Flashcards in CM- Pleural Diseases Deck (38):
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?
2. pleuritic pain
4. weight loss, fatigue
5. 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 ______.
Infectious processes like TB or pneumonia
TB or PE
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?
1. asymmetry of findings
2. dullness to percussion = effusion, hyperresonance to percussion = pneumothorax
3. decreased breath sounds = both
4. pleural rub = inflammatory process
What is noted on the abdominal exam for a person with pleural effusion?
1. 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 :
2. 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?
1. intercostal arteries
2. internal mammary arteries
1. bronchial arteries
What are the six mechanisms that cause pleural effusion?
1. increased hydrostatic pressure- PVH (usually from LHF)
2. decreased plasma oncotic pressure
3. decreased intrapleural pressure (spontaneous pneumothorax)
4. increased permeability of microvasculature (inflammation)
5. impaired lymphatic drainage (malignancy)
6. 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.
2. hypoalbuminemic states
3. ascites with hypoalbuminemia
- 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?
1. Fluid/serum LDH ratio
2. fluid/serum protein ratio
4. cell count
5. 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?
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?
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 >>>> _________________ and RBC >>>>> _______________________.
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).
4. 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?
- 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:
1. loculated fluid on CXR (defies gravity)
2. fluid pH < 40mg/dl (bacteria use glucose and impair transport)
4. High WBC (neutrophil = bacteria, lymphocyte= mycobacteria)
5. Fever despite antibiotics
6. enlarging effusion on antibiotics
What are the 6 drainage options for empyema?
2. repetitive thoracentesis
3. chest tube w/without thrombolytics
4. CT-guided drainage
5. VATS (video assisted thorascopic surgery)
6. open surgical drainage
You do a CXR in a younger patient and see a unilateral pleural effusion. What should you immediately be suspicious of?
What test is done next?
TB- if the patient has a + PPD and an unexplained unilateral pleural effusion, begin RIPE
How can lupus and RA be differentiated as causes of pleural effusion?
uni or bilateral
glucose is VERY low
A patient comes into the ER and has been severely vomiting. They are in severe pain. You do a CXR and see a left pleural effusion with left pneumothorax/pneumomediastinum. What is your immediate suspicion?
What is your next test?
Esophageal rupture- Boerhave's syndrome
It is associated with:
1. left pleural effusion
2. left pneumothorax, pneumomediastinum
3. coughing and/or iatrogenic (NG tube, variceal sclerosis)
You need a CT with contrast to look for where the tear is and how the air is getting to the mediastinum
What will lab values of the pleural effusion fluid show if there is an esophageal rupture?
This is what helps differentiate it from pancreatitis because the low pH is due to gastric content (vomit or tube placement) and the high amylase is salivary.
A person comes in with a grossly bloodly pleural effusion (>100,000 RBC). What should you suspect and what is your next step?
You should suspect malignancy and send for cytology.
Possible do biopsy of breast, lung, mesothelioma, lymphoma
You do a thorascentesis and notice grossly bloody (>100,000 RBC) and painful. You suspect malignancy and the man said he worked with insulation, so now you are extra suspicious for mesothelioma due to asbestos exposure.
What is required for diagnosis?
Diagnosis requires an open lung biopsy
What is the difference between chylous and pseudochylous effusion?
- caused by obstruction of lymphatic drainage due to malignancy or trauma to thoracic duct
- triglycerides <50mg/dl
- no chylomicrons
- caused by chronic inflammation (TB, lupus, RA)
When should an open pleural biopsy be performed?
What is the method of choice?
When neoplasm or infectious etiology is likely.
VATS is the procedure of choice because it is diagnostic AND therapeutic
What are common causes of pneumothorax?
2. emphysema with bullae
3. necrotizing bacterial infections (s. aureus, G-, anaerobes, PCP, TB)
4. necrotizing granulmonatous processes (sarcoidosis, eosinophilic granuloma)
Any HIV + individual with a pneumothorax should be immediately presumed to have ____________.
What does the physical exam of the lung look like for pneumothoraces?
No breath sounds, but hyperresonant to percussion
The presence of intrapleural pressure under positive pressure is sometimes called a ____________________. The CXR will show a shift of the mediastinum ____________ the pneumothorax. The pressure is enough to impede __________ and cause ______________.
tension pneumothorax will shift the mediastinum AWAY from the pneumothorax.
The positive pressure is enough to impede venous return to the right atrium and cause hemodynamic compromise.