OS 3.5: Pleural Disease Flashcards Preview

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Flashcards in OS 3.5: Pleural Disease Deck (48)
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1
Q

pleurisy

A

inflammation of pleural membranes

2
Q

pleural effusion

A

abnormal accumulation of >15 mL in pleural space

3
Q

pneumothorax

A

air in the pleural space

4
Q

pathophys of pleurisy

A

infection, injury (if ribs are bruised or fractured the pleura can become inflammed), PE, sickle cell anemia, chemo or radio therapy, uremia

5
Q

presentation of pleurisy

A

sharp chest pain associated with breathing and may notice referral of pain to shoulder, worse with cough, sneeze or movement

  • patients often present to ER due to severity and acuity of pain
  • may or may not be associated with pleural effusion or pneumothorax
6
Q

pleurisy accompanied by effusion or pneumothorax is uncommon with?

A

viral infection (common with other causes)

7
Q

viral causes of pleurisy

A

influenze, EBV, CMV, parainfluenza

8
Q

epidemic pleuredynia is due to

A

coxsackie B virus

*this is not a pleurisy–it is inflammation of the intercostal muscles that causes pleuritic pain

9
Q

treatment of uncomplicated pleurisy or pleuredynia

A

*NSAIDs
may need corticosteroids
RARELY need narcotics

10
Q

what is used to determine transudate vs exudate

A

light criteria (pleural fluid LDH/serum LDH ratio>0.6, Pleural fluid LDH>2/3x the upper limits of the laboratory’s normal serum, pleural fluid protein/serum ratio of >0.5)
transudate if no light criteria are present
exudate if 1+ of the light criteria are present

11
Q

normally Qf is?

A

negative or zero–indicating fluid flow into capillary from the interstitium with no accumulation of interstitial fluid (effusion)

12
Q

Qf is abnormal if

A

it is positive–this indicates that fluid flow out of capillary into interstitium resulting in an effusion
*can be caused by elevated capillary pressure due to LVHF, lower capillary oncotic pressure due to hypoalbumenia, or increased leakiness of capillaries due to septic shock or vasculitis

13
Q

causes of pleural transudate

A

increased capillary hydrostatic pressure (LVCHF, cirrhosis), decreased capillary oncotic pressure (hypoalbumineia–malnutrition, hepatic failure, critical care/iatrogenic due to fluid resuscitation of shock), increased capillary leakage (septic shock, anaphylactic shock, vasculitis

14
Q

pathophys of pleural exudates

A

inflammation (infection: viral or bacterial–para-pneumonic is noninfected and empyema is infected), connective tissue disease (RA, SLE), malignant (metastatic–common due to lung, breast most often or primary mesothelioma), injury (trauma or surgery–typically hemothorax)

15
Q

pleural exudates use to infection

A

viral: high lymphocyte count, low neutrophil count
fungal: high lymphocyte count, low neutrophil count, usually immunosuppressed px
TB pleural effusion: rare in US, high lympohcyte count, low neutrophil count, adenosine deaminase and/or IFN gamma is elevated, TB mycobacteria observed on slide/culture
Bacterial: parapneumonia is not infection so pH>7.2 with non-cloudy and non-purulent fluid; empyema is infected and will have pH<7.2 with cloudy or purulent fluid and growth of bacteria in culture

16
Q

malignant pleural effusion

A

exudate associated with malignant cell invasion of the pleural space–>cancer cells secrete fluid into pleural space and cancer cells block draining lymphatics
*malignancies most commonly associated with MPE are lung, breast, and lymphoma

17
Q

what may cause transudate effusion associated with malignancy

A

collapse of lung from obstruction, resulting in decreased extra capillary (interstitial) pressure)

18
Q

other causes of exudate effusion associated with malignant

A

hemorrhage from tumor to cause hemothorax, PE/pulmonary infarct, post-obstructive pneumonia

19
Q

MPE are commonly loculated

A

not free-flowing, confined to one or more fixed spaced; caused by proteinaceous membranes

20
Q

diagnosis of PE

A

chest xray or chest CT scan
ultrasound to look for fluid or air, etc
ultrasound guided thoracentesis to remove a sample of pleural fluid for testing
blood test for causative conditions

21
Q

what is associated with TG >110 mg/dL with a pleural effusion

A

injury to thoracic duct and chronic effusions

*this is considered a chylothorax

22
Q

what is associated with glucose fluid content <60 mg/dL with a pleural effusion

A

RA, bacterial infection, malignant effusion, TB

23
Q

what is associated with pleural effusion fluid pH <7.3

A

infection, malignancy, etc

24
Q

pH range for transudates

A

7.40-7.55

25
Q

pH range for exudates

A

7.40-7.45

26
Q

treatment of pleural effusions

A

treat underlying condition! most transudates can be treated thru threatment of CHF, ascites, malnutrition

27
Q

what decreases risk of complications in thoracentesis

A

ultrasound guidance

28
Q

medical management of empyema

A

injection of fibrinolytic and DNAse

29
Q

when are chest tubes used

A

exudates; most commonly empyema or malignant effusion

30
Q

surgical management of empyema

A

remove proteinaceous septae, pockets of fluid, pus, blood, and decortication to enable full expansion of the lung

31
Q

Most common cause of pleural effusion in outpatient clinic

A

previous diagnosed CHF transudate or previously diagnosed malignant pleural effusion

32
Q

most common cause of pleural effusion in ER and ICU

A

new or decompensated CHF, pneumonia (parapneumonia or empyema), new MPE, pulmonary infarct, systemic inflammatory response from septic shock

33
Q

pneumothorax pathophysiology

A

connection develops between alveoli and pleural space (bronchopleural fistula) or between chest wall and pleural space (knife wound)
connection may be limited or persistent
*persistant can lead to air-trapping and tension pneumothorax

34
Q

primary spontaneous pneumothorax

A

no apparent trauma or obvious cause
usually caused by rupture of an apical bleb (increased risk for tall, slender, young men who smoke cigarettes and/or inhale recreational drugs–associated with Marfan syndrome and homocyteniuria)

35
Q

Secondary spontaneous pneumothorax

A

caused by underlying lung disease (COPD, TB)

36
Q

traumatic pneumothorax

A

trauma from rib fracture or penetrating injury–>most common in the ER
iatrogenic (most common in hospitalized patient from needle insertion for central line placement, needle insertion for transthoracic lung biopsy, mechanical ventilation (high positive airway pressures)

37
Q

treatment for pneumothorax

A

small (<3 cm at apex) and stable: discharge with NSAID for pain and obtain follow-up CXR
Large (>3 cm at apex): pleural aspiration with catheter, admit for observation, supplemental oxygen, chest tube if not resolved
Unstable: needle thoracostomy, chest tube

38
Q

prevention of recurrent spontaneous pneumothorax

A

behavior modification (quite smoking/dont start smoking), quit inhalation of recreational drugs (deep inhalation and breath hold increases risk)

39
Q

who is more likely to have another spontaneous pneumothorax

A

people who have underlying lung disease

40
Q

do primary or secondary spontaneous pneumothorax occur more often?

A

secondary

41
Q

when is surgical intervention with pleuredesis to obtain pleural space done?

A

after second recurrence of primary spontaneous pneumothorax or after first recurrence of secondary spontaneous pneumothorax

42
Q

pathophys of tension pneumothorax

A

air flows into pleural space but cant get out (one way valve)
*can be due to traumatic penetrating or iatrogenic injuries
increasing intrathoracic pressure prevents venous return to heart and prevents effective breathing

43
Q

what is the cause of most bronchopulmonary fistulas

A

secondary sponataneous pneumothorax

44
Q

clinical exam signs of tension pneumothorax

A

decreased tactile fremitus, decreased chest expansion on affected side, tracheal deviation away from affected side of tension, hyperresonance on percussion, decreased or absent breath sounds on auscultation, decreased vocal resonance

45
Q

how to diagnose tension pneumothorax

A

Chest xray showing mediastinal shift from side of pneumothorax and hyperlucency on side of pneumothorax
*ideally these patients should be diagnosed and treated based on physical exam without need for CXR because the delay may lead to cardiac arrest due to intrathoracic pressure preventing venous return

46
Q

tension pneumothorax treatment

A

insert large bore needle into second intercostal space on affected side. after resolution of tension pneumothorax, convert to small bore chest tube

47
Q

which intercostal space would be used for insertion of the bore needle in tension pneumothorax treatment

A

second or third intercostal space

48
Q

which intercostal space is used for placement of a chest tube

A

fifth intercostal space