pleurisy
inflammation of pleural membranes
pleural effusion
abnormal accumulation of >15 mL in pleural space
pneumothorax
air in the pleural space
pathophys of pleurisy
infection, injury (if ribs are bruised or fractured the pleura can become inflammed), PE, sickle cell anemia, chemo or radio therapy, uremia
presentation of pleurisy
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
pleurisy accompanied by effusion or pneumothorax is uncommon with?
viral infection (common with other causes)
viral causes of pleurisy
influenze, EBV, CMV, parainfluenza
epidemic pleuredynia is due to
coxsackie B virus
*this is not a pleurisy–it is inflammation of the intercostal muscles that causes pleuritic pain
treatment of uncomplicated pleurisy or pleuredynia
*NSAIDs
may need corticosteroids
RARELY need narcotics
what is used to determine transudate vs exudate
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
normally Qf is?
negative or zero–indicating fluid flow into capillary from the interstitium with no accumulation of interstitial fluid (effusion)
Qf is abnormal if
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
causes of pleural transudate
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
pathophys of pleural exudates
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)
pleural exudates use to infection
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
malignant pleural effusion
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
what may cause transudate effusion associated with malignancy
collapse of lung from obstruction, resulting in decreased extra capillary (interstitial) pressure)
other causes of exudate effusion associated with malignant
hemorrhage from tumor to cause hemothorax, PE/pulmonary infarct, post-obstructive pneumonia
MPE are commonly loculated
not free-flowing, confined to one or more fixed spaced; caused by proteinaceous membranes
diagnosis of PE
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
what is associated with TG >110 mg/dL with a pleural effusion
injury to thoracic duct and chronic effusions
*this is considered a chylothorax
what is associated with glucose fluid content <60 mg/dL with a pleural effusion
RA, bacterial infection, malignant effusion, TB
what is associated with pleural effusion fluid pH <7.3
infection, malignancy, etc
pH range for transudates
7.40-7.55
pH range for exudates
7.40-7.45
treatment of pleural effusions
treat underlying condition! most transudates can be treated thru threatment of CHF, ascites, malnutrition
what decreases risk of complications in thoracentesis
ultrasound guidance
medical management of empyema
injection of fibrinolytic and DNAse
when are chest tubes used
exudates; most commonly empyema or malignant effusion
surgical management of empyema
remove proteinaceous septae, pockets of fluid, pus, blood, and decortication to enable full expansion of the lung
Most common cause of pleural effusion in outpatient clinic
previous diagnosed CHF transudate or previously diagnosed malignant pleural effusion
most common cause of pleural effusion in ER and ICU
new or decompensated CHF, pneumonia (parapneumonia or empyema), new MPE, pulmonary infarct, systemic inflammatory response from septic shock
pneumothorax pathophysiology
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
primary spontaneous pneumothorax
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)
Secondary spontaneous pneumothorax
caused by underlying lung disease (COPD, TB)
traumatic pneumothorax
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)
treatment for pneumothorax
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
prevention of recurrent spontaneous pneumothorax
behavior modification (quite smoking/dont start smoking), quit inhalation of recreational drugs (deep inhalation and breath hold increases risk)
who is more likely to have another spontaneous pneumothorax
people who have underlying lung disease
do primary or secondary spontaneous pneumothorax occur more often?
secondary
when is surgical intervention with pleuredesis to obtain pleural space done?
after second recurrence of primary spontaneous pneumothorax or after first recurrence of secondary spontaneous pneumothorax
pathophys of tension pneumothorax
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
what is the cause of most bronchopulmonary fistulas
secondary sponataneous pneumothorax
clinical exam signs of tension pneumothorax
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
how to diagnose tension pneumothorax
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
tension pneumothorax treatment
insert large bore needle into second intercostal space on affected side. after resolution of tension pneumothorax, convert to small bore chest tube
which intercostal space would be used for insertion of the bore needle in tension pneumothorax treatment
second or third intercostal space
which intercostal space is used for placement of a chest tube
fifth intercostal space