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Pulm > Lecture 10: Pleural Diseases > Flashcards

Lecture 10: Pleural Diseases Flashcards

1
Q

Which pleura contains nerves and can therefore feel pain?

A

Parietal pleura

Painful pleura

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2
Q

What is the most common cause of noncardiac chest pain?

A

Pleurisy/pleuritis

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3
Q

What 3 drugs are likely to induce pleuritis?

A
  • Procainamide
  • Hydralazine
  • Isoniazid

|Pain In Here

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4
Q

How is pleurisy typically described by a patient?

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

Pleuritic chest pain

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5
Q

What should a PE show for pleurisy?

A
  • Pleural friction rub (localized)
  • Decreased breath sounds
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6
Q

What is the initial evaluation of pleurisy focused on?

A

Ruling out concerning sources of chest pain.

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7
Q

What is generally the last test to order for pleurisy?

A

CT w/ con or CTA.

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8
Q

What factors might suggest admitting a patient for pleurisy?

A
  • Hypoxemic < 90%
  • Parenteral pain control needed
  • Underlying etiology needs hospitalization.
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9
Q

What are the pharmacological treatments for pleurisy?

A
  • 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.

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10
Q

What might suggest pleural effusions are developing from pleurisy?

A

Transient pain improvement with worsening of SOB and cough.

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11
Q

How is pleural fluid homeostasis achieved?

A
  • 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.
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12
Q

What are the 5 pathophysiological processes that create pleural effusions?

A
  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

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13
Q

What is transudate?

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

Its like tea, which is generally just watery.

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14
Q

What is exudate?

A
  • Fluid rich in protein and cellular elements from nearby blood vessesls due to inflammation.
  • Results from altered permeability, which is 2/2 inflammation.
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15
Q

What etiology can produce both transudate and exudate?

A

PE

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16
Q

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

A
  • TB
  • Asbestos
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17
Q

What are the MC symptoms that present with pleural effusion?

A
  • Dyspnea
  • Cough
  • Pleuritic chest pain
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18
Q

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

A
  • CHF: LE edema, orthopnea, PND
  • TB: night sweats, hemoptysis, wt loss
  • Malignancy: hemoptysis, wt loss
  • PNA: Fever, purulent sputum, pleuritic chest pain
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19
Q

What does a pleural effusion do to the lung exam?

A
  • Diminished/absent breath sounds
  • Dullness to percussion
  • Decreased tactile fremitus
  • Diminished chest expansion
  • Tracheal deviation (large effusion)
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20
Q

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

A

175mL or 6oz

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21
Q

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

A

Left-lateral decubitus CXR

We want gravity to pull the fluid down.

22
Q

What imaging is highly sensitive for pleural effusion?

A

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.

23
Q

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

A
  • Benign etiology
  • Small effusion with clear diagnosis.
24
Q

Where should a thoracentesis be inserted?

A
  • Lower part of the chest wall
  • Just above a rib (Avoid neurovascular bundle)
25
Q

When should a thoracentesis absolutely not be performed?

A
  • Uncooperative patient
  • Cutaneous disease over the proposed puncture site.
26
Q

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

A

Risk of tension pneumothorax

27
Q

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

A
  • Needle larger than 20G
  • Lack of US guidance

Smaller gauge number = larger needle.

28
Q

What is Light’s criteria?

Transudate vs exudate

A
  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.

29
Q

What conditions would prompt tube thoracostomy?

A
  • Empyema
  • Complicated effusion
  • Large or unstable hemothorax

Repeat CXR when drainage drops under 100 mL/day

Blood is thick, so you need a bigger tube.

30
Q

What is pleurodesis?

A
  • 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.

31
Q

What are the 5 types of pneumothorax?

A
  1. Primary spontaneous
  2. Secondary spontaneous
  3. Traumatic
  4. Iatrogenic
  5. Tension
32
Q

Who is a primary spontaneous pneumo MC in?

A
  • Tall, thin males between 10-40yo.
  • FMHx and cigarette smoking.
33
Q

What specifically happens in a primary spontaneous pneumothorax?

A

Rupture of subpleural apical blebs.

Occurs in response to high negative intrapleural pressures.

34
Q

What typically precipitates a secondary spontaneous pneumothorax?

A

Preexisting pulmonary disease.

35
Q

What is catamenial pneumothorax?

A

Pneumothorax everytime you menstruate

36
Q

What is the MCC of tension pneumothorax?

A
  • CPR
  • Positive-pressure mechanical ventilation

This is the most emergent of pneumothorax.

37
Q

How does pneumothorax present on exam?

A
  • Diminished breath sounds and decreased tactile fremitus on affected side.
  • Tension: Severe vitals with tracheal deviation
38
Q

What are considered unstable vital signs for a pneumothorax?

A
  • RR > 24
  • HR < 60 or > 120
  • Abnormal BP
  • O2 < 90%
39
Q

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

A
  • Expiratory PA
  • Lateral decubitus on contralateral side.
40
Q

What is the purpose of a chest CT in pneumothorax?

A
  • More sensitive
  • Primarily to determine associated pathology.
41
Q

How do we manage a spontaneous pneumothorax?

A
  • Airway
  • Breathing (O2 supplementation)
  • Remove air if needed.
42
Q

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

A
  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.

43
Q

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

A
  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.

Essentially same indications as obs except the pneumo is bigger.

44
Q

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

A

Aspiration for 4L without any resistance.

This indicates a need for a chest tube.

45
Q

Where should aspiration be performed for pneumothorax?

A

2nd ICS in midclavicular.

This is different from pleural effusion, which is performed lower.

Air rises, fluid sinks.

46
Q

Where is a chest tube generally placed?

A

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

47
Q

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

A

Loculated pneumothorax

48
Q

What are the pros and cons of tube vs catheter?

A
  • Tubes: larger, needs surgical incision, more painful, doesn’t kink.
  • Catheter: smaller, guidewire, less painful, can kink.

Higher FRENCH catheter = bigger.

49
Q

What is the managment for a secondary spontaneous pneumothorax?

A
  • O2 supplementation in caution
  • Tube/catheter thoracostomy + admission
  • Consider pleurodesis
50
Q

What is the treatment for a tension pneumothorax?

A

Needle decompression

51
Q

How is needle decompression performed?

A
  • 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.

5th ICS can be used because it doubles as the entry point for a chest tube.

Pulm (12 decks)

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