Week 9 Respiratory Flashcards
define pneumothorax
gas/air in the pleural space that usually arises from a bronco-pleural fistula (hole in the broncho-pleural space) or chest wall trauma
what are the classifications of pneumothorax
Primary spontaneous (PSP)
Secondary spontaneous (SSP)
iatrogenic
penetrating trauma
what is primary spontaneous pneumothorax
pneumothorax with no underlying lung disease (more common ages 15-34)
what is secondary spontaneous pneumothorax
occurs with underlying lung disease (COPD/emphysema, infection, malignancy, CF, Cystic lung disease)
-most common in individuals >55 y/o
what is iatrogenic pneumothorax
complication from a medical procedure resulting in pneumothorax
what is penetrating trauma pneumothorax
trauma to the chest wall (injury) resulting in air entry at lungs
list the symptoms of spontaneous pneumothorax
-chest pain
-dyspnoea
-tachycardia
-hypoxia
-coughing
-fatigue & cyanosis
why does pneumothorax present with chest pain
air in the pleural space irritates the pleurae, causing sharp pain
why does pneumothorax present with dyspnoea
the collapsed lung reduces lung capacity, limiting oxygen in take
why does pneumothorax present with tachycardia
the heart pumps faster to compensate for reduced oxygen delivery
why does pneumothorax present with hypoxia
collapsed lung impairs gas exchange, lowering oxygen levels in the blood
why does pneumothorax present with cough
body reflexively trying to clear the airways
why does pneumothorax present with cyanosis and fatigue
low oxygen levels in the blood
what is tension pneumothorax
rare situation where a one-way valve effect results in progressive increase in intrapleural pressure, resulting in mediastinal shift, collapse of the great vessels and ventricle, ultimately leading to cardiopulmonary compromise
list the symptoms of tension pneumothorax
dyspnoea
chest pain
hypoxemia
tachycardia
tachypnoea
progressive hypotension
list the risk factors for pneumothorax
smoking
lung disease
sub pleural blebs
male
explain smoking as a risk factor for pneumothorax
airway inflammation damages lung tissue and weakens the alveoli, making them more susceptible to rupture and leakage into the pleural space
explain lung disease as a risk factor for pneumothorax
impairs lung function and makes it easier for air to escape into the pleural cavity
explain sub pleural blebs as a risk factor for pneumothorax
small, blister like formations on the lung’s surface, can rupture and release air into the pleural space, leading to pneumothorax
explain make sex as a risk factor for pneumothorax
males are 3-6x more likely to present with pneumothorax
what would the ‘inspection’ show for pneumothorax
-chest wall trauma due to injury
-increased work of breathing
-use of accessory muscles
what would be present on palpation in a pneumothorax patient
tracheal deviation, trachea may deviate to opposite side (common to also be at midline)
what would be present on chest expansion in pneumothorax patient
reduced ipsilateral chest expansion (same side as the pneumothorax)
what would be present on percussion in a pneumothorax patient
hyper resonant (extra air in the pleural space)
what would be present on auscultation in a patient with pneumothorax
reduced or absent breath sounds (muffled by excess air)
list the investigations for pneumothorax
vital signs
blood tests
ECG
CXR
CT
CXR for pneumothorax
key diagnostic tool, looking for if you are unable to trace lung markings to the lung borders
CT for pneumothorax
used as primary investigation, can determine underlain lung pathology for SSP
Management for primary pneumothorax
-typically self resolves
-simple aspiration
Management for secondary pneumothorax
-typically requires chest tube insertion due to underlying lung disease and greater risk of complications
whats pleurodesis
it uses agents to damage pleura (inflammation of mesothelial cells) leading to scar tissue, similar to how sealant hardens.
how to treat a tension pneumothorax
insert a large bore cannula into the 2nd ICS MCL
Define pleural effusion
abnormal or excess fluid in the pleural space
define empyema
prescience of pus in the pleural space eg pneumonia
define haemothorax
presence of blood in the pleural space eg chest wall trauma/injury
define chylothorax
presence of chyle in the pleural space eg thoracic duct trauma/inury
define urinothorax
presence of urine in the pleural space eg Gastrourinary trauma/injury
what are the causes of pleural effusion
-abnormal increased hydrostatic or decreased osmotic forces (transudate)
-increased permeability (exudate)
-disruption of fluid-containing structure
example of abnormal hydrostatic/osmotic force causing pleural effusion
increased hydrostatic force in HF
example of increased permeability causing pleural effusion
inflammation leading to pleural abnormality
example of disruption to fluid containing structure causing pleural effusion
thoracic duct, oesophageal and vessel injury
most common causes of transudative pleural effusion
HF
Liver cirrhosis
Nephrotic syndrome
most common causes of exudative pleural effusion
malignancy
infection
pericardial disease
list the forms of infective pleural effusions
parapneumonic
complex parapneumonic
empyema thoracis
what is parapneumonic infective pleural effusions
an accumulation of fluid in the pleural cavity that occurs alongside a lung infections, such as pneumonia, without direct bacterial invasion of the pleura
what is complex parapneumonic pleural effusion
a more severe form of para-pneumonic effusion, characterised by an increased amount of pleural fluid with a higher risk of complications, often requiring drainage or intervention
what is empyema thoracis infective pleural effusion
a purulent or infected pleural effusion where bacteria invade the pleural space, leading to the accumulation of pus in the pleural cavity, typically requiring drainage and antibiotic treatment
describe the mechanism for the development of malignant pleural effusion
primary cancer–>tumour growth–>enter lymph or blood–>pleural invasion–>implantation and growth–>inflammatory response–>increased vascular permeability–>Pleural effusion
what are the clinical presentations of pleural effusion (history)
dyspnoea
cough
chest pain
describe dyspnoea in pleural effusion
related to the mechanical effects on the diaphragm/chest wall and shunting
describe cough in pleural effusion
related to the mechanical effects on the airways
describe chest pain in pleural effusion
sharp pleuritic chest pain, related to parietal pleural inflammation or infiltration
list the clinical presentations upon exam for pleural effusion
HF signs
Infective signs
tracheal deviation
Chest expansion
Percussion
Auscultation
describe HF signs as a presentation in Pleural effusion
elevated JVP, clubbing, calf pain
describe infective signs as a presentation in Pleural effusion
enlarged lymph nodes, etc indicative of infections
describe tracheal deviation as a presentation in pleural effusion
trachea may deviate to opposite side in the instance of plural effusion
describe chest expansion as a presentation in pleural effusion
reduced on ipsilateral (same) side of the body
describe percussion as a presentation of pleural effusion
stony dullness due to reduced resonance of percussion over fluid medium
describe auscultation as a presentation of pleural effusion
reduced or absent breath sounds, may have bronchial breathing at lung-effusion interface
what are the investigations for pleural effusion
vital signs
inflammatory markers
troponin
d-dimer
ECG
CXR
Thoracic ultrasound
CT
why do vitals in pleural effusion
RR, HR, BP,SPO2, to determine presence of infection or underlying cause
why check inflammatory markers in pleural effusion
WCC and CRP to look for indications of inflammation or infection
why check troponin in pleural effusion
collection of serum troponin levels to look for MI
why check d dimer in pleural effusion
to rule out a pulmonary embolism
why check ECG in pleural effusion
to investigate MI or pericarditis
why check CXR in pleural effusion
key dx tool to determine effusion of pleura
why check thoracic ultrasound in Pleural effusion
key diagnostic test, not really available though
what are the options for surgery in managing pleural conditions
VATS: video assisted thoracoscopic surgery
Thoracotomy
pros of VATS for pleural diseases
less invasive
reduced post operative pain
less complex
pros of thoracotomy for pleural diseases
greater access
greater visibility of procedure
superior outcomes generally
treatments for pleural infection
-antibiotics if bacterial
-drainage of pleural fluid
-fibrinolytics
-mucolytics
describe antibiotic use for treating pleural infection
antibiotics are used to target and eliminate the underlying infection in pleural disease, playing a crucial role in controlling and eradicating the infectious microorganisms responsible for the condition
describe drainage of pleural fluid in treating pleural infection
effectively draining infected plural fluid bia thoracentesis or chest tube placement
describe fibrinolytic use in treating pleural infection
fibrinolytics, such as tissue plasminogen activator (tPA) help break down fibrin clots and adhesions in the pleural space, facilitating the drainage of infected pleural fluid and improving lung re-expansion
describe mucolytics use in treating pleural infection
mucolytics, such as DNase, are used to reduce the viscosity of thick and purulent pleural fluid, aiding in its removal and helping create a more conducive environment for other treatments in complex pleural infections
list the management for malignant pleural effusion
watch and wait
pleurodesis
VATS
IPC
describe watch and wait as a management for malignant pleural effusion
a conservative approach involving regular monitoring without immediate intervention for asymptomatic or minimally symptomatic malignant pleural effusion to assess disease progression
describe pleurodesis as management for malignant pleural effusion
a procedure to induce adhesion between layers of pleura, preventing further fluid accumulation in pleural space, often using substances like talc or doxycycline
describe VATS aș a management for malignant pleural effusion
minimally invasive surgical technique for diagnosing and treating malignant pleural effusion , including pleural biopsy, drainage and pleruodesis
describe IPC use as management for malignant plural effusion
long term drainage device inserted into the plural space to allow repeated drainage and management of malignant pleural
what are the benefits of large volume thoracentesis
-assessment of fluid chemistry and cytology (dx)
-symptom relief
-enables non expansive lung to be relieved
-enables rate of fluid re accumulation to ascertained
-leaves room for alternative approaches if cytology is inconclusive
what is lights criteria
used to classify pleural effusion
clear, low viscosity, straw coloured fluid in pleural effusion = what dx
suggests transudate
serosangiunous (blood) pleural effusion= what dx
none (indicates little bit of RBC)
frank bloody in pleural effusion = what dx
indicates malignancy (not all malignancy have frank bloody)
milky/turbid in pleural effusion = what dx
infection, chylothorax, cholesterol effusion
putrid smelling pus in pleural effusion = what dx
infection , likely from anaerobes
mechanism for pneumothorax
-fistula/puncture to chest wall
-pressure in the pleura exceeds the alveolar presure
-leading to air entry into the pleural space
-deflation of the lung (atelectasis)
mechanism for PE
-Virchow’s triad (hypercoagulations, venous stasis, vessel injury)
-blood clot develops in the deep veins of the legs
-clot dislodges and migrates into IVC–> RA->RV->lodges in pulmonary arteries
what are the classifications for PE
sub massive and massive
what is a sub massive PE
systolic BP>90 and right ventricular dysfunction
what is a PE
obstruction of a pulmonary artery, or a branch thereof, by a thrombus created elsewhere in the body
what is a massive PE
sustained hypotension, inotropic failure, pulselessness, sustained bradycardia
list the signs and symptoms of PE
Pleuritic chest pain
dyspnoea
haemoptysis
palpitations
unilateral oedema
dizziness
tachypnoea
hypoxia
hypotension
calf tenderness
describe pleurtic chest pain in PE
sharp chest pain worsened by deep breathing or coughing, often associated with pleurisy or pleural inflammation
describe dyspnoea in PE
SOB due to reduced oxygen exchange
describe hameoptysis in PE
coughing up blood or blood-tinged sputum, which can occur when PE damages lung tissue
describe palpitations in PE
irregular or rapid heart beats, due to strain on heart
describe unilateral oedema in PE
swelling in one limb, typically due to DVT in affected leg (which can lead to PE)
describe dizziness in PE
feeling lightheaded or unsteady, due to reduced O2 supply to brain
describe tachypnoea in PE
rapid breathing as body attempt to compensate for decreased O2 levels
describe hypoxia in PE
inadequate oxygen in body tissues, serious consequence in PE that leads to oxygen deficiency
describe hypotension in PE
low BP in serious PE, which can indicate haemodynamic compromise
describe calf tenderness in PE
pain and tenderness in calf, often indicates DVT (risk factor for PE)
list the risk factors for PE
inherited conditions
recent surgery
immobilisation
smoking
describe inherited conditions as a risk factor for PE
genetic clotting disorders such as Factor V Leiden deficiency make you higher risk
describe recent surgery as a risk factor for PE
increased likelihood of inflammatory mediators in bloodstream post surgery
describe immobilisations as a risk factor for PE
leads to blood stasis forming within the vasculature
describe smoking as a risk factor for PE
introduces toxin into the body–> eliciting vessel damage
what are the cardiopulmonary effects of PE
-occlusion of pulmonary artery leading
-increased RV afterload
-increased RV pressure due to tricuspid regurgitation
-reduced RV contractility and RV SV
-reduced LV preload
-reduced CO and SBP
-reduced coronary perfusion
-RV ischaemia
list the investigations for PE
CBE, EUC, troponin
ECG
CTPA
VQ scan
Echo
D-dimer
describe CBE,EUC, troponin use in dx PE
provides assessment of bloods for checking haemodynamic state
describe ECG use in dx PE
enables detection of changes in heart rhythm or signs of RV strain often seen in PE
describe CTPA use in dx PE
high res CT that visualises PA, allows for definitive dx of PE and severity of PE
describe VQ scan use in dx PE
compares ventilation and perfusion, highlighting areas where airflow and blood flow don’t match (indicating PE)
describe echo use in dx PE
looking for signs of RV strain or S1Q3T3 (large S wave (1), Q wave (3), inverted T (3))
Q and T on lead III
describe D dimer use in dx PE
blood test to measure breakdown product of blood clots, used to rule out PE if negative and prompt further investigation if positive
list the factors of well criteria and their worth
-Clinical signs and symptoms of DVT (3)
-PE most likely dx (3)
-Tachycardic (1.5)
-immobilisation for at least 3 days or recent surgery 4 weeks (1.5)
-previous DVT or PE (1.5)
-haemeoptysis (1)
-malignancy treatment within six moths or palliative care (1)
what is wells criteria
tool used to dx PE
-score of 4.0 warrants further testing
list the management for PE
Anticoagulation
thrombolysis
analgesia
describe anticoagulation for managing PE
administration of blood thinning meds to prevent formation of blood clots in PE
describe thrombolysis for managing PE
use of clot dissolving drugs to rapidly break down existing blood clots in sever or life threatening pulmonary embolism
describe analgesia for managing PE
pain relief medications to manage pleuritic chest pain, a common symptom of PE
list the clinical signs and symptoms of pulmonary HTN
dyspnoea
fatigue
exertion intolerance
weakness
anginal chest pain
syncope
describe dyspnoea as a sign of pulmonary HTN
increased pressure in the pulmonary arteries makes it harder for blood to pass through the lungs, reducing oxygen exchange. The heart struggles to pump effectively, causing shortness of breath, especially during exertion.
describe fatigue aș a sign of pulmonary HTN
As the right side of the heart works harder to pump blood against the high resistance in the pulmonary arteries, the body receives less oxygenated blood, leading to fatigue and muscle weakness
describe exertion intolerance as a sign of pulmonary HTN
Reduced cardiac output during physical activity leads to a mismatch between oxygen supply and demand, causing early fatigue and breathlessness with minimal exertion.
describe anginal chest pain in pulmonary HTN
The increased workload on the right ventricle (RV) leads to RV hypertrophy, and eventually, the demand for oxygen by the heart muscle surpasses supply, leading to chest pain, much like angina in coronary artery disease
describe syncope in pulmonary HTN
With severe pulmonary hypertension, the heart may not pump enough blood to meet the body’s demands, especially during exertion. This can cause a temporary drop in blood flow to the brain, leading to fainting (syncope)
what is pulmonary HTN
pulmonary hypertension is a condition where elevated pressure in the pulmonary arteries leads to right heart strain and reduced oxygenation
identify the common causes of pulmonary HTN
idiopathic (primary)
drug induced
heritable
portal HTN
what is portal HTN
elevated BP within the portal vein system, can lead to pulmonary HTN die to increased blood flow and pressure in lungs
list the investigations for pulmonary HTN
ECG
echocardiography
V/Q scan
chest CT
PFT’s
describe the use of ECG in pulmonary HTN
helps assess heart rhythm and identify signs of right heart strain, which can be indicative of pulmonary HTN
describe the use of V/Q scan in pulmonary HTN
detects V/Q mismatch to identify PE, which is a potential cause of pulmonary HTN
describe the use of echo in pulmonary HTN
evaluation of cardiac structure and function , including right ventricular size and function
describe the use of chest CT in pulmonary HTN
enables identification of PE, vascular changes, and lung abnormalities associated with pulmonary HTN
describe the use of PFT’s in pulmonary HTN
measures lung function parameters, admin assessment of lung condition that can contribute to pulmonary HTN
identify the management for pulmonary HTN
lifestyle modifications
anticoagulants
oxygen
supportive care
describe lifestyle modification as management for pulmonary HTN
encourage patients to adopt heart healthy lifestyle, exercise, low salt, smoking cessation
describe anticoagulants as management for pulmonary HTN
for pt at risk of blood clots, especially in cases of chronic thromboembolic pulmonary HTN
describe oxygen therapy as management for pulmonary HTN
can help alleviate hypoxia and improve exercise capacity in pt with low levels of oxygen
describe supportive care as a management for pulmonary HTN
-procedures like pulmonary thromboendarterectomy may be indicated to remove chronic thromboembolic obstruction
-lung or heart-lung transplants also an option
what classifies as exudative according to lights criteria
-fluid protein/serum troponin >0.5
-fluid LDH/Serum LDH > 0.6
*>2/3 of upper limit of normal serum LDH
what classifies as transudative according to lights criteria
-fluid protein/serum troponin <0.5
-fluid LDH/Serum LDH < 0.6
*<2/3 of upper limit of normal serum LDH
mechanism for transudative PE
-decreased oncotic pressure eg liver cirrhosis or increased hydrostatic pressures eg HF
-increased fluid diffusion into lung and pleural interstitial
-lymph drainage is overwhelmed
-fluid escapes into pleural cavity
-transudative PE
mechanism for malignancy exudative PE
-malignancy produces proteases that increase blood vessel permeability
-angiogenesis to keep up with cell proliferation
-formation of incomplete capillaries increases permeability
-increased permeability of pleura
-increased fluid entering the pleural cavity
mechanism for infective exudative PE
-inflammation response increases blood vessel permeability
-inflammatory mediators bring more WBC’s to the site of infection
-increases permeability of pleura
-fluid enters the pleural cavity
