CM- Pleural Diseases Flashcards
(38 cards)
The pleural space is supplied by _______ but is drained largely by ____________.
When is the only real time lymphatics come into play?
Supplied by systemic arteries but drained by low-pressure pulmonary veins
Lymphatics increased the efficiency of pleural space drainage in the setting of chronic pleural effusion.
Pleural disease can present as incidental finding on CXR or can be associated with what 5 common respiratory complaints?
- dyspnea
- pleuritic pain
- cough
- weight loss, fatigue
- fever, rigors
What worsens the dyspnea associated with a massive pleural effusion?
change in position or laying flat.
Large effusions produce worse symptoms when flat.
What alleviates symptoms associated with a unilateral pleural effusion?
lying in a position where the effusion is dependent
When does pleuritic chest pain get worse in the setting of pleural effusions? What process does NOT cause pleuritic pain?
Pleuritic pain gets worse with inspiration
Transudative processes do NOT cause pleuritic pain
Pneumothoraces DO cause pleuritic pain
A productive cough assiciated with __________ like _______ and ________ may be the presenting complaint in pleural disease.
Hemoptysis raises the posibility of ________ or _________.
Foul-spelling sputum makes you suspicious of ______.
Productive:
Infectious processes like TB or pneumonia
Hemoptysis:
TB or PE
Foul-smelling:
anaerobic infections
Where there is fever and rigors in a patient with a pleural effusion, what does this strongly suggest?
Aerobic bacterial process or less commonly Legionella
What are the key findings on a cardiac exam suggestive of pleural disease?
- S3 gallop would suggest CHF which can lead to pleural effusion.
- Murmur/thrill can be suggestive of valvular disease
- Pericardial friction rub is diagnositic of pericarditis which may be associated with left pleural effusion
What are the key findings on lung exam for a person with pleural effusion?
- asymmetry of findings
- dullness to percussion = effusion, hyperresonance to percussion = pneumothorax
- decreased breath sounds = both
- pleural rub = inflammatory process
What is noted on the abdominal exam for a person with pleural effusion?
- Ascites indicates CHF or hypoalbuminemia
2. Tenderness = local infection of subphrenic fluid with spread to pleural space or pancreatitis
What is noted on the extremities of someone with pleural effusion?
Peripheral edema can indicate :
- CHF
- DVT with PE
Evidence suggests that there is a constant flux from parietal to visceral pleura. Both are supplied by systemic arteries.
What arteries supply parietal pleura?
What arteries supply visceral pleura?
Parietal:
- intercostal arteries
- internal mammary arteries
Visceral:
1. bronchial arteries
What are the six mechanisms that cause pleural effusion?
- increased hydrostatic pressure- PVH (usually from LHF)
- decreased plasma oncotic pressure
- decreased intrapleural pressure (spontaneous pneumothorax)
- increased permeability of microvasculature (inflammation)
- impaired lymphatic drainage (malignancy)
- Movement of fluid from peritoneal space
What is a transudative effusion?
What are the 3 main etiologies that can cause it?
What are other “exam pearls” that are associated with transudative effusion but are difficult to explain?
How does the patient present?
What is the next step for “work up”?
It is caused by increased hydrostatic pressure or decreased oncotic pressure.
- CHF
- hypoalbuminemic states
- ascites with hypoalbuminemia
Exam pearls:
- constrictive pericarditis
- valvular heart disease (AS, MS)
- SVC syndrome
Patient will have SOB, DOE but no pain, fever, toxic look.
They do not require further invasive workup because they do not have suspicion for malignancy or infectious etiology.
What is an exudative effusion?
What is the differential diagnosis?
How does the patient appear when they present?
What is the next step for workup?
It is caused by inflammation of the pleural surface or obstruction of lymphatic drainage so there is proteinaceous fluid in the pleural space.
Diff diagnosis is very long and neoplastic and infectious causes should be considered.
The patient will have dyspnea, pain, possible fever/rigors, weight loss, cough
They need pleural biopsy and extensive workup
Thoracentesis removes fluid from the pleural space and is the key diagnostic test to differentiate transudates from exudates.
What 5 values are measured?
- Fluid/serum LDH ratio
- fluid/serum protein ratio
- protein
- cell count
- serum-effusion albumin gradient
A thoracentesis is done and the pleural fluid/LDH ratio is 0.5. Is it likely to be a transudate or exudate?
Transudate because
Fluid/LDH >0.6 is an exudate
Fluid/LDH <0.6 is a transudate
You do a thoracentesis and the fluid/serum protein ratio is 0.6. Is this likely to be a transudate or exudate?
Exudate because:
Fluid/protein >0.5 is exudate
Fluid/protein <0.5 is transudate
In you thoracentesis you note a protein level of 4 g/dl. What does this suggest?
Wht can this be misleading?
It suggests an exudate because
Protein over 3 = exudate
Protein less than 3 = transudate
It can be misleading in long standing effusions
Cell counts for thoracentesis are not helpful unless the WBC»_space;» _________________ and RBC»_space;»> _______________________.
WBC should be much greater than 10,000 and the RBC should be much greater than 50,000 to be considered an exudate
What is the serum-effusion albumin gradient most useful for testing?
What are the values that determine it to be a transudate?
It is useful for determining whether fluid is a true exudate (malignant/inflammatory) or a long-standing chronic CHF which can have high protein.
Albs-Albe >1.2 is a transudate (because serum is high and effusion is low)
Albs-Albe <1.2 is an exudate
What is the very short differential of you have a bloody pleural effusion (RBC > 100,000).
- Tumor
- trauma
- TB
- PE with infarction
(usually 1 or 2 are the most common)
If a patient has clinical signs/symptoms of pneumonia (cough, fever SOB, new radiographic infiltrate) AND effusion what is this called?
Is the effusion likely transudate or exudate?
What should you do for the patient?
Parapneumonic effusion
- exudate
- if infected = empyema
Admit the patient for observation
How is diagnosis of empyema suggested?
1 CXR finding, 3 lab values, 2 clinical presentations
Empyema is infected parapneumonic effusion. Gram stains and cultures are often negative so look for:
- loculated fluid on CXR (defies gravity)
- fluid pH < 40mg/dl (bacteria use glucose and impair transport)
- High WBC (neutrophil = bacteria, lymphocyte= mycobacteria)
- Fever despite antibiotics
- enlarging effusion on antibiotics
