What does this PE indicate:
Decreased breath sounds
Hyperresonance
Decreased or absent tactile fremitus
Mediastinal or tracheal deviation = tension
Increased JVP, pulsus paradoxus, HOTN
pneumothorax
What type of pneumothorax: : no pre-existing lung disease
tall, thin boys + men 10 - 30 years w/ smoking + family hx
primary spontaneous pneumothorax
What type of pneumothorax: pre-existing lung disease
more life-threatening, COPD, asthma, interstitial lung disease, TB, pneumocystis pneumonia
secondary spontaneous pneumothorax
What type of pneumothorax: penetrating trauma, lung infections, CPR, + pressure mechanical ventilation
life-threatening, organs pushed to contralateral side
tension pneumothorax
For unstable patients what imaging do you pick for a pneumothorax?
rapid bedside imaging w/ US: lung point, absence of lung sliding
For stable patients what imaging do you pick for a pneumothorax?
CXR (TOC), showing visceral pleural line (companion lines), deep sulcus sign
CT, if dx is uncertain, loculated pneumothorax, or further trauma
A small pneumothorax is <_
2 cm
A large pneumothorax is _
> / 2 cm
What values of the average intrapleural distance dictate a small or large pneumothorax?
<15% small, 50% large
What’s the first step for pneumothorax?
stabilize patient
- RR <24
- HR>60 but <120
- normal BP
- O2>90%
- ability to speak in whole sentences
What is treatment for a small primary pneumothorax?
6 hour observation
Repeat CXR to confirm no progression
Follow up in 24 hours
What’s treatment for a large primary pneumothorax?
Needle aspiration followed by chest tube (second intercostal space at midclavicular line of the affected side) if fails
Attach to heimlich valve to prevent tension
What’s treatment for a secondary pneumothorax?
Chest tube placement (large, severe, or from mechanical ventilation) + hospitalization
Thoracostomy (recurrence, bilateral, failure)
How do you treat a tension pneumothorax?
Medical emergency → emergent chest decompression with a large-bore needle followed by immediate chest tube placement
What can be seen as asymptomatic or pain referring to shoulder from pleural inflammation and dyspnea, cough?
pleural effusion
What does this PE indicate:
absent or diminished movements on affected side
Fullness of chest w/ bulging intercostal spaces
Diminished breath sounds
decreased/absent tactile fremitus
Dullness to percussion
Absence of breath sounds
Absent vocal resonance
Pneumonia-like findings (crackles)
pleural effusion
associated w/ bacterial pneumonia, bronchiectasis, or lung abscess
parapneumonic
anatomically confined within a sac
loculated effusion
accumulation of fluid between lung and diaphragm
subpulmonic effusion
increased hydrostatic or decreased oncotic pressures (CHF, atelectasis, renal/liver disease)
transudative pleural effusion
leaky capillaries from infection, malignancy, trauma
exudative pleural effusion
A pleural effusion is classified by:
1) site
2) type
3) mechanism
Protein <.5
LDH <.6
LDH <⅔ upper limit of normal for serum LDH
transudative pleural effusion
Protein >.5
LDH >.6
LDH > ⅔ upper limit of normal for serum LDH
exudative pleural effusion
Increased WBC count pleural effusion
empyema
Pleural fluid: blood ratio >.5
hemothorax
Light’s criteria purpose
If any are true, pleural effusion is EXUDATIVE
protein >.5
serum LDH >.6
pleural LDH > 2/3
light’s criteria – exudative
elevated amylase in pleural effusion
pancreatic disease, malignancy, esophageal rupture
elevated triglycerides in pleural effusion
chylothorax from thoracic duct disruption
How do you diagnose pleural effusion?
CBC - leukocyte counts
CXR: initial TOC
PA: need fluid to diagnose, blunting of costophrenic angle (meniscus sign), diaphragm + heart poorly demarcated, shifts to uninvolved side
Lateral decubitus: smaller effusions, free flowing vs. loculated - best
CT scan: if minimal or loculated, US or CT for loculated or empyema
pleural effusion TOC
chest xray
What’s the gold standard for diagnosis of pleural effusion
thoracentesis
For all acute effusions + differentiation –
Analyze protein, LDH, pH, WBC, glucose, cytology, Gram stain
Glucose <60 =
TB, malignancy, rheumatoid arthritis, parapneumonic effusion
Thoracentesis
How do you treat a transudative pleural effusion?
treat underlying cause, diuretics + sodium restriction
How do you treat an exudative pleural effusion?
drainage w/ consideration for placement of indwelling pleural catheter
(pleurodesis for refractory >2 or 3)
How do you treat an empyema?
antibiotics + drainage
How do you treat a hemothorax?
drainage
What type of acute respiratory failure is:
Dyspnea, tachypnea, tachycardia, peripheral or central cyanosis
Restlessness, confusion, AMS
Tripoding, inability to lie supine, manifestations of stress response (HTN, diaphoresis), use of accessory muscles
hypoxic
What type of acute respiratory failure is:
Dyspnea + HA = classic
Peripheral + conjunctival hyperemia, HTN, tachycardia, tachypnea, impaired consciousness, papilledema, myoclonus (spasms), asterixis
COPD exacerbation - reduced air movement, wheezing, squeaking, rhonchi
Acute asthma - wheezing, retractions
Pulmonary edema - crackles
hypercapnic
Respiratory dysfunction resulting in abnormalities of oxygenation or ventilation enough to threaten the function of vital organs
acute respiratory failure
arterial hypoxemia caused by inflammatory lung injury or severe hypoventilation w/ escalating need for supplemental oxygen, acute or chronic
From pneumonia, COPD, exacerbation, ACS, PE, sepsis, asthma, ARDS, interstitial lung disease, trauma
Type 1 = hypoxicemic
imbalance between load on respiratory muscles + muscle pump capacity leading to PaCO2>45mmHG and pH<7.35 (lungs not functioning), acute, acute on chronic, chronic
From obstructive, pulmonary edema, OHS, drug intoxication, neuromuscular disorders, chest wall disorders
Type 2 = hypercapnic
What are rough guidelines for acute respiratory failure diagnosis?
PO2<60 (SpO2 <91%) in a nonCOPD and (SPO2<88% in COPD)
PCO2>50mmHG
What are diagnostic tools for acute respiratory failure?
Repeat vitals
Continuous pulse ox
ABG
CXR
EKG
Troponin
pro-BNP
UDS
Echo
What’s first line for acute respiratory failure?
ABCs: airway, breathing, circulation
Oxygenation -
low flow, simple face mask, high flow, non-invasive positive airway pressure, intubation
Goal: >92% for non-COPD
88-92% w/ COPD
Goal for oxygenation in ARF w/ non-COPD:
> 92%
Goal for oxygenation in ARF w/ COPD
88-92%
What are these indications for:
Respiratory muscle fatigue (current or impending)
Hypoxia not corrected by nasal cannula, HFNC, or mask
Pulmonary edema
FIRST LINE FOR COPD in hypercapnic failure
NIPPV
When is NIPPV contraindicated?
CI IF: significant secretions, facial trauma, burns, high risk of aspiration, AMS, long-term need
What are these indications for:
Hypercapnic encephalopathy (CO2 narcosis)
Hypoxemia despite oxygen therapy
Impaired airway protection
Respiratory acidosis
Refractory hypoxemia despite HFNC or biPAP
Respiratory muscle exhaustion
Apnea
intubation
What are these indications for:
apnea
Acute hypercapnia
Severe hypoxemia
Progressive patient fatigue
mechanical ventilation
When do you use ECMO in acute respiratory failure?
for cardiac failure or both cardiac/resp failures
ARDS requirements are
Acute hypoxemia <1 week
Ratio<300 P/F on ABG
Diffuse BL infiltrates
Swan cath or echo - PCWP <18 (NO CARDIOGENIC PULM EDEMA)
hypoxemia is defined by
O2 <60 on ABG
Hypercapnia is defined by
CO2 >50 on ABG
Hypercapnia means
hypoventilation, commonly from a drug or obstructive disease process slowing ability to breathe
Hypoxemia means
likely something is blocking ventilation like pneumonia, aspiration
