Clin Med: Disorders of the Pleural Space, mediastinum and chest wall

Question 1

A pleural effusion is

Answer 1

accumulation of fluid in the pleural space
between the visceral and parietal pleura

Question 2

Pleural effusions 2 types

Answer 2

transudative
exudative

Question 3

Transudative Pleural Effusion is

Answer 3

decreased oncotic or increased hydrostatic pressure
(too much fluid or too few proteins in fluid - fluid overload)

Question 4

Exudative Pleural Effusion is

Answer 4

inflammation –> increased capillary permeability
“leaky capillaries”, primarily infectious agents or malignancy

Question 5

Pleural effusion presentation

Answer 5

SOB
orthopnea
PND
CP
Cough - usually dry

Question 6

PE of pleural effusion

Answer 6

dullness to percussion
diminished breath sounds
decreased tactile fremitus
E –> A on egophony
+/- pleural friction rub

Question 7

Work up of pleural effusion

Answer 7

CXR (meniscus sign)
ultrasound (more sensitive)
+/- CT
thoracentesis (dx and therapeutic)

Question 8

Helpful clues for Pleural effusions:
if lots of fluid think…

Answer 8

malignancy, CHF, ascites, TB

Question 9

Helpful clues for Pleural effusions:
if bilateral think…

Answer 9

CHF or malignancy

Question 10

Helpful clues for Pleural effusions:
if right sided think…

Answer 10

CHF

Question 11

Helpful clues for Pleural effusions:
if left sided think…

Answer 11

esophageal rupture, pancreatic, post-CABG

Question 12

Contraindications to a thoracentesis

Answer 12

overlying skin infection/ wound
small fluid accumulation
bleeding disorders

Question 13

Pleural effusion treatment

Answer 13

treat underlying cause
therapeutic thoracentesis
+/- chest tube
+/- surgical management

Question 14

Hemothorax is when

Answer 14

there is pooling of blood in the pleural space
(bloody pleural effusion)

Question 15

Hemothorax is most commonly secondary to

Answer 15

trauma

Question 16

Presentation of a Hemothorax

Answer 16

more rapid development
may not be able to provide sx/hx
may present hemodynamically unstable
if AAO - chest pain, dyspnea

Question 17

Clues from MOI for Hemothorax

Answer 17

MCA > 35 mph
fall > 15 ft
ejection > 10 ft
LOC

Question 18

work up Hemothorax

Answer 18

CT preferred

Question 19

treatment of Hemothorax

Answer 19

IV, O2, monitor
less than 300mL and stable –> obs.
if unstable –> emergent decompression (usually chest tube)

Question 20

Who do we open for a Hemothorax

Answer 20

massive - >1-1.5 L
continued bleeding - >300-500mL in first hour
worsening on CXR
persistent despite treatment

Question 21

Pneumothorax is

Answer 21

accumulation of air in the pleural space

Question 22

Pneumothorax classifications

Answer 22

primary
secondary
traumatic
iatrogenic
tension

Question 23

Primary Pneumothorax is

Answer 23

spontaneous
no underlying pulm disease
usually tall, think males often with +FH and smokers, secondary to ruptured pleural blebs

Question 24

Secondary Pneumothorax is

Answer 24

Spontaneous
underlying pulmonary disease
injury to lung parenchyma – air out of lung

Question 25

Traumatic Pneumothorax is

Answer 25

blunt or penetrating trauma injury to chest wall/ lungs --- air in pleural space open (chest wall injury) or closed (lung injury)

Question 26

Pneumothorax: inspiration and expiration (what occurs during each)

Answer 26

inspiration - air into pleural space expiration - air leaves pleural space

Question 27

Iatrogenic Pneumothorax is

Answer 27

secondary to procedure or mechanical ventilation

Question 28

Tension Pneumothorax is

Answer 28

usually penetrating trauma, mechanical vent, CPR, infection pleural space pressure > lung pressures --> impaired expansion --> collapse

Question 29

Pneumothorax presentation

Answer 29

sudden, severe, pleuritic CP on affected side dyspnea at rest --> respiratory distress

Question 30

if tension Pneumothorax treatment is ______, ______ imaging

Answer 30

immediately, no

Question 31

workup of Pneumothorax

Answer 31

hypoxia (pulse ox) chest XR

Question 32

CXR on a Pneumothorax will show

Answer 32

lung markings don't extend to chest wall visible pleural edge increased radiolucency (darker) on chest wall periphery

Question 33

Tension Pneumothorax CXR will show a shift of

Answer 33

contralateral mediastinal shift

Question 34

Pneumothorax treatment: small (>15%) and stable --> bigger and stable --> resp distress --> tension pneumo -->

Answer 34

supportive treatment - upright positioning, analgesia, O2 as needed small and stable --> obs bigger and stable --> chest tube resp distress --> mechanical vent and chest tube tension pneumo --> immediate needle thoracostomy

Question 35

Mediastinal disease 3 main processes

Answer 35

mediastinal masses pneumomediastinum Mediastinitis

Question 36

treatment of pneumothorax if recurent

Answer 36

consider pleurodesis (taking up the lung)

Question 37

mediastinum is the area

Answer 37

between the lungs

Question 38

Anterior mediastinum can present with

Answer 38

thymoma, lymphoma

Question 39

Middle mediastinum can present with

Answer 39

vascular, lymphadenopathy

Question 40

Posterior mediastinum can present with

Answer 40

neurogenic, esophagus

Question 41

Mediastinum masses: Peds usually present adults mostly present

Answer 41

symptomatic asymptomatic

Question 42

Mediastinum masses workup

Answer 42

mostly found incidentally on CXR CT chest is test of choice

Question 43

What condition is linked with mediastinal tumors

Answer 43

myasthenia gravis

Question 44

Definitive dx of mediastinum masses

Answer 44

bx

Question 45

Mediastinum masses treatment

Answer 45

treat underlying cause

Question 46

Treatment of a thymoma

Answer 46

surgical resection +/- chemo and radiation

Question 47

Thymoma sx

Answer 47

phrenic nerve palsy cough dyspnea CP hoarseness SVC syndrome

Question 48

Pneumomediastinum is

Answer 48

air in the mediastinal space rare - young adults, M

Question 49

Pneumomediastinum presentation

Answer 49

sudden severe retrosternal CP chest pain radiating to back/ neck cough dyspnea increased work of breathing voice changes

Question 50

dx Pneumomediastinum

Answer 50

CXR CT to confirm

Question 51

Pneumomediastinum treatment

Answer 51

most resolve on its own - air reabsorbs treat underlying disorder sx treatment

Question 52

Mediastinitis is

Answer 52

inflammation of the mediastinal space

Question 53

Mediastinitis is m/c secondary to

Answer 53

infection esophageal rupture or chest surgery

Question 54

Mediastinitis presentation

Answer 54

sudden or insidious onset severe CP, dyspnea and fever

Question 55

Mediastinitis dx

Answer 55

CXR or chest CT

Question 56

Mediastinitis treatment

Answer 56

abx - clindamycin and ceftriaxone