Session 11 - Pneumothorax/ Effusions Flashcards
What is a pneumothorax?
When air gets between the visceral and parietal pleura of the lungs.
This can cause the lung to collapse.
Where can the air from a pneumothorax come from?
Most commonly the lung itself.
Through the chest wall (rare), e.g. trauma.
Or from both (rare), e.g. stabbing.
What are two iatrogenic causes of pneumothorax?
High pressure ventilation (air from lungs)
Insertion of Central venous line, or fine needle aspiration of breast (air through chest wall)
What is a primary pneumothorax?
Pneumothorax not caused by an injury (spontaneous)
Most commonly caused by a small subpleural bulla (air filled sac).
Which group are most at risk from primary pneumothorax?
Young, tall thin men.
Smoking increase risk x9.
What causes a secondary pneumothorax?
Underlying lung disease:
E.g. COPD, Asthma, Bronchiectasis with CF etc.
Secondary to trauma:
- Fractured rib (puncture visceral pleura)
- Blunt chest trauma.
Etc.
What is a tension pneumothorax?
Occurs when air can enter the pleura (via chest wall of visceral pleura) but cannot escape, because of a flap that closes on Expiration.
This acts like a one way valve.
What are the outcomes of a pneumothorax?
When pneumothorax is suspected it is life threatening.
If a stab wound or trauma, the valve where air is entering must be blocked (e.g. plastic bag, credit card etc) (in the field)
Eventually the lung affected will collapse, and will cause a shift of the oesophagus to the contralateral side.
The heart will also become compressed.
How is a tension pneumothorax treated?
Insertion of a plastic cannula (venflon) into the second intercostal space, in the midclavicular line.
Where is a chest drain for a pneumothorax placed?
5th Intercostal space, Mid axillary line. (against superior border of 6th rib, to avoid the neurovascular bundle)
How is a chest drain removed?
Removed whist the patient holds their breath at the end of expiration, when intrapulmonary pressure is lowest, meaning the risk of pneumothorax is lowest.
In general terms, are bilateral pleural effusions more likely due to exudates or transudates?
Most likely transudates, as these are usually cause by systemic causes (e.g. liver failure/ heart failure).
Exudate usually one sided, as exudates usually due to an infection e.g. pneumonia, where vessels become more permeable and proteins and immune cells escape.
What are the six cardinal symptoms of respiratory disease.
- Dyspnoea (breathlessness)
- Cough
- Chest pain
- Wheeze/ Stridor
- Sputum
- Haemoptysis
What is haemoptysis?
Coughing up blood or blood stained mucus (from respiratory tract)
What are some common causes of dyspnoea?
Asthma, COPD, Myocardial dysfunction (failure, infarction), Anaemia, Obesity, deconditioning.
Which conditions would cause instantaneous breathlessness?
Pulmonary Embolism
Pneumothorax
Which conditions would cause acute (minutes/hours) breathlessness?
- Asthma
- Pulmonary Embolism
- Pneumonia
- LVF/ MI
- Hyperventilation syndrome
Which conditions would cause gradual (days) breathlessness?
Lobar collapse (e.g. lung cancer) Pleural Effusion
What would cause chronic breathlessness?(months/years)
COPD
Idiopathic pulmonary fibrosis
Bronchiectasis.
What is bronchiectasis? When is it most common?
- Persistent chronic inflammation leading to loss of elastin in bronchi, which dilate.
- Mucous secretions into bronchi.
Most common in UK in CF patients.
What causes the cough reflex?
Reflex arc initiated by mechan- or chemo-receptors in the respiratory epithelium, oesophagus and diaphragm.
How is diagnosis of pericarditis isolated?
It is relieved by sitting forwards.
What are some common causes of chest pain?
- Cardiac (MI, Angina, pericarditis etc)
- Oesophageal pain
- Chest wall:
Costochondritis
Rib fracture etc - Pleuritic chest pain:
Viral/bacterial pleurisy
Pulmonary embolsim
Pneumothorax
What is a wheeze?
Noisy musical sound on expiration, most commonly caused by turbulent flow through narrowed airways.
(Asthma, COPD, etc)
What underlying physiology causes a wheeze?
Bronchial smooth muscle contraction, oedema, mucus production. (often describe: chest tightness in asthma)
What is the relevance of an absent wheeze during severe asthma attack?
Medical emergency!
No airflow, meaning patient is about to die without intervention.
Why is a wheeze an expiratory sound?
Due to positive intrapulmonary pressure on expiration, which exacerbates any narrowing of intrathoracic airways.
What is stridor? What causes it?
A course inspiratory wheeze.
Caused by extrathoracic upper airways obstruction.
(epiglottis, croup, diptheria, aspirated foreign bodies, extrinsic obstruction)
Why does stridor occur in inspiration?
Because the extra-thoracic airway normally narrows during inspiration due to negative intrathoracic pressure. This exacerbates a narrowing, causing the stridor sound.
When is more sputum than normal produced? What does green/yellow sputum show?
- Increased sputum volume is due to allergy, infection or bronchial irritants.
- Green/yellow is indicative of infection, e.g. pneumonia.
Which conditions commonly cause haemoptysis?
Commonly Infections.
- Pneumonia
- TB
- Bronchitis
Lung cancer, Pulmonary embolism, anticoagulation, LVF.
What is cyanosis?
Visible blue/ pruplish colouring to part of body.
Central cyanosis: At mouth/ tongue.
Peripheral: Fingers, hands, feet, nose, ears etc.
Caused by more than 50g/l of deoxygenated haemoglobin.
What are the causes of central cyanosis?
- Congenital cardiac disease with R>L shunt. Or severe heart failure.
- Severe respiratory diseases: COPD, severe pneumonia, severe bronchospasm (asthma).
What is the main cause of peripheral cyanosis?
Reynaud’s disease.
Cold exposure.
What is clubbing? What causes it?
Clubbing/ widening of finger tips (at distal phalanx), and flattening of nails.
Lung cancer - mesothelioma
Bronchiectasis (including CF)
Empyema
Idiopathic pulmonary fibrosis
What are some Accessory muscles of inspiration? When are the used?
Sternocleidomastoid
Scalene muscles
Used if inadeqaute pulmonary ventilation.
(advanced emphysema, severe asthma attack, stridor due to obstruction)
What are some Accessory muscles of expiration? When are they used?
Internal Intercostals
External/ internal oblique
Rectus abdominus
If insufficient elastic recoil of lungs can’t empty alveoli.
Or in an obstruction of airway.
(Emphysema, some chronic bronchitis, asthma)
What is purse lip breathing, and why is it used?
Breathing against pursed lips, and not taking a full breath out.
This means the alveoli do not fully empty, and the next breath is easier (La Place’s Law) due to diameter.
Often seen in COPD.
When is a barrel chest seen?
Signature sign of COPD.
Elastin loss in the lungs, allows less opposition to outward expansion of chest wall, so ribs expand more.
What causes tracheal deviation towards, or away from an affected lung?
Away: Tension pneumothorax, Large pleural effusion.
Towards: Lung/ lobar collapse, Pulmonary fibrosis.
What causes lung/lobar collapse?
Common following a bronchus obstruction.
The gas distal to the obstruction is reabsorbed by the lung parenchyma, causing the lung to collapse, with volume reduction.
Where do you auscultate/ percuss the Upper and middle lobes?
On the anterior surface of the chest.
Where do you auscultate/ percuss the Lower lobes?
On the posterior/ back.
Where will percussion sound dull on the anterior of the chest?
- Cardiac Dullness
- Dull at liver.
- Tympany at stomach (fuller, boxy sound, from stomach bubble)
- Dull over bone/muscle above ribs (e.g. at arms and near neck)
Where would percussion be dull on the posterior?
Over the Viscera - Liver, Stomach etc.
Over both scapulae.
What are normal breath sounds caused by?
Normal sounds from turbulent airflow through the respiratory system.
What are tracheal, bronchial, and vesicular breath sounds?
Normal Vesicular
- Long inspiration, short sound on expiration
Bronchial
- Much Louder, Longer expiration sound.
Tracheal
- Inspiration and Expiration sounds are equal in length.
What is consolidation?
Solidification of the lung tissue due to filling of the lungs with liquid and solid material.
The liquids replace air normally in the alveoli.
Most commonly caused by pneumonia.
Why are bronchial breath sounds heard over an area of consolidation?
Due to increased resonance through the consolidation (more solid), bronchial sounds travel better through the lungs and can be heard in the affected lobe.
What are some discontinuous abnormal breath sounds?
- Crackles
- Pleural friction rubs (pleurisy) (like leather rubbing)
Name the continuous abnormal breath sounds?
- Wheezes (musical high-pitched sound)
- Stridors
What are the different types of crackles heard? Why?
Coarse: loud, low pitched
- early/fine idiopathic pulmonary fibrosis, consolidation, LVF
Fine: Soft, high pitched sounds.
- early + coarse COPD, bronchiectasis (due to secretions, which may reduce after coughing)
What are the signs of pleural effusion?
Mediastinal shift: Normal, or away from effusion.
Chest wall movements: decreased
Percussion: Duller (most distinguishing sign)
Breath sounds: Softer
What are the signs of pneumothorax?
Mediastinal shift: No (without tension), Yes (with tension)
Chest wall movement: Normal or Reduced.
Percussion: More Resonant
Breath sounds: Decreased/ softer (distinguishing sign)
What are the signs of consolidation?
Mediastinal shift: NO Chest wall movement: Normal or < Percussion: Normal or < Breath sounds: Increase (bronchial) - defining! CRACKLES!
What are the signs of Lobar collapse?
Mediastinal Shift: YES (towards collapse)
Chest wall movement: LESS
Percussion: Duller
Breath sounds:
