Flashcards in Pleural Diseases Deck (56):
What is the pleura?
serous membranes, consists of mesothelial cells, CT
Visceral-covers lungs and adjoining structures
Parietal- attached to CW, covers the diaphragm
What is pleuritis?
inflammation or irritation of the pleura
the 2 layers rub together which produces pain with inhalation and exhalation
What are some causes of pleuritis?
Infection, autoimmune disorder, PE, pneumothorax, lung CA, rib , meds, sick cell disease, post op...
Sxs of pleuritis?
Sharp CP worse with breathing, coughing, sneezing. May radiate to shoulders/back
+ other signs and sxs depending on underlying cause: fever, chills, SOB, etc.
PE findings of pleuritis?
pleural friction rub
Can you see pleuritis on CXR?
NO, it is a clinical dx
Work up for pleuritis?
CXR- look for pna, pleural effuse, mass..
CTA chest- r/o PE
Tx of pleuritis?
NSAIDS --> try for 2/3 wks and re-eval
Steroids for refractory pain
treat the underlying cause
involvement of lung, pleura and pulmonary vasculature is common in SLE
pleurisy can be first sign of disease
Serological testing for SLE
ANA if +
anti-dsDNA, anti-Sm, etc.
Tx for lupus pleuritis?
Common signs of rheumatoid pleuritis? tx?
pleuritic CP, fever, +/- dyspnea
What is a pleural effusion?
Abnormal fluid collecting in the pleural space as a result of excess fluid production and/or decreased lymphatic absorption
How much fluid is normally contained in the pleural cavity?
Causes of pleural effusion?
can be caused by lots of disorders.
most caused by: CHF, pna, malignancy, pulmonary embolism
What are the 2 different categories of pleural effusions?
1. Transudative effusions
2. Exudative effusions
sxs of pleural effusion?
dyspnea, cough, pleuritic CP
PE findings in pt with pleural effusion?
dullness to percussion, decrease/absent tactile fremitus, decreased BS, no voice transmission
How can you dx pleural effusion?
CXR-pleural fluid may blunt costophrenic angle and form a meniscus laterally (lat decubitus view is most sensitive)
CT chest/ US
Indications for thoracentesis?
-newly dx pleural effusion (for dx purposes)
- Atypical feat. in CHF
- therapeutic sxs relief
-if imaging suggests complicated effusion: loculated, empyema
Contraindications for thoracentesis?
small volume of fluid (risk for pneumothorax), skin infx at needle site, mechanical ventilation, uncooperative pt
Potential complications of thoracentesis?
pain at puncture site, int. bleeding, pneumothorax, empyema
What is Light's criteria used for?
to differentiate transudate v. exudate
exudate if one of following:
-ratio of pleural fluid protein: serum protein >0.5
-ratio of pleural fluid lactate dehydrogenase: serum LDH >0.6
-pleural fluid LDH level > 2/3 of the upper limit of norm serum LDH
What causes transudative effusions?
systemic imbalances in hydrostatic and oncotic forces
i.e HF, atelectasis, nephrotic syndrome, hepatic hydrothorax
What causes exudative effusions?
occurs when local factors influencing accumulation of pleural fluid are altered
increased pleural capillary permeability leads to elevated protein/cellular content
i.e. malignancy, infection, PE, post cardiac injury
Long term management of pleural effusion?
-tx underlying illness
-pleurX catheter (refractor effusions)
-Pleurodesis (obliterates pleural space)
What is a pneumothorax?
presence of air/gas in the pleural cavity
Primary spontaneous pneumothorax? Secondary spontaneous pneumothorax?
occurs w/o precipitating event in person w/o known lung disease
occurs as comp. of an underlying lung disease
When does a pt have the highest risk for recurrent pneumothorax?
within the first 30 days
risk factors for pneumothorax?
Presentation of spontaneous pneumothorax?
usually in 20s
tall, thin, young men 20-40
sudden onset dyspnea and pleuritic CP
pain is usually unilateral and can be sharp, agonizing and associated with considerable apprehension
PE findings in pt with spontaneous pneumothorax?
decreased chest expansion on one side
diminished BS, hyperresoinant percussions, labored breathing, subcutaneous emphysema
How can you dx spontaneous pneumothorax?
1st line: CXR, CT chest
blebs and bullae can...
rupture and cause pneumothorax
they are seen in COPD
What US finding would you seen in a pt with a pneumothorax?
absence of "sliding lung sign"
used when dx needed emergently at bedside
Tx of spontaneous pneumothorax?
100% oxygen administration
If small (<2-3cm) --> observe if clinically stable
If large (>3cm)--> needle aspiration
Recurrent --> chest tube insertion
Unstable --> chest tube
When can you discharge a pt with a pneumothorax?
After observing for at least 6 hrs
CXR must demonstrate NO progression of pneumothorax
How do you perform a needle aspiration?
1. needle inserted in 2nd intercostal space in midclavicular line
2. catheter left in place & attached to a 3 way stopcock and large syringe
3. air is aspirated until resistance is met of pt starts coughing
4. repeat CXR to document lung re-expansion
Indications for chest tube?
no response to needle aspiration, secondary spontaneous pneumothorax (SSP), recurrent pneumothorax, hemothorax
Clinical presentation of SSP?
generally more severe than PSP - have less reserve due to underlying lung disease
CXR in pt with SSP?
may be difficult to distinguish from underlying bleb, emphysematous changes
Tx for SSP?
almost all will require drainage
tuve thoracostomy > needle aspiration
What is a tension pneumothorax?
occurs in 1-2% of PSP
Presentation of tension pneumothorax?
worsening dyspnea, hypotension, diminished BS on affected side, distended neck veins, tracheal deviated away from the affected side
Tx of tension pneumothorax?
needle decompression can be used temporarily until chest tube is placed
What is acute respiratory distress syndrome?
acute hypoxemic respiratory failure following a systemic or pulmonary insult w/o evidence of HF
Clinical findings in ARDS?
bilateral radiographic opacities and hypoxemia
Pathologic findings in ARDS?
diffuse alveolar damage
ARDS is a...
dx of exclusion
Berlin definition to dx ARDS?
-Acute onset w/in 1 week of a known clinical insult
-B/L radiographic pulmonary infiltrates
-Respiratory failure not fully explained by HF or volume overload
-Moderate-severe oxygenation impairment
Pathophys of ARDS?
acute/diffuse inflammatory lung or systemic disease-> damage to pulmonary capillary endothelial cells and alveolar epithelial cells -> increased vascular permeability (and decreased surfactant) -> pulmonary edema and alveolar collapse --> hypoxemia
What are some systemic insults? pulmonary insults?
sepsis, shock, trauma, multiple blood transfusions, burns, etc.
diffuse PNA, aspiration, lung contusion, etc.
clinical presentation of ARDS?
sig. SOB 6-62 hrs after inciting event, worsen quickly
respiratory distress, accessory muscle use, tachypnea, tachycardia, diaphoresis
hypoxemia that is unresponsive to O2
other signs of multiple organ failure
Dx tests for ARDS?
CXR, CT chest
typically see: diffuse/patchy B/L infiltrates, usually spare the costophrenic angels
- pleural effusions, enlarged heart
ABGs: hypoxemia, acute respiratory alkalosis
tests to r/o other conditions: BNP, echo, blood cultures
Tx for ARDS?
identify initial systemic/pulmonary insult and tx
Prone positioning (turn bed upside)
prompt tx VAP