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Pulm by Minnie: AH Update > SM 172a - Pleural Diseases > Flashcards

SM 172a - Pleural Diseases Flashcards

1
Q

Which layer of pleura is thicker?

A

The visceral pleura is thicker than the parietal pleura

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2
Q

An exudative pleural effusion with low glucose on thoracentesis is most worrisome for…

A
  • Infection
  • Malignancy with metastasis to the pleura
  • Rheumatoid arthritis
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3
Q

A cardiogenic pleural infusion is [transudative/exudative]

A

A cardiogenic pleural infusion is transudative

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4
Q

How is pleural effusion diagnosed?

A

Bedside ultrasound

Confirms findings of chest x-ray and can guide safe drainage

(Chest x-ray may miss a pleural effusion)

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5
Q

What is the treatment for a plerual effusion?

A

THORACENTESIS

Drain if large and symptomatic or when infected

  • If transudative
    • Treat HF first, effusion will usually resolve on its own
  • If exudative
    • Additional testing is necessary
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6
Q

What is the treatment for pneumothorax?

A
  • Small pneumothorax
    • May go away on its own
  • Large pneumothorax (tension)
    • Emergent needle decompression
    • Chest tube drainage
    • May obliterate pleural space to prevent recurrence
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7
Q

An exudative pleural effusion with low pH on thoracentesis is most worrisome for…

A
  • Infection
  • Malignancy w/pleural metastasis
  • Esophageal perforation

Must place a CHEST TUBE if pH < 7.2

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8
Q

A patient with a pleural effusion has the following labs:

Pleural fluid LDH = 200 units/L

Serum LDH = 200 units/L

Lymphocytes = 80%

What are the most likely causes of the pleural effusion?

A

This is an exudative pleural effusion
Pleural LDH / Serum LDH = 1

Lymphocyte-predominance increases the liklihood of:

  • Autimmune disorder (ex: connective tissue diesease)
  • Cancer/malignancy
  • Tuberculosis
    • If >5% mesothelial cells, it is not TB
  • Fungal infection
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9
Q

How does parapneumonic effusion lead to plerual effusion?

A

A parapneumonic effusion is caused by inflammation

Inflammation -> increased permeabiltiy of capillaries and pleural lining, leading to fluid leakage into the pleural space

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10
Q

How can a pneumothorax lead to heart failure?

A

If the pneumothorax is closed, air will build up in the pleural space with every expiration

Intrapleural pressure becomes positive, and puts pressure on the right atirum

This impairs filling fo the heart, leading to circulatory collapse

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11
Q

Describe the presentation of a patient with a pleural effusion

A

Often asymptomatic and usually nonspecific if symptomatic

  • Nonproductive cough
  • Chest discomfort
    • Pain indicates inflammation of the parietal pleura
  • Dyspnea
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12
Q

What is an empyema?

A

Pus in the pleural space

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13
Q

What determines fluid flow in the pleural space?

A

Starling forces

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14
Q

A patient with a pleural effusion has the following labs:

Pleural fluid LDH = 200 units/L

Serum LDH = 200 units/L

Neutrophils = 80%

What is the most likely cause of the pleural effusion?

A

This is an exudative pleural effusion
Pleural LDH / Serum LDH = 1

Neutrophil-predominance increases the liklihood of infection (ex: bacterial pneumonia) as the cause of the pleural effusion

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15
Q

What is the function of pleural fluid?

A

Lubricates the pleural space, allowing for mechanical coupling of the lung, chest wall, and diaphragm

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16
Q

Where is microfilration pressure highest:

The parietal or visceral pleura?

A

The microfiltration pressure is higher in the parietal pleura - it drains into the systemic circulation

The visceral pleura drains into the lower-pressure pulmonary veins, so the microfiltration pressure is lower

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17
Q

What is the function of the parietal pleura?

A

Forms pleural fluid

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18
Q

How does congestive heart failure lead to pleural effusion?

A

Congestive HF increases microvascular hydrostatic pressure

More fluid will leak out of the microvasculature, leading to pleural effusion

19
Q

What is the pleura made from?

A

Collagen + Elastin, covered by a single layer of mesothelium

20
Q

What is the function of the visceral pleura?

A

The visceral pleura provides mechanical support for the lung

21
Q

An exudative pleural effusion with high lymphocytes on thoracentesis is most worrisome for…

A
  • Autimmune disease
    • Ex: connective tissue disease
  • Malignancy
  • Tuberculous infecion (MTB or NTM)
  • Fungal infection
22
Q

What are the 3 most common causes of transudative pleural effusions?

A
  1. Congestive heart failure -> Increased capillary hydrostatic P
  2. Liver cirrhosis -> Decreased capillary oncotic P
  3. Nephrotic syndrome -> Decreased capillary oncotic P
23
Q

LDH levels in the pleura correlate with…

A

Inflammation ino or near the pleural.

LDH in the pleural fluid is increased when the pleura is leaky or inflamed, such as in an exudative pleural effusion

24
Q

What are the characteristics of a primary, spontaneous pneumothorax?

A
  • No underlying lung pathology
  • No inciting event
  • Tends to occur in young, thin, tall patients
  • High recurrence rates
    • May obliterate pleural space to prevent
25
Q

What are the characterisitcs of a secondary spontaneous pneumothorax?

A

A spontaneous pneumothorax (no inciting event) in a patient with underlying lung disease

May be caused by anything that causes holes in the lung

  • Cystic lung disease
  • Infection
  • Malignancy
26
Q

An exudative pleural effusion with cholesterol > 45 mg/dL on thoracentesis is most worrisome for…

A

Chylothorax - cholesterol in the pleural space

27
Q

What is the function of the pleural space?

A

Reservoir for excess lung water

28
Q

Blood flow in the pleura comes from…

A

The systemic circulation

29
Q

What physical exam findings would be worrisome for tension pneumothorax?

A

Tracheal shift

30
Q

What lung diseases can predispose a patient to pneumothorax?

A

Anything that can cause holes in the lung

  • Cystic lung disease
    • Lymphangioleiomatosis
    • Cystic fibrosis
  • Infection
    • Cavitary pneumonia
  • Malignancy
31
Q

What are lymphatic stroma?

Which layer of pleura has them?

A

Lymphatic stroma are little vaccumes that drain pleural fluid from the tissue to the lymphatics

They are found in the parietal pleura but not the visceral pleura

32
Q

Blood supply to the parietal pleura drains into the
_________

A

Blood supply to the parietal pleura drains into the
systemic circulation

33
Q

Describe Light’s Criteria for classification of pleural effusion

A

An effusion is exudative if it meets any of these criteria

  • (Plerual fluid total protein) / (serum total protein) > 0.5
  • (Pleural fluid LDH) / (serum LDH) > 0.6
  • Pleural fluid LDH > 2/3 of the upper normal value of serum LDH

The concentration of protein in the pleural fluid is an estimate of the leakinesss of the pleural membrane to protein

More leaky = more protein in the effusion = exudative

34
Q

How does nephrotic syndrome lead to pleural effusion?

A

Nephrotic syndrome -> decreased microvascular oncotic pressure

Less force sucking fluid into the capillaries = more fluid leaking out into the pleural space

35
Q

In a patient with pleural effusion, what is the cause of the patient’s chest pain?

  1. Inflammed lung tissue
  2. Punctured visceral plerua
  3. Inflammed parietal pleura
  4. Hypoxia
A

d. Inflammed parietal pleura

Visceral pleura and lung tissue do not have sensory innervation

Hypoxia may cause pain, but not localized to the chest

36
Q

An exudative pleural effusion with high neutrophils on thoracentesis is most worrisome for…

A

Bacterial infection

37
Q

How can malignancy lead to pleural effusion?

A

A tumor an cause obstuction to lymphatic drainage.

This increased microcirculatory hydrostatic pressure, casuing fluid to filter into the interstitial space

38
Q

What is more dangerous:

An open pneumothorax or a closed pneumothorax?

Why?

A

Closed pneumothorax: Air gets trapped in the pleural space with every expiration, leading to tension pneumothorax

In an open pneumothorax (hole in the chest wall), expiration just pushes the air out

39
Q

How does a trapped lung lead to plerual effusion?

A

A trapped lung leads to decreased pleural space pressure

This decreases the hydrostatic pressur of the pleural space, and promotes fluid leakeage from the microvasculatrue into the pleural space

40
Q

What patient condition might cause a “false positive” for an exudative effusion, based on Light’s Criteria?

A

Heart failure treated with diuretics

Diuretics increase the protein content of the pleural effusion, even when the cause of the effusion is transudative

41
Q

What determines the subatmospheric pressure in the pleural space (PiP)?

A
  • Pleural surface pressure
    • The lung pulling in and the chest wall pulling out
  • Pleural liquid pressure
    • Pumping pressure of parietal pleura lymphatic stroma that suck liquid out of the pleural space
42
Q

Blood supply to the visceral pleura drains into the
​_________

A

Blood supply to the visceral pleura drains into the
​ low-pressure pulmonary veins

43
Q

In the most general sense, what causes pleural effusion?

A

Pleural effusion = fluid in the pleural space

Due to imbalance between
pleural fluid filtration and lymphatic clearance

44
Q

Describe the clinical presentation and physical exam findings of pneumothorax

A

Usually symptomatic

  • Pleuritic chest pain
  • Dyspnea
  • Cough
  • On the side with the pneumothorax
    • Increased volume
    • Hyperresonance to percussion
    • Decreased breath sounds
    • Increased fremitus

Pulm by Minnie: AH Update (34 decks)

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