Lecture 10: Pleural Diseases

Question 1

Which pleura contains nerves and can therefore feel pain?

Answer 1

Parietal pleura

Painful pleura

Question 2

What is the most common cause of noncardiac chest pain?

Answer 2

Pleurisy/pleuritis

Question 3

What 3 drugs are likely to induce pleuritis?

Answer 3

• Procainamide
• Hydralazine
• Isoniazid

|Pain In Here

Question 4

How is pleurisy typically described by a patient?

Answer 4

• Sharp, knife-like, fleeting pain worsened by inspiration.
• Radiation of pain to IPSILATERAL scapula if diaphragmatic pleura affected.

Pleuritic chest pain

Question 5

What should a PE show for pleurisy?

Answer 5

• Pleural friction rub (localized)
• Decreased breath sounds

Question 6

What is the initial evaluation of pleurisy focused on?

Answer 6

Ruling out concerning sources of chest pain.

Question 7

What is generally the last test to order for pleurisy?

Answer 7

CT w/ con or CTA.

Question 8

What factors might suggest admitting a patient for pleurisy?

Answer 8

• Hypoxemic < 90%
• Parenteral pain control needed
• Underlying etiology needs hospitalization.

Question 9

What are the pharmacological treatments for pleurisy?

Answer 9

• Indomethacin 25mg BID-TID for only 7-10d
• Cough suppressants (Codeine, DXM, Tessalon)

Cannot be given for a long time.

NSAIDs and general analgesics are also indicated.
Cough suppressants are only indicated if its hard for them to sleep.

Question 10

What might suggest pleural effusions are developing from pleurisy?

Answer 10

Transient pain improvement with worsening of SOB and cough.

Question 11

How is pleural fluid homeostasis achieved?

Answer 11

• Movement of fluid between capillaries of parietal and visceral pleura into the pleura.
• Lymphatics absorb the pleural fluid.
• 5-15 mL is normal for pleural space.

Question 12

What are the 5 pathophysiological processes that create pleural effusions?

Answer 12

1. Increased fluid production 2/2 increased hydrostatic or decreased oncotic capillary pressure. (Transudate)
2. Increased fluid production 2/2 abnormal capillary permeability (Exudate)
3. Decreased lymphatic clearance (Exudate)
4. Infection in the space (Empyema)
5. Bleeding into the space (Hemothorax)

1 has to do wth proteins
2 has to do with inflammation
3 has to do with poor drainage

Question 13

What is transudate?

Answer 13

• Filtrate of blood caused by imbalance in hydrostatic and colloid pressures.
• Watery

Its like tea, which is generally just watery.

Question 14

What is exudate?

Answer 14

• Fluid rich in protein and cellular elements from nearby blood vessesls due to inflammation.
• Results from altered permeability, which is 2/2 inflammation.

Question 15

What etiology can produce both transudate and exudate?

Answer 15

PE

Question 16

What kind of exposures should we be concerned about that could precipitate a pleural effusion?

Answer 16

• TB
• Asbestos

Question 17

What are the MC symptoms that present with pleural effusion?

Answer 17

• Dyspnea
• Cough
• Pleuritic chest pain

Question 18

What symptoms might suggest that a pleural effusion is due to CHF? TB? Malignancy? PNA?

Answer 18

• CHF: LE edema, orthopnea, PND
• TB: night sweats, hemoptysis, wt loss
• Malignancy: hemoptysis, wt loss
• PNA: Fever, purulent sputum, pleuritic chest pain

Question 19

What does a pleural effusion do to the lung exam?

Answer 19

• Diminished/absent breath sounds
• Dullness to percussion
• Decreased tactile fremitus
• Diminished chest expansion
• Tracheal deviation (large effusion)

Question 20

How much fluid is required to blunt a CPA on CXR?

Answer 20

175mL or 6oz

Question 21

If a patient presents with a left-sided pleural effusion on CXR, what can we order to confirm it?

Answer 21

Left-lateral decubitus CXR

We want gravity to pull the fluid down.

Question 22

What imaging is highly sensitive for pleural effusion?

Answer 22

CT Chest

You do NOT order this simply to identify a pleural effusion.

It is best reserved for underlying pathology. No need for contrast unless malignancy is suspected.

Question 23

Why might a patient only receive observation regarding their confirmed pleural effusion?

Answer 23

• Benign etiology
• Small effusion with clear diagnosis.

Question 24

Where should a thoracentesis be inserted?

Answer 24

• Lower part of the chest wall
• Just above a rib (Avoid neurovascular bundle)

Question 25

When should a thoracentesis absolutely not be performed?

Answer 25

* Uncooperative patient * Cutaneous disease over the proposed puncture site.

Question 26

If a thoracentesis is performed on someone that is vented, what is the main complication?

Answer 26

Risk of tension pneumothorax

Question 27

What two factors during a thoracentesis can increase risk of pneumothorax?

Answer 27

* Needle larger than 20G * Lack of US guidance ## Footnote Smaller gauge number = larger needle.

Question 28

What is Light's criteria? | Transudate vs exudate

Answer 28

1. Fluid Protein: serum protein > 0.5 2. Fluid LDH: LDH > 0.6 3. Fluid LDH > 2/3 ULN | Any of these being positive means the fluid is EXUDATIVE.

Question 29

What conditions would prompt tube thoracostomy?

Answer 29

* Empyema * Complicated effusion * Large or unstable hemothorax | Repeat CXR when drainage drops under 100 mL/day ## Footnote Blood is thick, so you need a bigger tube.

Question 30

What is pleurodesis?

Answer 30

* Sclerosing agent given to a patient to force scarring. * Palliative option only for someone with recurrent pleural effusions and malignancy. | Prevents pleural effusions from recurring.

Question 31

What are the 5 types of pneumothorax?

Answer 31

1. Primary spontaneous 2. Secondary spontaneous 3. Traumatic 4. Iatrogenic 5. Tension

Question 32

Who is a primary spontaneous pneumo MC in?

Answer 32

* Tall, thin males between 10-40yo. * FMHx and cigarette smoking.

Question 33

What specifically happens in a primary spontaneous pneumothorax?

Answer 33

Rupture of subpleural apical blebs. | Occurs in response to high negative intrapleural pressures.

Question 34

What typically precipitates a secondary spontaneous pneumothorax?

Answer 34

Preexisting pulmonary disease.

Question 35

What is catamenial pneumothorax?

Answer 35

Pneumothorax everytime you menstruate

Question 36

What is the MCC of tension pneumothorax?

Answer 36

* CPR * Positive-pressure mechanical ventilation | This is the most emergent of pneumothorax.

Question 37

How does pneumothorax present on exam?

Answer 37

* Diminished breath sounds and decreased tactile fremitus on affected side. * Tension: Severe vitals with tracheal deviation

Question 38

What are considered unstable vital signs for a pneumothorax?

Answer 38

* RR > 24 * HR < 60 or > 120 * Abnormal BP * O2 < 90%

Question 39

What two variations of a CXR might help us to diagnose a pneumothorax?

Answer 39

* Expiratory PA * Lateral decubitus on contralateral side.

Question 40

What is the purpose of a chest CT in pneumothorax?

Answer 40

* More sensitive * Primarily to determine associated pathology.

Question 41

How do we manage a spontaneous pneumothorax?

Answer 41

* Airway * Breathing (O2 supplementation) * Remove air if needed.

Question 42

When is it indicated to only provide supplemental oxygen and observation for a primary spontaneous pneumothorax?

Answer 42

1. Very small (<= 3cm at apex or <= 2cm at hilum) 2. Stable vitals 3. First time 4. No effusions 5. O2 at 6L with goal of 96%. 6. Repeat CXR post 6 hrs. | ALL MUST BE PRESENT.

Question 43

When is it indicated to do an aspiration for primary spontaneous pneumothorax?

Answer 43

1. Large pneumo (>= 3cm at apex or 2cm at hilum) 2. Stable vitals 3. First time 4. Experienced provider. | Catheter > needle in terms of preference. ## Footnote Essentially same indications as obs except the pneumo is bigger.

Question 44

While performing an aspiration for primary spontaneous pneumothorax, what would suggest that there is a persistent air leak?

Answer 44

Aspiration for 4L without any resistance. | This indicates a need for a chest tube.

Question 45

Where should aspiration be performed for pneumothorax?

Answer 45

2nd ICS in midclavicular. | This is different from pleural effusion, which is performed lower. ## Footnote Air rises, fluid sinks.

Question 46

Where is a chest tube generally placed?

Answer 46

4th/5th ICS in anterior or mid-axillary line.

Question 47

What kind of pneumothorax requires imaging assistance for chest tube placement?

Answer 47

Loculated pneumothorax

Question 48

What are the pros and cons of tube vs catheter?

Answer 48

* Tubes: larger, needs surgical incision, more painful, doesn't kink. * Catheter: smaller, guidewire, less painful, can kink. | Higher FRENCH catheter = bigger.

Question 49

What is the managment for a secondary spontaneous pneumothorax?

Answer 49

* O2 supplementation in caution * Tube/catheter thoracostomy + admission * Consider pleurodesis

Question 50

What is the treatment for a tension pneumothorax?

Answer 50

Needle decompression

Question 51

How is needle decompression performed?

Answer 51

* Large bore needle inserted into 2nd ICS at midclavicular. (can consider 5th ICS instead) * Confirmed by large amounts of gas escape after insertion. | Leave needle in place until chest tube is placed. ## Footnote 5th ICS can be used because it doubles as the entry point for a chest tube.