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Medicine I > Respiratory Pleural Space Disease > Flashcards

Respiratory Pleural Space Disease Flashcards

1
Q

What types of tissues does the pleura contain?

A
  • Mesothelial cells
  • Elastic fibers
  • Smooth muscle fibers
  • Lymphatics, arteries, veins, and capilaries
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2
Q

What is the Basic physiology of the pleural space?

A
  • Starling’s Laws
    • Fluid leaves from systemic circulation, crosses the parietal pleura into the pleural space
    • Reabsorbed by visceral pleura
      • pulmonic circulation-venous caps
    • Parietal pleura lymphatics also reabsorb fluid
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3
Q

How do pleural effusions occur?

A
  • Increased Capillary Pressure (hydrostatic)
    • High pressure from heart failure or venous obstruction
  • Decreased Plasma Proteins (oncotic)
    • Liver disease, Protein loss (Kidney/GI), cutaneous loss, severe malnutrition
  • Increased Capillary Permeability (leakage)
    • sepsis, neoplasia, infections, immune-mediated diseases
  • Blockage of Lymph Return (obstruction)
    • True obstruction (neoplasia, granuloma, thrombus, heartworms)
    • Relative/Functional (right heart failure or increased lymph production)
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4
Q

What are the types of Pleural Space Disease?

A
  • Pneumothorax - air in pleural space
  • Pleural effusion - fluid in pleural space
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5
Q

What are causes of Pneumothorax?

A
  • Trauma
    • closed-blunt trauma (lung leaking)
    • Open-penetrating trauma (external environment air)
    • Tension Pneumothorax
      • the ‘hole’ acts as a one-way valve, allowing air to enter on inspiration but not leave on expiration
      • Shifts hear and vessels resulting in compression, shock, and hypoxia
  • Spontaneous
    • Abscess, bullae, neoplasia, foreign body, parasites
  • Iatrogenic
    • Lung aspirate, chest tube placement, anesthesia, ventilation
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6
Q

What is the pathophysiology of a pneumothorax?

A
  • Air/fluid in pleural space causes lung collapse (atelectasis)
    • ⇣ Tidal volume
    • Hypoxemia
    • ⇡ respiratory rate
  • ⇡ pressure in pleural space cause ⇣ venous return to the heart
    • ⇡HR to maintain cardiac output
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7
Q

What are the clinical signs of penumothorax?

A
  • Variable respiratory distress
    • Tachypnea, dyspnea, cyanosis, abdominal breathing
  • Decreased lung sounds
    • Initially decreased in dorsal fields
    • As more air leaks in, sounds decrease everywhere
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8
Q

What is a Bulla?

A
  • “Bleb”
  • Air-filled spaces in the lung parenchyma due to rupture of alveolar walls
  • More in large, deep-chested dogs
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9
Q

What is the treatment for pneumothorax?

A
  • Oxygen and Low stress
  • Thoracocentesis
    • Repeat radiographs to look for underlying disease
  • Repeat thoracocentesis if air returns and dyspneic
    • consider chest tubes w/ recurrent air buildup (3Taps then tube)
  • If traumatic provide analgesia and address other injuries
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10
Q

What are the indications for a thoracocentesis?

A
  • Diagnostic
  • Therapeutic
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11
Q

How is a thoracocentesis performed? What equipment is used?

A
  1. Clip and scrub 6-8th intercostal space
    1. Xray/US to pick best one
    2. Ventral for fluid
    3. Dorsal for air
  2. Patient in sternal recumbency
  3. Insert needle cranial to rib
  4. Remove as much air/fluid as possible
    • Purple/Red top tubes for Dx
  5. Repeat on other side as needed
  • Sterile gloves, clipper, prep
  • Butterfly/needle/catheter
  • Extension set
  • 3-way stop cock
  • 60ml syringe
  • Bowl for fluid, Red and Purple top tube
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12
Q

What are the complications that can occur with a thoracocentesis?

A
  • Lung laceration and pneumothorax
  • hemorrhage
  • cardiac irritation/arrhythmia
  • introduce infection
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13
Q

What are the indications of chest tubes?

A

When air/fluid continues to build up despite repeated taps

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14
Q

When should a chest tube be removed?

A

When <2-3ml/kg fluid in 24 hrs

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15
Q

What are the different types of effusions?

A
  • Exudate
  • Chylus
  • Transudate
  • Hemorrhagic
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16
Q

What is exudative fluid?

A
  • Cloudy fluid, color varies
  • Septic or nonseptic
  • High cellularity
    • mostly neutrophils and macrophages
    • look for intracellular bacteria
    • look for neoplastic cells
  • Caused by:
    • infection
    • neoplasia
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17
Q

What is Chylus effusion?

A
  • Chylus fluid
    • Milky color from chylomicrons
    • moderate cellularity
    • Many small lymphocytes
    • Triglycerides in fluid:serum is 2-3:1
    • Chylous effusion TG > 100mg/dL
  • Causes:
    • Cardiomyopathy
    • Lymphatic obstruction
    • Heartworm disease
    • Idiopathic
18
Q

What is Transudate effusion?

A
  • Pure:
    • Clear or straw-colored
    • low cellularity
    • from low oncotic pressure
    • hypoalbunemia
      • liver failure, Renal or GI loss
  • Modified
    • Moderate cellularity
    • from high hydrostatic pressure
    • Normal albumin
    • Right CHF, Neoplasia
19
Q

What are hemorrhagic effusions?

A
  • Hemorrhagic: bloody but low PCV
  • Hemothorax: high PCV, almost the same as peripheral blood
  • Often see erythrophagocytosis
  • Causes:
    • Coagulopathies
    • Neoplasia
    • Trauma
    • Lung lobe torsions
20
Q

What is the pathophysiology of a pyothorax?

A
  • Bacterial entrance:
    • through perforated respiratory tract or esophagus
      • inhaled grass awn/foreign body
    • Through chest wall - penetrative wounds
    • Local (lung abscess) or hematogenous spread
  • Inflammation increases vascular permeability
    • Proteins leak out of vessels
      • increases oncotic pull in pleural space, more fluid follows
    • Pleura thicken and clog so can’t reabsorb fluid
21
Q

What are the treatment options for pyothorax?

A
  • Medical Management
    • ICU car and chest tube for drainage and lavage
    • IV fluids and antibiotic therapy
      • cytology to help chose pending culture and susceptibility
  • Surgical management
    • Indications for exploratory thoracotomy
      • Suspect foreign body
      • no improvement with medical management in 2-3 days
22
Q

What type of fluid is seen in Feline Infectious Peritonitis (FIP)

A
  • Non-septic exudate
    • High protein count, lower cellularity
    • Mostly non-degenerate neutrophils and macrophages
23
Q

How is FIP diagnosed?

A
  • Submit effusion for immunocytochemistry or PCR
  • limitations of coronavirus serology (IFA)
24
Q

What are the common neoplastic effusions?

A
  • Lymphoma
  • Mesothelioma
  • Carcinomatosis
  • Metastatic neoplasia
  • Thymoma
  • Primary lung tumor
  • Can be exudative, transudate, chylous or hemorrhagic
25
Q

how are Neoplastic effusions diagnosed

A
  • Cats with mediastinal lymphoma and effusion
    • decreased compressibility of cranial thorax on exam
    • can aspirate mass/node with ultrasound guidance
  • Radiographs, thoracic ultrasound, CT/MRI
  • Cytology of pleural fluid
  • Ultrasound-guided aspirates when possible
  • Thoracoscopy or thoracotomy
    • biopsy the pleura and lungs
26
Q

What is the treatment for neoplastic effusions?

A
  • chemotherapy +/- surgery
    • consult oncologist
27
Q

What is the common signalment of Chylothorax patients?

A
  • More cats than dogs - any breed
  • Dogs- Afgans (middle age) & Shiba Inus (<1yo)
  • Cats- Siamese and Himalayan (older)
28
Q

What are the clinical signs of chylothorax?

A
  • Coughing and dyspnea
  • Can be slow onset over months
29
Q

What causes Chylothorax?

A
  • Mediastinal lymphoma
  • Cardiomyopathy
  • Pericardial disease
  • Heartworm disease
  • Fungal granuloma
  • Lung lobe torsion
  • Cranial vena cava thrombus
  • Lymphangiectasia
  • Idiopathic
30
Q

How is Chylothorax diagnosed?

A
  • Fluid Analysis and Cytology
    • Purple top EDTA tube
    • Color varies with fat content and degree of hemorrhage (white to pink)
    • small lymphocytes or neutrophils
  • Compare triglycerides in fluid:serum
    • Red top tube
    • Chylous effusion will have 2-3x more triglycerides than serum
    • Chylous effusion should have triglycerides >100mg/dL
  • Test for heartworm disease
    • antigen for dogs
    • antigen and antibody for cats
  • Echocardiogram
  • Thoracic Ultrasound
    • helps find mediastinal mass, lymphadenomegaly
    • Aspirate if possible
31
Q

What is the treatment for chylothorax

A
  • Minimize stress and address primary cause if identified
  • If idiopathic:
    • Thoracocentesis as needed
      • Chest tubes usually not needed
    • Low fat diet (⇣ fat in effusion, improves reabsorption)
    • Rutin 50-100mg/kg PO TID
      • MOA theories: reduces buildup of fluid, improves lymphatic drainage, recruits and stimulates macrophage phagocytosis of chyle
  • Surgical options:
    • If known trauma
    • If idiopathic and unmanageable medically
      • Over time fibrin causes pockets of fluid, challenge to drain
      • If tapping more than once weekly
      • If tapping does not resolve dyspnea
    • Multiple surgical procedures in combo:
      • thoracic duct ligation with partial pericardiectomy is an option
      • Recommend consultation or referral to a boarded surgeon
32
Q

What are transudates?

A
  • Low protein, low to moderate cellularity fluid
  • Most macrophages and mesothelial cells, some neutrophils
    • look carefully for neoplastic cells
33
Q

What causes Pure transudates?

A
  • Decreased Oncotic Pressure (hypoproteinemia)
    • Protein losing enteropathy
    • protein losing nephropathy
    • liver failure
34
Q

What causes modified transudates?

A
  • ⇡ Hydrostatic Pressure
    • congestive heart failure, thromboembolic disease, neoplasia
  • Neoplastic Effusions
    • Mesothelioma, lymphoma, thymoma, carcinomatosis
  • Vasculitis
    • Infection (sepsis, rickettsial, leptospirosis….)
    • Immune (lupus, bee stings, snake bites)
    • Other inflammatory (pancreatitis)
35
Q

How are transudates diagnosed?

A
  • Good history and physical exam
  • Minimum Database
    • CBC- inflammatory (maybe)
    • Chemistry- normal albumin concentration ≠ oncotic problem
      • low albumin look for liver, GI, or kidney disease
    • UA- proteinuria (maybe)
  • Radiographs post-thoracocentesis +/- thoracic ultrasound
  • Rule out heart disease with echocardiogram
  • Abdominal ultrasound may be helpful
    • Assess liver, pancreas, GI, Kidneys, nodes, look for masses
  • If not hydrostatic or oncotic, then is vasculitis the cause?
    • consider infectious, immune disease
      • tick titers (RMSF), ANA, Fundic exam
  • Is primary GI causing low protein and fluid buildup?
    • can be bicavity effusion
    • Requires GI biopsies
36
Q

What is the treatment for transudates?

A
  • Minimize stress
  • Provide oxygen when needed
  • Thoracocentesis as needed
  • Tailor treatment to specific underlying disease
37
Q

What are the differentials for Hemothorax/hemorrhagic effusion?

A
  • Trauma
  • Malignancy
  • Coagulopathy
  • Lung lobe torsion
  • Heartworm disease
  • Pulmonary Infarct
  • pulmonary abscess
  • Recent surgery
38
Q

How is hemothorax/hemorrhagic effusion diagnosed?

A
  • Thoracocentesis - avoid if suspected coagulopathy
  • Tests may include:
    • clotting test
    • thoracic radiographs
    • ultrasound
    • CT
    • heartworm
39
Q

What is the treatment for hemothorax/hemorrhagic effusion?

A
  • Minor bleeding should reabsorb
  • Severe cases may need thoracocentesis and transfusion
  • Treat any identified underlying disease
  • Ongoing bleeding might require surgical exploratory
40
Q

How is Anticoagulant Rodenticide Toxicity diagnosed and treated?

A
  • Dx based on history and ⇡ coagulation times
    • PT will be elevated first
    • can test for rodenticide to confirm
  • Treatment
    • induce emesis w/in 2-3hrs of ingestion
    • Vit K1 supplementation for 4 weeks
    • Remove exposure
    • keep safe from trauma
    • Monitor respirations
40
Q

How is Anticoagulant Rodenticide Toxicity diagnosed and treated?

A
  • Dx based on history and ⇡ coagulation times
    • PT will be elevated first
    • can test for rodenticide to confirm
  • Treatment
    • induce emesis w/in 2-3hrs of ingestion
    • Vit K1 supplementation for 4 weeks
    • Remove exposure
    • keep safe from trauma
    • Monitor respirations

Medicine I (43 decks)

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