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EORE Emergency Medicine > Pulmonary > Flashcards

Pulmonary Flashcards

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1
Q

Normal pleural fluid function and composition

A

Normal function: provide smooth surface that reduces friction as pleura (visceral and parietal) move across each other

Normal composition: 1-10mL. Ultrafiltrate of plasma. NO protein (<1-2g), almost no WBC (<1,000), glucose similar to plasma and LDH < 50% of plasma

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2
Q

Factors affecting interstitial fluid formation

A

Force #1: Hydrostatic pressure (pushing force)

Force #2: Oncotic pressure (pulling force)

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3
Q

Pleural Effusion definition

A

Abnormally large collection of fluid in the pleural cavity - usually an indicator of a pathologic process/manifestation of an underlying disease

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4
Q

Clinical presentation pleural effusion

A

Often ASYMPTOMATIC

  1. SOB
  2. Cough
  3. Pleuritic chest pain

If caused by CHF, then LE edema in combo with above

IF caused by Tb/CA then night sweats, fever, weight loss in combo with above

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5
Q

PE Findings pleural effusion

A 
Decreased tactile fremitus
Decreased breath sounds
Dullness to percussion 
Egophany (E --> A) 
\+/- pleural friction rub
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6
Q

Exudative effusion vs transudative effusion

A

Exudative: 2/2 increased vascular permeability (infection (acute-empyema, chronic-Tb), inflammation (SLE/RA), malignancy) - contains increased plasma proteins, WBCs, platelets

Transudative: Due to increased hydrostatic pressure (CHF) or decreased oncotic pressure (nephrotic syndrome, liver cirrhosis/failure, atelectasis

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7
Q

Light’s Criteria

A

Fluid is exudative if > 1 of the following criteria are met:

  1. Ratio of pleural fluid LDH: serum LDH >0.6
  2. Pleural fluid LDH > 2/3 upper limit of reference range for serum LDH
  3. Ratio of pleural fluid protein : serum protein >0.5
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8
Q

4 Types of fluid that accumulate in pleural space

A
  1. Serous fluid = hydrothorax
  2. Chyle = chylothorax (lymph fluid w/ TB & fat)
  3. Blood = hemothorax
  4. Pus = empyema (infected pleural cavity)
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9
Q

Pleural fluid analysis (3 items always analyzed)

A
  1. Protein
  2. LDH
  3. Specific gravity (<1.015 = transudative)
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10
Q

MCC Exudative effusion

A

Malignancy

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11
Q

MCC Transudative effusion

A

CHF

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12
Q

Empyema definition and etiology

A

Infection of the pleural space causing a pus-filled pleural effusion

Etiology

  1. Complication of PNA where bac escape to pleural space
  2. Penetrating trauma
  3. Complication of surgery, thoracentesis, chest tube
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13
Q

Fluid analysis of empyema

A 
Grossly purulent fluid (pus-like) 
pH level <7.2
WBC >50,000 
Glucose <60mg/dL 
LDH > 1,000 IU/mL
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14
Q

Treatment empyema

A

DRAINAGE (thoracentesis) & ABX vs…

VATs thoracoscopy with tube drainage vs…

Clagett window (open drainage of empyema cavity)

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15
Q

Pathophysiology, etiology, treatmentof malignancy pleural effusion

A

BFTP: Malignancy = MCC exudative pleural effusion

Patho: CA = inc capillary permeability, disruption of capillary endothelium, impaired lymphatic drainage, direct invasion of pleural space by tumor & malnourishment (hypoalbuminemia)

Etio: Primary sites of MPE tumors - lung, lymphoma, breasts, ovary

Tx: Thoracentesis & tx of malignancy (radiation, chemo)

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16
Q

Tx options for repeat pleural effusions (2)

A
  1. Pleurodesis - artificially obliterate pleural space via chamical sclerosant (Talc, Doxy) or pleural abrasion (mechanical)
  2. Indwelling pleural catheters - small tube is inserted to drain fluid from around lungs - denver vs bard - pros = less pain, shorter hospital stay than pleurodesis
17
Q

Diagnosis of pleural effusion

A
  1. CXR - can see p. effusions >150 ml as blunting of the lateral costophrenic sulcus, 500 cc blunts the costophrenic angles on PA view (called the + menisci sign) - lateral
  2. CT - can detect v. sm effusions that can easily be missed by CXR
  3. Thoracentesis (GOLD STANDARD) - both therapeutic and diagnostic - done with all effusions of unknown causes
18
Q

PTX definition & mechanism

A

Presence of air or gas in the pleural cavity.

Air can enter thru a communication from the chest wall (trauma)

Or more commonly a communication thru the lung parenchyma across the visceral pleura

19
Q

Primary spontaneous pneumothorax

A

Occur in people WITHOUT underlying lung disease - caused by ruptured pulmonary blebs (congenital)

Occurs in pt ages 18-40 YO, male, tall, thin & smokers

20
Q

Secondary spontaneous pneumothorax

A

Secondary spontaneous pneumothorax occurs in patients WITH underlying lung disease

COPD = MCC, others = severe asthma, lung infections, CF, sarcoidosis, marfan’s, catamenial ptx (endometriosis in lung pleura)

21
Q

Traumatic pneumothorax

A

MC due to penetration of sharp bony points at a new rib fracture 2/2 trauma (blunt or penetrating)

Iatrogenic 2/2 central venous catheter placement, mechanical ventilation, biopsy of lung, thoracentesis

Turns into a tension pneumothorax commonly

22
Q

Tension pneumothorax etiology

A

Progressive build up of air within pleural space 2/2 lung laceration via trauma or iatrogenic cause

Air pushes mediastinum to the OPPOSITE side & obstructs venous return to the heart causing cardiac arrest

23
Q

Clinical presentation tension PTX (5)

A 
Tachycardia > 135
Hypotension
Chest pain 
Diaphoresis
Cyanotic
24
Q

PE Findings tension PTX

A

Deviation of trachea to contralateral side (CXR)

Hyper-expanded chest

Distended neck veins (venous return obstructed so backs up into jugular veins)

Absent breath sounds (chest cavity filled w/ air not lung tissue)

25
Q

Treatment tension pneumothorax

A

Needle decompression - 2nd intercostal space, mid-clavicular line right ABOVE the third rib (2nd interspace)

26
Q

Signs and symptoms of PTX

A

Symptoms:
SOB
Pleuritic chest pain
Shoulder pain

Signs:
Hyper-resonance to percussion (hollow air)
Decreased tactile fremitus
Decreased breath sounds

27
Q

Treatment small pneumothorax

A

(<10-15% decrease) - conservative management = observe for 6 hours, repeat CXR (make sure not increasing) & supplemental 100% oxygen (inc rate of resorption). Follow up in 24 hours - often spontaneous resolves w/in 10 days

Chest decompression via chest tube or pigtail catheter (if getting bigger & bigger (<30%) on serial CXR then we need to intervene

28
Q

Treatment recurrent PTX

A

Pleurodesis or surgery (VAT blebectomy)

29
Q

Foreign body aspiration epidemiology & MC items aspirated

A

80% of FBA occur in children < 3 TO - infants & toddlers aspirate on food items (nuts = MC) & older children aspirate on non-food items

30
Q

Most fatal foreign body aspirations

A

Marbles, toy balloons, rubber gloves (round, smooth, slipper surface = BAD)

31
Q

MC location FBA

A

Right main bronchus

32
Q

Symptoms of foreign body aspiration

A

Sudden onset wheezing or severe respiratory distress
Cyanosis
Change in mental status
Hoarseness, SOB, wheezing

33
Q

CXR FBA

A

Only helpful if object aspirated is radiopaque

Lower airway FBA causes hyperinflated lungs proximal to the FB, atelectasis (collapsed lung) distal to the FB, and later PNA (collapsed lung = nidus for bacterial infection)

34
Q

FBA treatment

A

Detailed clinical history and physical exam is the main determinant of whether bronchoscopy is needed

Rigid or flexible bronchoscopy is almost always successful in FB removal (95%)

35
Q

Pulmonary embolism definition & etiology

A

Thrombus in the pulmonary artery or its branches
Not a disease itself but a complication of a DVT (95% of PEs arise from DVTs in lower extremities above the knee (iliofemoral or pelvis) - other causes = fat emboli from long bone fracture or air emboli from central line

36
Q

History questions pulmonary embolism

A

VIrchow’s triad - ask about:

  1. Stasis (sedentary, long travel, recent surgery or hospital stay (immobilized in hospital bed)
  2. Hyper-coagulability (pregnancy, cancer, family hx)
  3. Endothelial trauma (surgery, trauma)
37
Q

Signs & symptoms PE

A

SOB, tachypnea, tachycardia, pleuritic chest pain

Also: Cough, hemoptysis, +homan’s sign (pain w/ dorsiflexion)

38
Q

Signs & symptoms of massive PE

A

Syncope, hypotension, PEA

39
Q

Diagnosis PE

A

CTA (pulmonary angiography) = GOLD STANDARD

Helical CT scan = best initial test for suspected PE (most sensitive for proximal emboli)

V/Q scan - may be used if CT scan is contraindicated (pregnancy, CrCl < 30)

DVT - 70% of pt w/ PE will be + for LE DVT - can miss pelvic DVTs - serial US may be performed to increase diagnostic specificity

Ancillary evaluation tests:
CXR is usually normal - can have pleural effusion, atelectasis or abrupt cutoff of vessels - classic but rare signs can have Westermark’s sign (avascularity distal to embolus) or Hampton’s hump (wedge-shaped infiltrate (represents infarction)

EKG: Sinus tach w/ NSSTTWC - S1Q3T3 = classic but rare (represents cor pulmonale/right heart strain)

ABG: Initial respiratory alkalosis 2/2

EORE Emergency Medicine (15 decks)

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