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Flashcards in Pleural Cavity Disorders Deck (49):
1

Define pneumothorax

Accumulation of air in pleural space that leads to partial or complete collapse of lung

2

How is at an increased risk of pneumothorax?

1. Tall thin males between10-30 yr are at ↑ risk
2. (+) FH
3. M > F
4. Smoker

3

What are the causes of pneumothorax?

1. Spontaneous-most common
2. Rupture of subpleural blebs of lung
A. Blebs or bullae are thin walled balloon-like extensions of air sacs

4

What is the most common cause of pneumo?

Spontaneous

5

How are blebs and bullae differentiated?


1. Blebs are blister-like air pockets that form on the surface of the lung 
A. 1-2 cm
 
2. Bullae are air-filled cavities within the lung tissue
A. > 2 cm

6

What is primary spontanous pneumo caused by?

Etiology unknown

7

What is secondary spontaneous pneumo caused by?

COPD
Asthma
CF
TB
Pertussis
Interstitial lung diseases

8

What is traumatic pneumo caused by?

1. Traumatic
A. Blunt chest injury
B. Penetrating chest injury
C. Iatrogenic
-Mechanical ventilation
- Puncture of lung
- Needle aspiration lung Bx
- Thoracentesis
- Central line placement

9

Define tension pneumo

1. Lung collapse forced by excessive pressure
2. Usually assoc w/ traumatic event

10

What is the pathophys of an open or closed pneumo?

1. Rupture in visceral or parietal pleura & chest wall
2. Visceral & parietal pleura separate
3. Lung recoils by collapsing toward hilum

11

What is the pathophys of a tension pneumo?

1. Air enters pleural space from site of pleural rupture but is unable to escape since rupture site closes on inspiration
2. Increased air pressure pushes on mediastinum  compresses and displaces heart and great vessels
3. Decreases venous return & cardiac output, leading to hypotension

12

What are the sxs of a pneumo?

1. Acute onset chest pain & dyspnea
2. Unilateral chest expansion
3. ↓ tactile fremitus
4. Hyper-resonant lung
5. ↓ or absent breath sounds in lung field

13

What are the sxs of a tension pneumo?

1. Acute onset chest pain & dyspnea
2. Unilateral chest expansion
3. ↓ tactile fremitus
4. Hyper-resonant lung
5. ↓ or absent breath sounds in lung field
6. Hypotension
7. ↓ cardiac output
8. Tachycardia

14

What is the study that diagnoses pneumo? What are the results?

1. CXR
2. Visceral pleural line is evident and diagnostic
A. may only be seen on an expiratory film
3. Tension pneumothorax
A. Mediastinal or tracheal shift to contralateral side

15

What is the general treatment for pneumo?

1. Observation w/out oxygen
2. Observation w/oxygen
3. Simple aspiration
4. Chest tube placement
A. One-way valve insertion (portable system)
B. Thoracostomy with continuous wall suction
-First-time secondary spontaneous pneumothorax (SPS) (including chronic obstructive pulmonary disease [COPD])
-Traumatic pneumothorax

16

How is a small pneumo treated?

1. Small (< 15%) pneumothorax
A. Pt stable, may observe
B. Usually resolves spontaneously
C. O2 via NC @ ≥ 3L/min → 4-fold increase in the rate of pleural air absorption compared with room air alone
D. Close F/U

17

How is a moderate to large pneumo treated?

1. O2 as above
2. Chest tube insertion
3. Needle aspiration (primary spontaneous pneumo)
4. 1-way Heimlich valve insertion (> 48 hr → wall suction)

18

How is a tension pneumo treated?

1. Medical Emergency!
A. Insert large bore needle STAT, then chest tube placement w/continuous wall suction

19

When is a one-way heimlich valve used?

1. Used for stable ambulatory pt.
2. Used for persistent air leak after chest tube

20

What is the prognosis for pneumo?

1. Approximately 70% recover without recurrence

2. 30% of patients with spontaneous pneumothorax experience recurrence of disorder after first episode

21

What is chemical pleurodesis?

1. Procedure that artificially obliterates pleural space
2. Irritant (talc, minocycline, etc.) instilled inside the pleural space via chest tube to create inflammation that tacks the two pleura together permanently
3. Pre-medicate for pain

22

When is a chemical pleurodesis indicated?

1. Repeated pneumothoraces , not good candidates for surgery
2. Severe recurrent pleural effusions

23

Define pleural effusion

Excess of fluid in pleural space

Normally this space contains a small amount of extracellular fluid that lubricates the pleural surfaces

Increased production or inadequate removal

24

What is the normal pleural physiology?

1. Balanced osmotic and hydrostatic pressures in parietal pleural capillaries normally result in movement of fluid into pleural space

2. Balanced pressures in visceral pleural capillaries promote reabsorption of this fluid

25

What are the 4 types of pleural effusions?

Transudate
Exudate
Empyema
Hemothorax

26

Define transudate pleural effusion

Excessive hydrostatic pressure or decreased colloid osmotic pressure can cause excess fluid to pass across intact capillaries

27

What is the characteristic finding in transudate pleural effusion?

Low protein fluid

28

What are the causes of transudate pleural effusion?

1. CHF (most common)
2. Hepatic disease w/ ascites
3. Hypoalbuminemia

29

What are the characteristics of exudate pleural effusion?

1. Results from increased capillary permeability
2. May or may not have asst hydrostatic or colloid osmotic pressure changes
3. High protein fluid

30

What are the causes of exudate pleural effusion?

1. Malignancy
2. Bacterial pneumonia
3. TB
4. Asbestosis
5. Sarcoidosis
6. Collagen disease
7. SLE

31

Define Empyema

1. Infection in the pleural space
2. Pus in pleural space

32

What are the causes of empyema?

1. Pneumonia (70%)
2. Carcinoma
3. Lung abscess
4. Iatrogenic (20%)
A. Chest surgery
B. Thoracentesis

33

Define Hemothorax

Bleeding into the pleural space

34

What are causes of hemothorax?

Chest trauma
Malignancy
Iatrogenic

35

What are the sxs of a small PE?

1. Pleuritic pain (pleurisy)
2. Pleural friction rub

36

What are the sxs of a large or bilateral PE?

1. Dyspnea
2. Orthopnea (asst with CHF effusion)
3. Dullness to percussion
4. ↓ breath sounds
5. Mediastinum may be shifted away from side of effusion

37

What are the CXR results in PE?

1. Blunting of costophrenic angle
2. Loss of sharp demarcation of diaphragm and heart
3. Mediastinal shift to uninvolved side

38

What are the lateral decubitus xray results in PE?

1. Identify small effusions
2. Differentiate free flowing vs. loculated fluid

39

When is a CT chest indicated in PE?

Small effusions
R/O tumor

40

What is the gold standard for diagnosing the type of fluid present in a PE?

Thoracentesis

41

How is the PE fluid analyzed?

Fluid analysis:
WBC & differential count
Glucose
Cytology
Gram stain/ C&S
Protein
LDH
pH

42

What are the characteristics of transudative fluid?

1. Color: clear
2. Consistency: thin and watery
3. pH: Alkaline
4. Glucose: normal
5. LDH: <3 gm/dl
7. Cell Count: low, no or few WBCs & RBCs
8. Bacteria: None

43

What are the characteristics of Exudative fluid?

1. Color: cloudy, white
2. Consistency: thick and creamy, contains tissue fragments
3. pH: Acid
4. Glucose: Low
5. LDH: >200 IU
6. Protein: High, >4gm/dl
7. Cell Count: High, many WBCs & RBCs
8. Bacteria: May be present

44

What is the treatment for exudate effusions?

1. Treat underlying problem
2. Pleurodesis if recurrent
3. Pneumonia
A. Thoracentesis
B. Antibiotics

45

What is the treatment for transudate effusions?

1. Thoracentesis
2. Treat underlying problem

46

What is the treatment for empyema effusions?

1. Thoracentesis
2. Antibiotics

47

What is the treatment for hemothorax effusions?

Thoracentesis

48

What is the treatment for pneumonia effusions?

1. Thoracentesis
2. Empiric TB protocol until Cx results

49

What is the treatment for malignant effusions?

1. Thoracentesis, prn
2. Chemo
3. Radiation Tx
4. +/- surgery