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STEP 2 Pulmonary > Pulmo. Pleural effusion/empyema (09-30) (1) > Flashcards

Pulmo. Pleural effusion/empyema (09-30) (1) Flashcards

1
Q

2 types: transudate and exudate

A

.

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2
Q

transudate causes.
Increased hydrostatic pressure?

A

CHF

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3
Q

transudate causes.
Decreased oncotic pressure? 3

A

nephrotic syndrome, gastrosis (kwashiorkor), and cirrhosis (hepatic hydrothorax).

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4
Q

transudate causes.
Decreased intrapleural pressure

A

pulls fluid from the vascular membrane to the
pleural space.
▪ Atelectasis.

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5
Q

transudate causes.
also constrictive pericarditis

A

.

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6
Q

exudate causes. 3 in general

A

malignancy
pneumonia
tuberculosos

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7
Q

exudate and transudate both in what disease?

A

PE

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8
Q

exudate causes from table?6

A

infection (Tb, pneumonia)
malignancy
connective tissue disease
PE
pancreatitis
post CABG (coronary artery bypass grafting)

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9
Q

transudate patho?

A

hydrastotic or oncotic pressure

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10
Q

exudate patho?

A

inflammation

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11
Q

exudate. light criteria.
pleural/serum protein?

A

> 0,5

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12
Q

exudate. light criteria.
pleural/serum LDH?

A

> 0,6

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13
Q

exudate. light criteria.
pleural LDH >2/3 upper limit of normal of serum LDH

A

.

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14
Q

exudate causes. Empyema characteristics?

A

purulent fluid, neuropjil predominant, + gram stain/culture

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15
Q

exudate causes. Chylothorax characteristics?

A

milky white fluid, incr. triglycerides

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16
Q

exudate causes. malignancy characteristics?

A

abnormal cytology

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17
Q

exudate causes. tuberculosis characteristics?

A

+acid-fast bacterium stain/culture

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18
Q

Pleural effusions. 2 diagnostic?

A

xray and thoracenthesis

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19
Q

Pleural effusions.
xray findings?

A

▪ Obliteration of the costophrenic angle.
▪ Horizontal meniscus if large.
▪ Can be chylothorax, hemothorax (hematocrit >50% of peripheral
blood), or effusion.

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20
Q

Pleural effusions.
xray: if <1cm watch and wait

A

.

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21
Q

Pleural effusions.
xray: if septations and lobes involved (loculated)?

A

Septations and lobes involved (loculated): thoracentesis (+/- tPA).
▪ Thoracentesis fails -> thoracotomy.

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22
Q

Pleural effusions.
xray: CHF?

A

CHF (BNP>500): do diuresis.
▪ Fails –> thoracentesis.

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23
Q

Pleural effusions.
Thoracentesis. Send 4 tubes. for what?

A
  1. Cell count and differentials
  2. Cytology
  3. Glucose, pH, LDH, protein
  4. Gram stain and culture
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24
Q

Pleural effusions.
Thoracentesis.
Cell count and differentials. Pneumonia, TB, cancer?

A

Pneumonia; PMNs

TBC/malignancy: lymphocytes

Cancer: RBCs

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25
Q

Pleural effusions.
Thoracentesis.
Cytology?

A

malignancy; lung, breast cancer, and lymphoma

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26
Q

Pleural effusions.
Thoracentesis.
Glucose < 60 in what cases?

A

o Rheumatoid pleurisy.
o Complicated parapneumonic effusions or empyema.
o Malignant effusion.
o Tuberculous pleurisy.
o Lupus pleuritis.
o Esophageal rupture.

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27
Q

Pleural effusions.
Thoracentesis.
Glucose < 30 in what cases?

A

o Rheumatic effusion.
o Empyema.

28
Q

Pleural effusions.
Thoracentesis.
Triglycerides for chylothorax. in what cases seen?

A

Seen in cardiothoracic surgery, congenital
malformations, down syndrome, noonan syndrome,
and malignancy.

29
Q

Pleural effusions.
Thoracentesis.
Chylothorax, what lab findings?

A

triglycerides, cholesterol, chylomicrons,
and fat-soluble vitamins, HYPONATREMIA.

30
Q

Pleural effusions.
Thoracentesis. chylothorax management?

A

drainage, limitation of dietary fat, and
possible thoracic duct ligation.

31
Q

Pleural effusions.
Thoracentesis.
Chylothorax to differentiate from empyema?

A

To differentiate it from empyema: do centrifugation;
chylothorax remains uniform and empyema becomes a clear supernatant overlying a precipitate.

31
Q

Pleural effusions.
Thoracentesis. what lab for TB?

A

Adenosine deaminase for TB.

32
Q

Pleural effusions.
Thoracentesis. what lab for pancreatitis?

A

Amylase: pancreatitis or esophageal perforation.

33
Q

Pleural effusions.
Thoracentesis. normal pH, what in transudate and exudate?

A

Normal pleural pH: 7.60.
o Transudate: 7.40-7.55.
o Exudate:7.30-7.45

34
Q

Pleural effusions.
Thoracentesis.
gram stain and culture for what?

A

Bacteria or fungi or TB.

35
Q

Parapneumonic effusions table.
Uncomplicated etiology?

A

Sterile exudate in pleural space

36
Q

Parapneumonic effusions table.
complicated etiology?

A

bacterial invasion of pleural space

37
Q

Parapneumonic effusions table.
Uncomplicated. pleural fluid analysis. 3 - pH, WBC, glucose

A

pH >= 7,2
WBC =<50k
glucose >= 60 mg/dl

38
Q

Parapneumonic effusions table.
Complicated.
3 - pH, WBC, glucose

A

pH < 7,2
WBC >50k
glucose ><60 mg/dl

39
Q

Parapneumonic effusions table.
Uncomplicated.
Pleural fluid gram stain and culture?

A

negative

40
Q

Parapneumonic effusions table.
Complicated.
Pleural fluid gram stain and culture?

A

can be positive/Negative*

*negative is typically a false negative due to ow bacterial count. Both (stain and culture) are typically positive in empyema

41
Q

Parapneumonic effusions table.
Uncomplicated.
treatment?

A

antibiotics

42
Q

Parapneumonic effusions table.
Complicated.
treatment?

A

antibiotics + drainage

43
Q

Parapneumonic effusions table.
Uncomplicated.
Pathophysiology?

A

Inflammatory fluid from pneumonia –> pleural space

44
Q

Parapneumonic effusions table.
Complicated.
Pathophysiology?

A

Bacterial invasion into pleural fluid

45
Q

Parapneumonic effusions table.
Uncomplicated.
LDH ratio?

A

> 0,6

46
Q

Parapneumonic effusions table.
Complicated.
LDH ratio?

A

> 0,6

47
Q

Parapneumonic effusions table.
Uncomplicated. glucose?

A

decr./normal

48
Q

Parapneumonic effusions table.
Complicated.
glucose?

A

decreased

49
Q

Parapneumonic effusions table.
Empyema. pathophysiology?

A

Bacterial colonization –> purulent fluid

50
Q

Parapneumonic effusions table.
Empyema. pleural fluid analysis?

A

pH < 7,2
decr. glucose
LDH > 0,6

51
Q

Parapneumonic effusions table.
Empyema. pleural fluid gram stain and culture?

A

positive

52
Q

How to differentiate empyemas from complicated effusions?

A

by the presence of
gross pus or bacteria on Gram stain.

53
Q

what LDH indicated bacterial invasion of the pleural space?

A

LDH >1000 indicates bacterial invasion of the pleural space.

54
Q

What treatment may be required for empyema and complicated effusions?

A

Most complicated effusions and all empyemas require drainage in addition to
antibiotics (2-4 weeks).

55
Q

Treatment. empyema?

A

Empyema: chest tube placement and systemic antibiotic treatment.

Doesn’t resolve → thoracoscopic debridement.

56
Q

Management of pleural effusions algo.
1st: penumonia and effusion on XRAY –>

Small effusions AND no resp. distress or hypoxia ->?

A

oral abs
close monitoring

57
Q

Management of pleural effusions algo.
1st: penumonia and effusion on XRAY –>

Moderate/large effusion
OR
respiratory distress
OR
hypoxia
–>

A

Ultrasound
IV abs
drainage

58
Q

Empyema table. etiology?

A

bacterial invasion of pleural space resulting in fibrinopurulent consolidation

Usually due to progression of a complicated parapneumonic effusion

59
Q

Empyema table.
mos?

A

oral anaerobic bacteria (likely most common)

Strep. pneumonia
Staph. aureus

60
Q

Empyema table.
clinical? symptoms

A

Symptoms of pneumonia (fever, dyspnea, pleuritic chest pain)

61
Q

Empyema table.
clinical? onset

A

insidious presentation (eg 1-2 weeks or more), weight loss

62
Q

Empyema table.
clinical? labs

A

lab evidence of inflammation (leukocytosis, thrombocytosis)

63
Q

Empyema table.
management - all mentioned IN ADDITION TO ABS. 3

A

Chest tube drainage when possible (ie empyema is free flowing)

Intrapleural fibrinolytic durgs (tPA/DNase) may assist drainage

Surgical decortication for highly fibrotic, loculated effusions

64
Q

Empyema table.
tPA/DNase - tissue plasminogen activator/recombinant deoxyribonuclease

A

.

STEP 2 Pulmonary (30 decks)

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