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Pulmonary > Pleural Effusion and Pneumothorax > Flashcards

Pleural Effusion and Pneumothorax Flashcards

1
Q

What does the visceral pleura cover?

A

surface of lungs and interlobar fissures

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2
Q

What does the parietal pleura cover?

A

surface of chest wall
diaphragm
mediastinum

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3
Q

How are the surfaces of the visceral and parietal pleura different?

A

visceral: the mesothelial cells are loosely arranged but have very tight junctions (bumpy) and they have very dense microvilli
parietal: the mesothelial cells are very tightly arranged but have leaky tight junctions with very sparse microvilli

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4
Q

Describe are the components of the pleura?

A

mesothelial cells, BM, CT with blood vessels, lymphatics, and nerves

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5
Q

Describe the normal pleural fluid.

A

Clear, odorless with mostly macrophages (some lymphocytes and few polys)
Its function is to lubricate the pleural surface

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6
Q

What determines the amount of pleural fluid formed?

A

HP and OP balance
tissue pressure
lymphatic drainage

F = K (HPc-HPpl) - (OPc-OPpl)

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7
Q

Describe how the normal movement of pleural fluid and (include how much in ml/hr)

A

HP in the parietal pleura > HP in visceral pleura
(HP systemic circulation > HP pulmonary circulation)

this HP gradient drives the movement of fluid from the parietal layer into the pleural space thru mesothelial junctions. The fluid is them absorbed by the visceral pleura
**the oncotic pressure of the parietal and the visceral pleura are = and therefore does not oppose the HP gradient

100 ml/hr fluid formed –> 300 ml/hr fluid absorbed

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8
Q

Lymphatic drainage is present in (parietal or visceral pleura). * Why is this significant???

A

parietal
To transport cells and protein out of the parietal pleura to maintain low OP and maintain the balance so that fluid moves parietal –> space –> viceral ???? not sure she never really explained this, it is just my reasoning….

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9
Q

What are the 2 types of pleural effusions?

A

exudates and transudates

high pro and low pro

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10
Q

Increased HP will form (transudate or exudate)

A

trans

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11
Q

decreased pleural pressure will form (transudate or exudate)

A

trans

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12
Q

decreased oncotic pressure will form (transudate or exudate)

A

trans

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13
Q

increased oncotic pressure will form (transudate or exudate)

A

exudate

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14
Q

CHF will form (transudate or exudate). Why?

A

transudate bc the pulmonary artery HP > OP which causes the visceral pleura to shift from fluid absorption to fluid production

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15
Q

What are addnl characteristics of pleural effusion due to CHF

A

bilateral + cardiomegaly

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16
Q

How can malnutrition lead to a pleural effusion?

transudate or exudate

A

the decrease in plasma OP causes fluid to shift out of capillaries and into the pleural space from both the parietal and visceral sides
*transudate

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17
Q

How can atelectasis cause pleural effusion?

transudate or exudate

A

the collapse makes the pleural pressure more negative –> causes the HP gradient to become > OP gradient –> fluid formation from both sides
*transudate

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18
Q

How does inflammation cause pleural effusion?

transudate or exudate

A

inflammation increases vascular permeability –> leakage –> OP gradient decreases –> fluid moves into pleural space from both sides
*Exudate

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19
Q

With a large pleural effusion:
RR (inc or dec)
Chest expansion (inc or dec)
fremitus (inc or dec)

A

RR increases
Chest expansion decreases
fremitus decreases

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20
Q

What type of effusion will an increase in permeability lead to?

A

exudative

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21
Q

Why are diminished or absent breath sounds a sign on pleural effusion?

A

the lung is farther ways from the chest wall

**i thought liquid transmitted sound waves better then air though..?

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22
Q

What is the most common eitiology of pleural effusion?

A

CHF

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23
Q

What is the most common noncardiac etiology of pleural effusion? 2nd most common?

A
  1. neoplastic

2. infectous

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24
Q

What types of neoplasms most commonly cause effusions? Why?

A

lung and breast

*close proximity to pleura

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25
Q

What are the 2 forces that control the arrangement of free fluid in the pleural space?

A
  1. gravity

2. elastic recoil of lung (aka how much it relaxes during expiration)

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26
Q

What is the first radiologic sign of pleural effusion? Later/when it gets bigger?

A
  1. blunting of costophrenic angle

2. meniscus sign

27
Q

What is the purpose of obtaining a lateral decubitus film?

A

once you suspect an effusion from an AP or PA CXR you can look at a lateral decubitus film to see if the fluid moves with gravity doue to the change in position = proves it is a fluid

28
Q

If you see evidence of an effusion + an infiltrate, you might suspect …

A

parapneumonic effusion

29
Q

If you see evidence of an effusion + a mass or nodule, you might suspect …

A

carconoma of the lung
lymphoma
mesothelioma metastatic carcinome

30
Q

If you see evidence of an effusion + a wedge shaped infarct, you might suspect …

A

PE

31
Q

If you see evidence of an effusion + cardiomegaly, you might suspect …

A

CHF

32
Q

If you see a pleural effusion without any other radiologic abnormalities what diseases might you suspect?

A 
TB or viral pleurisy
pancreatitis 
Lupus or RA
PE
Low albumin = Nephrotic syndrome or chirrosis
33
Q

What is the indication for performing a thoracentesis?

A

> 10 mm on lateral decubitus XR

34
Q

What does a reddish tinged to bloody pleural fluid sample suggest?

A

if not traumatic tap..

  • tumor
  • pulmonary infarction
  • trauma
  • post cardiac syndrome
  • asbestosis

**due to RBCs in sample

35
Q

What does a turbid/cloudy pleural fluid sample suggest?

A

infection (including TB)

36
Q

What does a turbid/cloudy green pleural fluid sample suggest?

A

rheumatoid pleuritis

37
Q

What does a cloudy, milky white pleural fluid sample suggest?

A

Chylothorax

= disruption of thoracic duct from trauma or tumor

38
Q

What is an empyema?

A

puss is the pleural effusion

39
Q

What does a thick, bloody effusion sample suggest?

A

malignant mesothelioma

40
Q

What is a chylothorax

A

milky white pleural effusion = collection of lymphatic fluid
*usually due to trauma to the thoracic duct

41
Q

What are lights criteria for distinguishing between transudate and exudate?

A

one ore more of the following:

  1. Pleural/serum protein ratio:
    transudate: 0.5
    1. Pleural/serum LDH ratio:
      transudate: 0.6
  3. Pleural LDH
    transudate: 200 U/L
42
Q

What are the most common causes of transudative pleural effusions?

A

CHF, Nephrotic syndroms, cirrhosis w/ ascites

43
Q

What are the most common causes of exudative pleural effusions?

A

parapneumonia effusion
malignancy (bilateral)
PE
collagen vascular disease (lupus, RA, scleroderma) (bilateral)
pancreatitis (usually left sided)
TB
postcardiac injury syndrome (=pericarditis, so inflammation just spills over?)

44
Q

WHat are common causes of BILATERAL Effusions

A

malignacy
lupus, RA
nephrotic syndrome, cirrhosis w/ascities
esophageal rupture

45
Q

What does a lot of lymphocytes in an pleural effusion make you think?

A

exudate + chronic inflammation + TB, Malignancy, sarcoid, RA

46
Q

What does a lot of neutrophils in an pleural effusion make you think?

What about >50K/microL of neutrophils?

A

exudate + acute inflammation + paraneumonic, pancreatitis, or pulmonary infarction

paraneumonic

47
Q

What is the definitive diagnosis if you find ___ in the thoracentesis sample?

  • ADA
  • KOH
  • high triglycerides (>110)
  • high amylase and pH 6
  • Hct PF/blood >/= 0.5
A 
ADA = TB
KOH = funcgus
high triglycerides (>110) = chylothorax
high amylase and pH 6 = esophageal rupture
-Hct PF/blood >/= 0.5 = hemothorax
48
Q

What does >5% mesothial cells in thoracentesis sample mean?

A

it is NOT TB

49
Q

How do you identify wether or not the effusion sample is from a traumatic thoracentesis or is actually blood that has been there due to an underlying condition?

A

if the sample is allowed to sit and it clots within minutes, it is fresh blood = traumatic thoracentesis

50
Q

What does low glucose in pleural fluid sample suggest? (<60 mg/dl)

A

rheumatoid pleurisy (RA) due to dec transport of glc from blood to fluid

epmyema or TB due to increased utilization/consumption of glc

51
Q

What is the mechanism of pleural fluid acidosis?

A
  1. acid production by pleural fluid cells or bacteria
  2. acid efflux from pleuritis or fibrosis (RA or malignancy)

**think esophageal rupture, infection, RA

52
Q

What does a pleural fluid amylase/serum amylase >/= 1 suggest?

A

acute pancreatitis
pancreatic pseudocyts
**if amylase is salivary in origin = esophageal rupture

53
Q

How is an effusion due to a ruptured ectopic pregnancy unique?

A

pleural fluid amylase/serum amylase >/= 1 suggest

54
Q

T or F: a negative AFB rules out TB

A

false

55
Q

What is the pathophys of a pneumothorax?

A

pleural is breached –> air enters pleural space (Patm >Pps) –> lung collapses inward towards mediastinum

56
Q

What is the difference between primary and secondary pneumothorax?

A 
primary = NO clinical lung disease present
secondary = underlying clinical lung disease
57
Q

What is thge classic clinical presentation of a primary spontaneous phneumothorax?

A

young, previously healthy make with acute onset of pleuritic chest pain and dyspnea

58
Q

WHat are the possible mechanisms for a primary spontaneous pneumothorax?

A
  1. visceral pleural bleb: a collection of air within the layers of the visceral pleura (thin and easily ruptured?)
  2. bronchial obstruction with ball-valve mechanism (not sure how this works? i assume its a pressure thing)
59
Q

What are the causes of a secondary spontaneous pneumothorax?

A

OLD: COPD, asthma, CF

ILD: sarcoid, lymphangioleiomyomatosis (LAM), pulmonary langerhans cell histiocytosis (PLCH)

infections: pneumocystis carinii in AIDS ots, TB

60
Q

WHo gets a tension pneumothorax?

A

usually pts on MV (positive pressure ventilation)
*can occur with trauma

JUST NEED A ONE WAY VALVE, allowing air to enter the pleural space and preventing
the air from escaping naturally

61
Q

What is a serious complication of a tension pneumothorax?

A

impaired venous return (compression of RA and SVC)

**clinically manifests as JVD

62
Q

What are the 3 findings on a CXR that suggest a tension pneumothorax?

A

lung collape
contralateral mediastinal shift
depression of diaphragm

63
Q

What are the clinical manifestations of a tension pneumothorax?

A

hypotension

hypoxemia

64
Q

What is the Tx for a tension pneumothorax?

A
  1. emergent decompression with large bore needle

2. chest tube

Pulmonary (31 decks)

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