Week 9 Resp Flashcards
Types of Pneumothorax
Spontaneous
Primary (PSP): no underlying lung disease
Secondary (SSP): underlying lung disease eg COPD or malignancy
Traumatic
Latrogenic: complication of a medical procedure
Penetrating trauma:
Risk Factors of Pneumothorax
PSP: most common 15-34
SSP: most common over 50
3-6x more likely for males
Risk factors: smoking, fam history, sub plueural blebs, underlying lung disease
Presenting symptoms and differentials for pneumothorax
Symptoms
Acute onset Dyspnoea
Chest pain (often pleuritic)
NB: intensity varies very much/ young may be very little pain
Differentials
PE, Pleuritis,MI, pericarditis, Musculoskeltal inflammation
Clinical Sings of Pneumothroax
Inspection: Chest wall trauma, work of breathing, use of accessory ,muscles
Trachea: sometimes deviated to opposite side
Chest expansion reduced on same (ipsilateral) side
Percussion: hyper-resonant
Auscultation: reduced or absent breath sounds
Pneumothroax investigations:
Blood tests:
- Inflammatory markers (WCC and CRP)
- Troponins (to check for MI)
- D-Dimer (shows PE)
ECG:
- Rule out MI and pericarditis
CXR:
- main tool
- Check for abscences f lung markings, visceral pleural line
- Tracheal deviation
CT
Tension Pneumothorax
One way valve effects results in intrapleural pressure, resulting in mediastinal shift, collapse of great vessels and ventricle —> cardiopulmonary compromise
Signs and symptoms:
-Dyspnoea, chest pain, tachypnoea, tachycardia, hypoxaemia, progressive hypertension, signs of pneumothorax )decreased BS and hyper res)
Managment of Tension Pneumothorax
Needs urgent decompression
Needle decompression in 2nd ICS mid claviclular
Or tube thortacosotmy
management for a small, asymptomatic primary spontaneous pneumothorax?
Observation and oxygen therapy. Small pneumothoraces may resolve on their own with supplemental oxygen to help reabsorption.
treatment for a large or symptomatic primary spontaneous pneumothorax
Needle aspiration or chest tube insertion to remove air from the pleural space and allow lung re-expansion.
When is surgical intervention considered for primary spontaneous pneumothorax
Surgical options, such as video-assisted thoracoscopic surgery (VATS), are considered after recurrent episodes or persistent air leaks despite chest tube drainage.
What is pleurodesis and when is it used
Pleurodesis is a procedure that causes the pleural layers to adhere, preventing future pneumothorax. It’s used after recurrent spontaneous pneumothorax or in patients with high risk of recurrence.
Talc, doxycycline, and sterile betadine are common agents used to induce pleural adhesion in pleurodesis
What factors increase the risk of recurrence of a pneumothorax
Smoking, underlying lung disease (e.g., COPD), and prior pneumothorax increase the risk of recurrence, making preventive strategies like pleurodesis more important.
Three mechanisms for fluid in pleural space (broad)
- Abnormal hydrostatic or osmotic forces (transudate)
Eg: increases hydrostatic due to fluid overload during HF - Increased permeability (exudate)
Eg: usually due to neoplasm or inflamation - Disruption of the fluid continuing structure within the pleural cavity
Eg: Blood vessels, oesophagus, thoracic duct
Common causes of Pleural effusion
Heart Faiure, malignancy, infection, post surgical, pericardial disease, liver cirrhosis
More common in adults
25% are idiopathic
Symptoms of Pleural effusion and signs
Symptoms
Dyspnoea (due to increased weight on diaphragm and increased work of breathing)
Cough
Chest pain (usually pluertic)
Signs
Clubbing
tar staining
Enlarged lymph nodes
Chest wall scares
Raised JVP
Maybe deviated trachea to opposite side
Reduced chest expansion
Stony dull percussion
Reduced or absent breath sounds
Investigations for pleural effusions
CXR, Thoracic ultrasound, CT scan
Also things to rule out others such as
WCC and CRP
Troponin
D-Dimer
ECG
Thoracentesis
aspiration of pleural fluid
1st line approach - drain 1-1.5L
Allows
-assessment of fluid eg cytology
-Gauge symptomatic benefits
-Help identify non expansive lung
Estimation of rate of re accumulation
Diagnostic evaluation of pleural effusion based on fluid
-clear low viscosity suggested transudate
-Frank bloody suggests malignancy, benign asbestosis, Post cardiac injury syndrome, pulmonary fraction, trauma, or thoracic endometriosis
-Milky fluid suggests infection, chyothorax, or cholesterol
-Putrid smelling suggestions infection
-Urine like suggests urinothorax
Pleural Infection Symptoms
Dyspnoea
Cough
Chest pain (often pleurtic)
Fevers/night sweats
Malaise
Investigations for Pleeural infection
Blood
Inflammatory markers WCC and CRP
Blood culture
imaging
CXR
Thoracic ultrasound
CT
Sampling of pleural fluid
Pleural infection management
Consists of two parts:
evacuate infected fluid
-Chest tube
-fibrinolytic
-mucolytic
-surgery
Eradicate infection
-Broad spectrum antibiotics
Malignant pleural effusion
Dyspnoea
Cough
Chest pain
+ ones related to cancer eg:
Anorexia
Weight loss
Fever
Thoracocentesis
Draining of pleural fluid
Pulmonary embolism Classifications
Provoked vs Unprovoked
Haemodynamically stable vs sub massive vs massive
Haemodynamically stable = normal blood pressure and heart rate
Sub massive= systolic BP above 90, but right ventricular dysfunction
Massive= sustained hypotension (below 90 for 15mins), needs ionotropic support, lack of pulse, sustains HR below 40
