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pleural disease Flashcards

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1
Q

define pleuritis

A

inflammation or irritation of the pleura

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2
Q

pleuritis is both a ____ and ____

A

symptom and disease

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3
Q

keep a wide ddx for pleuritis, what would be in the ddx?

A 
MI
aortic dissection
HF
pericarditis
malignancy
PNA
asthma/COPD
esophagitis
esophageal rupture
costochondritis
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4
Q

what is the main cause of pleuritis?

A

viral

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5
Q

what is the clinical presentation of pleuritis?

A

SHARP chest pain aggravated by breathing, coughing and sneezing
may radiate to the shoulders and back
fever, chills, cough, SOB, pharygnitis, weight loss, arthralgias, rash

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6
Q

what may you see on physical exam with pleuritis?

A

pleural friction rub (sounds like scratching Velcro)

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7
Q

how to diagnose pleuritis?

A

clincial dx
can do:
CXR - PNA, pleural effusion, pneumothorax, rib fracture
CTA chest - PE
serology - sickle cell anemia, infection, rheumatologic disease

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8
Q

how to treat pleuritis?

A

NSAIDS naproxen 250-500mg q12h

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9
Q

if NSAID does not work, what can you take instead?

A

stop NSAID and start prednisone 20mg/d followed by a 2-3 week taper

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10
Q

define lupus pleuritis

A

involvement in lung, pleura, and pulmonary vasculature
usually manifests as pleuritic CP +/- pleural effusion
exudative effusion

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11
Q

how do you treat lupus pleuritis?

A

NSAIDS

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12
Q

what testing do you do for lupus pleuritis?

A

serologic testing for SLE

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13
Q

common signs of rheumatoid pleuritis?

A

pleuritic CP, fever, +/- dyspnea

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14
Q

what causes rheumatoid pleuritis?

A 
exudative "rheumatoid" effusion
drug-induced pleuritis
empyema
bronchopleural fistula
hemopneumothorax
pyopneumothorax
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15
Q

how do you treat rheumatoid pleuritis?

A

NSAIDS

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16
Q

what causes pleural effusion?

A

excess fluid production

decreased lymphatic absorption

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17
Q

what do you look for on the CXR for pleural effusion?

A

meniscus sign
white out from the fluid
blunted angle

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18
Q

how is the pleural cavity maintained?

A

balance of hydrostatic and oncotic pressures in the pleural capillaries
persistent lymphatic drainage

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19
Q

what are potential mechanisms of pleural effusion?

A

reduction in intravascular oncotic pressure -
hypoalbuminemia
increased capillary hydrostatic pressure -
CHF
altered permeability of the pleural membrane -
inflammation
increased capillary permeability or vascular disruption - PNA
decreased lymphatic drainage - maligancy
increased peritoneal fluid with microstructural diaphragmatic defect -
hepatic hydrothorax
thoracic duct rupture -
chylothorax
decreased intrapleural pressure - atelectasis

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20
Q

majority of pleural effusions are result of?

A

CHF
PNA
malignancy
PE

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21
Q

pleural effusions are separated into two distinct categories, what are they?

A
  1. transudative effusions

2. exudative effusions

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22
Q

what comorbidities are related to pleural effusions?

A 
SLE
RA
hypothyroidism
amyloid
hepatic disease
pancreatic disease
kidney failure
CHF
hypercoagulable state
malignancy
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23
Q

what drugs in the hx should you pay attention to for pleural effusion?

A

nitrofurantoin
amiodarone
ovarian stimulation therapy

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24
Q

what occupational exposure should you pay attention to for pleural effusions?

A

asbestos

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25
what is the clinical presentation of a pt with pleural effusion?
dyspnea cough pleuritic chest pain
26
what are the physical exam findings for pleural effusion?
dullness to percussion decreased or absent tactile fremitus decreased breath sounds no voice transmission
27
what is the best CXR view for pleural effusion?
lateral decubitus view can detect as little as 50cc of fluid
28
how much fluid is needed before PA/LAT CXR can detect?
300cc
29
what diagnostic test is more sensitive than CXR?
CT chest/US | we don't start here because of radiation/expensive
30
when do we want CT chest/US for pleural effusion?
if we suspect malignancy in undiagnosed pleural effusion
31
when do we consider CT Angiogram?
to r/o PE if suspicion is high
32
when do we consider pleural biopsy?
if pleural TB is suspected
33
where do we perform thoracentesis?
1-2 intercostal spaces below the height of the effusion | *thoracentesis helps distinguish the etiology of the fluid
34
what are indications for thoracentesis?
newly detected pleural effusion for dx purposes therapeutic symptom relief empyema if imaging suggests complicated effusion
35
what are contraindications for thoracentsis?
small volume of fluid (<1cm thickness on lateral decubitus film) high risk for pneumothorax
36
what are complications for thoracentesis?
pain at puncture site internal bleeding pneumothorax empyema
37
what does black pleural fluid represent?
aspergillosis
38
what does yellow-green pleural fluid represent?
rheumatoid pleurisy
39
what does ammonia odor represent?
urinothorax
40
what do food particles represent?
esophageal rupture
41
what does bloody pleural fluid represent?
trauma, malignancy, pulmonary infarct
42
what does white pleural fluid represent?
chylothorax, empyema
43
what does brown pleural fluid represent?
amebic liver abscess draining into pleural space?
44
what does viscous pleural fluid represent?
malignant mesothelioma
45
define Light's criteria
used to differentiate transudate vs exudate exudative effusion if one the following three is present: 1. ratio of pleural fluid protein to serum protein is > 0.5 2. ratio of LDH to serum LDH is > 0.6 3. LDH > 2/3 of the upper limit of normal for serum LDH
46
what are major causes of transudative effusions?
HF nephrotic syndrome hepatic hydrothorax
47
what are major causes for exudative effusions?
malignancy postcardiac injury infectious PE
48
what are long-term management strategies for pleural effusion?
PRN thorancentesis | pleurodesis (surgical, chemical)
49
define pneumothorax
present of air/gas in the pleural cavity | usually spontaneous
50
differentiate primary spontaneous pneumothorax (PSP) vs secondary spontaneous pneumothorax (SSP)
PSP occurs w/o a precipitating event in person without known lung disease SSP occurs as a complication of an underlying lung disease
51
what are facts on PSP?
males > females highest risk in first 30 days smoking is #1 risk factor
52
what is the clinical presentation of a pt with spontaneous pneumothorax?
tall, thin, young men from age 20-40 sudden onset of dyspnea and pleuritic CP pain is usually unilateral and can be sharp
53
what are physical exam findings for spontaneous pneumothorax?
decreased chest expansion on one side hyperresonant percussions labored breathing
54
what is the 1st line diagnostic for spontaneous pneumothorax?
CXR or CT chest
55
what ruptures and can cause pneumothorax?
blebs
56
what diagnostic do we use if we need spontaneous pneumothorax diagnosis emergently?
US at bedside
57
absence of _______ in US indicates pneumothorax?
"sliding lung sign" - small lung with fluid around it
58
what do we give to treat spontaneous pneumothorax?
100% oxygen administration
59
how do we treat small pneumothorax (2-3 cm between lung and chest wall on CXR)
observe
60
how do we treat large pneumothorax (>3cm between lung and chest wall)?
needle aspiration
61
how do we treat recurrent PSP or concomitant hemothorax?
chest tube insertion
62
in spontaneous pneumothorax, what does observation consist of?
should be at least 6 hours | CXR must demonstrate no progression of pneumothorax
63
define needle aspiration in pneumothorax
1. needle inserted in 2nd ICS in midclavicular line 2. catheter is left in place 3. air is aspirated until resistance is met 4. repeat CXR immediately after aspiration and again in 4-24 hours to document lung re-expansion
64
what are indications for chest tube insertion?
no response to needle aspiration SSP recurrent pneumothorax hemothorax
65
define chest tube insertion
connected to a water-seal device left in place until pneumothorax resolves clamp chest tube for ~12 hours before removing and repeat CXR to ensure resolution
66
what are the indications for VATS procedure?
``` persistent air leak recurrence chest tube required on first occurrence job where recurrent could be harmful to others (i.e. pilot) bleb/bullae resection ```
67
what are etiologies of SSP?
COPD CF catamenial (thoracic endometriosis)
68
how to treat SSP?
hospitalize mostly all will require drainage tube thoracostomy preferred over needle aspiration smoking cessation
69
what is the clinical presentation of tension pneumothorax?
``` medical emergency worsening dyspnea hypotension diminished breath sounds distended neck veins tracheal deviation ```
70
how to treat tension pneumothorax?
immediate decompression | chest tube needs to be placed
71
define ARDS
acute hypoxemic respiratory failure following a systemic or pulmonary insult w/o evidence of HF
72
what are the hallmarks for ARDS?
clinical: bilateral radiographic opacities and hypoxemia pathologic: diffuse alveolar damage
73
ARDS is what type of diagnosis?
diagnosis of exclusion
74
what is required for dx ARDS (berlin definition)?
1. acute onset w/in 1 week of a known clinical insult 2. B/L radiographic pulmonary infiltrates 3. respiratory failure not explained by HF 4. moderate-severe oxygenation impairment (ratio of PaO2 to FiO2 <300 mmHg)
75
what is the pathophysiology of ARDS?
1. acute, diffuse, inflammatory lung or systemic injury 2. damage to pulmonary capillary endothelial cells and alveolar epithelial cells 3. increased vascular permeability and decreased production and activity of surfactant 4. pulmonary edema and alveolar collapse 5. hypoxemia
76
what are the most common causes of ARDS?
PNA sepsis aspiration
77
about how many blood transfusions causes ARDS?
>15 and develops about 6 hours after being transfused
78
what are the clinical presentations for ARDS?
significant SOB 6-72 hrs after inciting event and worsen quickly respiratory distress hypoxemia that is unresponsive to supplemental O2 diffuse crackles cyanosis
79
what do you typically see in CXR/CT chest for ARDS?
diffuse/patchy B/L infiltrates | usually spares the costophrenic angles
80
pt with ARDS in acute respiratory acidosis or alkalosis?
respiratory alkalosis
81
how to treat ARDS?
``` supportive care intubation and mechanical ventilation hemodynamic monitoring nutrition support DVT and GI prophylaxis (DVT- SC heparin or lovenox and GI- PPI) ```

foundations pulm exam (10 decks)

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