Pneunothorax Flashcards
Pneumothorax arises when
free air enters the potential space between the visceral and parietal lung pleura
occur without clinically apparent lung disease, either spontaneously or from penetration of the intrapleural space by trauma
Primary pneumothoraces
happen in patients with underlying lung disease.
Secondary pneumothoraces
In secondary spontaneous pneumothorax, ______________________ is the most common cause
Chronic obstructive pulmonary disease
True or false
Hemopneumothorax occurs in 2% to 7% of patients with secondary pneumothorax; if associated with a large amount of blood in the pleural cavity, this can be life threatening.
 True
True or false
A primary spontaneous pneumothorax occurs when a subpleural bleb ruptures, disrupting pleural integrity and usually involving the lung apex
True
True or false
In secondary spontaneous pneumothoraces, disruption of the visceral pleura occurs secondary to underlying pulmonary disease processes
 True
develops as inhaled air accumulates in the pleural space but cannot exit due to a one-way valve system
Tension pneumothorax
As intrathoracic pressure increases up to _____________, venous return and cardiac and lung function are severely restricted, resulting in hypoxemia and shock
(>15 to 20 mm Hg)
clinical hallmarks of tension pneumothorax are
- tracheal deviation away from the involved side
- hyperresonance of the affected side
- hypotension
- dyspnea, profound
Classic symptoms of primary spontaneous pneumothorax are ____1___, and ___2____.
- sudden onset of dyspnea
and
- ipsilateral, pleuritic chest pain
is the most common physical finding in primary spontaneous pneumothorax
Sinus tachycardia
Chest Radiograph in Pneumothorax
loss of lung markings in the periphery and a pleural line that runs parallel to the chest wall
deep sulcus sign is
profound lateral costophrenic angle, on the affected side
To be seen in critically ill patients who cannot be moved to an erect position
Pneumothorax vs bullae: differentiate.
Pneumothoraces usually cross more than one lung segment, whereas bullae follow a single lobe
a pneumothorax pleural line will run parallel with the chest wall, whereas bullae will have a medially concave appearance.
British Thoracic Society defines a small pneumothorax as one with a ________ rim between the lung edge and chest wall; a large pneumothorax is defined as one with a ________rim
<2-cm
Large: ≥2-cm
True or false
In a normal lung, there is a sonographic reverberation distal to the pleura that looks like a comet tail and a sliding sign of the movement of the visceral pleura along the parietal pleura
True
Identify
Criteria for Stable Patient With Pneumothorax
Fill in the RED blanks
Safe location of chest tube
Complications of a pneumothorax
hypoxia, hypercapnia, and hypotension
True or false
Reexpansion lung injury is UNCOMMON and seen more often when there is collapse of the lung for >72 hours, a large pneumothorax, rapid reexpansion, or negative pleural pressure suction of >20 cm.
 True
True or false
Most patients need no treatment for reexpansion injury aside from observation or oxygen, with few adverse outcomes
 True
 True or false
Intervention complications
intercostal vessel hemorrhage, lung parenchymal injury, empyema, and tube malfunction (develop- ment of an air leak or tension pneumothorax)
How much O2 is needed and MOA?
Oxygen administration (>28%) increases pleural air resorption three- to fourfold over the base 1.25% reabsorbed per day by creating a nitrogen gas pressure gradient between the alveolus and trapped air
Recommended oxygen dosing ranges from 3 L/min by nasal cannula to 10 L/min by mask
When is observation feasible?
What to do during observation?
Observation is appropriate for small, stable pneumothoraces.
> at least 4 hours on supplemental oxygen
repeat the chest radiograph
If symptoms and chest radiograph improve, discharge
return in 1 to 2 weeks for repeat examination
≥5-mm induration is positive in:
• HIV
• Close contact
• Healed PTB with abnormal chest radiograph
• IMMUNOCOMPROMISED: organ transplants and receiving the equivalent of prednisone >15 milligrams per day for >1 month
≥10-mm induration is positive in patients not meeting the above criteria but who have other risks:
• Injection drug users
• High-prevalence groups (immigrants, long-term care facility residents, persons in local high-risk areas)
• Patients with conditions that increase the risk of progression to active disease (silicosis; diabetes; carcinoma of the head, neck, or lung)
• Children <4 y of age
True or false
A positive reaction does not necessarily indicate disease.
 True
True or false
Detection of newly infected persons in a screening program:
• ≥10-mm induration increase within any 2-y period is positive if <35 y
• ≥15-mm induration increase within any 2-y period is positive if >35 y
 True
indirectly assess for tuberculosis. The test seeks the response to peptides present in all M. tuberculosis proteins, which trigger the release of interferon-γ by the infected host.
Interferon-γ release assays (IGRAs)
True or false
the most common finding is a normal chest radiograph, especially in immunocompromised patients
True
True or false
Isolated ipsilateral hilar or mediastinal adenopathy is sometimes the only finding.
True
True or false
The radiographic appearance of tuberculosis is often dependent on the integrity of the immune system rather than the stage of tuberculous disease
True
Sputum Samples are stained using either a _____________stain or __________ procedure followed by exposure to an acidic agent.
Ziehl-Neelsen stain or a fluorochrome
_______________________ are the best method of confirming diagnosis and the most specific test for the disease, detecting as few as 10 bacteria/mL.
Sputum or other tissue cultures for M. tuberculosis
can yield results within 1 day and detect as few as 1 to 10 organisms/mL sample.
The WHO endorses this for diagnosis of pulmonary and extrapulmonary tuberculosis.
Probe-based tests, or the nucleic acid amplification test (NAAT)
portion of patients treated for tuberculosis worsen after the initiation of antituberculous medications
paradoxical reaction or immune reconstitution syndrome
Isoniazid
Potential Side Effects and Comments
Hepatitis, peripheral neuropathy, drug interactions.
No side effect of hepatitis
Ethambutol
Recommended by Centers for Disease Control and Prevention for continuation therapy only for human immunodeficiency virus–negative patients.
Rifapentine
Thrombocytopenia
Rifa
used for patients who cannot tolerate RIF.
Rifabutin
exacerbation of porphyria
Rifapentine
_______________ is a unique finding in paradoxical reactions.
Hypercalcemia
Athralgia
Pyrazinamide
Retrobulbar neuritis
Ethambutol
not approved in children <12 y old
Rifapentine
Engineering Controls to Reduce the Transmission of Tuberculosis
Define Extensive drug-resistant tuberculosis
occurs when resistance to INH, RIF, any fluoroquinolone, and at least one injectable second-line medication exists
Define Multidrug-resistant tuberculosis
is tuberculosis with isolates that demonstrate resistance to at least INH and RIF
In children, the most common extrapulmonary presentation is
Cervical lymphadenitis
