Pleural Diseases Flashcards
(92 cards)
1
Q
Pleural space is lined with what cells?
A
mesothelial cells
2
Q
What pneumothorax mean?
A
Accumulation of air in the pleural space
air in the lungs
3
Q
What are the types of pneumothorax?
A
Spontaneous (primary and secondary)
Tension
Iatrogenic
4
Q
What causes primary spont. pneumothorax?
A
Rupture of subpleural blebs (more common in tall thin young males)
5
Q
What is pneumothorx secondary result to?
A
Airway and pulmonary disease: COPD [most common], Asthma, CF ILD: pulmonary fibrosis, sarcoidosis Infectious: TB, HIV Catamenial Older patients with pulmonary diseases
6
Q
What are the symptoms of PTX?
A
sudden onset dyspnea
pleuritic chest pain
7
Q
What is the first investigation for PTX suspicion?
A
CXRAY
- there are faint line markings
- collapsed lung
8
Q
Whats treatment for PTX?
A
100% O2 –> displaces N2 from capillaries –> higher gradient of N2 in pleural space
OR
Chest tube to drain the air
9
Q
What kind of PTX develops from trauma?
A
tension pneumothorax
10
Q
What happen in tension PTX?
A
Air enters pleural cavity but cannot leave
11
Q
T or F: Tension pneumothorax is a medical emergency
A
T:
bc the pleural pressure can start compressing on vessels –: life threatening
12
Q
What is treatment for tension PTX?
A
Thoracentesis or Chest tube placement
13
Q
T or D: trachea deviates to affected side
A
F:
Spontaneous it goes to affected side
Tension goes away
14
Q
What is pleural effusion?
A
accumulation of fluid in pleural space
15
Q
What can be seen on CXR for Pleural effeusions?
A
no or blunted costophrenic reccess
miniscus sign
less black lung field
16
Q
What are the etiologies of pleural effusions?
A
Transudative
Exudative
Lymphatic
17
Q
What is transudative effusions?
A
high hydrostatic pressure or very little protein in blood drive fluid from capillaries into pleural space
18
Q
What can cause low protein?
A
nephrotic syndrome (low protein) cirrhosis (low albumin)
19
Q
What is exudative effusions?
A
fluid (ie. plasma and proteins) leaking to pleural space due to high vascular pneumonia
20
Q
What are causes of exudative effusions?
A
malignancy
pneumonia
21
Q
Whats the treatment for exudative?
A
drainage (as opposed to rectify underlying cause)
22
Q
How to differentiate between transudative and exudative?
A
perform thoracentesis then test for protein and LDH:
Use then Light’s criteria:
Exudate if:
pleural protein/serum protein ratio greater than 0.5
Pleural LDH/serum LDH greate rthan 0.6
pleural LDH greater than 2/3 upper limits normal LDH
23
Q
What is chylothorax?
A
Lymphatic effusions
24
Q
When does a lympatic pleural effusion happen?
A
from thoracic duct obstruction/injury (ie. fluid backs up and then floods to pleural space) due
- Malignancy OR
- surgical trauma
25
Whats the characteristics of lymphatic effusions?
milky-appearing fluid
| very high triglycerides
26
What are other types of effusions?
- hemothorax
| - empyema (infection of pleura)
27
What is a mesothelioma?
pleural tumor due to asbestos exposure (ie. from shipyards)
28
What is seen in CXR for mesothelioma?
pleural thickening with maybe pleural effusions
29
What are the symptoms of mesothelioma?
dyspnea, cough, chest pain
30
What is work-up for suspected pleural effusion?
US-guided thoracentesis
31
What are the functions of the pleura?
Facilitates movement of lungs
Mechanical support
Inflation: maintain shape & limit expansion
Deflation: increase elastic recoil
Route of escape for alveolar edema
32
What is the characteristics of a normal pleura?
- Volume: ~ 0.26 mL/kg = 18.2 mL in 70kg man
- low-protein (<15 g/l) filtrate containing few cells
- No RBCs
33
Where does the fluid in pleura come from?
systemic vessels that supply the parietal and visceral pleura
34
Where does the pleural fluid drain?
lymphatic stoma
35
What can cause pleural effusions?
Increased fluid entry (must be >30x normal)
| Decreased fluid clearance
36
What is the equation for flow?
Flow = Permeability x (Hydrostatic pressure – Osmotic pressure)
37
What can cause increased fluid entry?
```
Increased hydrostatic pressure (CHF)
Increased permeability (infection, ARDS)
Decreased osmotic pressure (nephrotic syndrome, cirrhosis)
```
38
What can cause decrease fluid clearance?
Lymphatics have one-way valves that propel lymph using rhythmic contractions and respiratory movements of chest
Flow is affected by intrinsic and extrinsic factors
39
What instrinic factoes?
Cytokine production
Injury due to radiation or drugs
Infiltration of lymphatics by cancer
40
What are extrinsic factors?
Extrinsic compression of lymphatics (pleural fibrosis)
| Blockage of lymphatic stoma (pleural malignancy ie. mesothelioma)
41
T or F: pleural effusion lead to increased work of breathing and dyspnea
T
Chest wall recoils outward, and lungs recoil inwards --> mechanical inefficiency
***Remember pleural pressure is due to patient effort***
42
T or F: physical maneuvers are relatively insensitive
T
| cannot detect fluid less than 300 mL
43
What physical findings would be present in pleural effusion?
Dullness to percussion
Decreased chest wall movement
Decreased tactile fremitus
Absent breath sounds
Bronchial breath sounds and Egophony at top of pleural effusion
44
What physical findings would be present in consolidation?
```
Dullness to percussion
Decreased chest wall movement
Increased tactile fremitus
Bronchial breath sounds
Egophony
```
45
Can chest xray help in the detection of pleural effusion?
YES PA & Lateral scans can BUT fluid greater than 150 mL
- especially lateral decubitus (side down)
46
what is thoracic ultrasound usually help in?
helps to guide thoracentesis procedure
47
T or F: thoracic ultrasound is highly sensitive and specific for the detection of pleural fluids
T:
| able to detect 10-50 mL
48
Which diagnostic imaging tool is more sensitive than TUS?
CT chest
49
T or F: thoracentesis is only diagnostic
F:
| Diagnostic and therapeutic
50
What are contraindications for thoracentesis?
- bleeding disorder
- anticoagulation meds
- no consent/cooperation
- small pleural effusion
- cutaneous disease at injection site
- on mechanical ventilation
51
What are some complications of thoracentesis?
```
Pneumothorax
<3% with ultrasound
Up to 12-30% without ultrasound
Hemothorax
Infection – cellulitis/empyema
Puncture of abdom structures (i.e. liver, spleen)
Rare with ultrasound
Re-expansion pulmonary edema
```
52
Is Light's criteria sensitive and specific?
Yes! (Sens 98%, Spec 83%)
53
T or F: in transudative effusions, pleural capillaries are normal
T:
| Due to imbalance between hydrostatic [congestive heart failure] and oncotic pressure [nephrotic sydrome/cirrhosis]
54
Will thoracentesis work for transudative effusions?
No - the underlying cause must be treated
55
What is causes exudative effusions?
implies the leakage of protein-rich plasma across an injured endothelial barrier
56
What may cause exudative effusions?
Infection:
Parapneumonic effusion
Empyema
Malignancy:
Lung
Lymphoma
Mesothelioma
Pulmonary Embolism/Infarction
Trauma
57
After a fluid from thoracentesis for diagnostic, what workups should follow?
```
Cell count and differential
Total Protein
Lactate dehydrogenase (LDH)
Glucose
Gramstain and Culture
Cytology
```
Blood should be sent at the same time for LDH and Total protein levels
58
What are the treatment if chylothorax is present after thoracentesis?
Restrict lipid intake and treat cause
59
What are the treatment if hemothorax is present after thoracentesis?
Consider chest tube insertion; consider referral to thoracic surgery
60
The pleural effusion is exudative and has a pH less than 7.2, what does it suggest?
Complicated parapneumonic effusion/Empyema
Esophageal rupture
Rheumatoid arthritis
61
The pleural effusion is exudative and has a glucose less than 3.4mmol/L, what does it suggest?
Complicated parapneumonic effusion/empyema
62
The pleural effusion is exudative and has a RBC greater than 100,000 cells/mm^3 less what does it suggest?
Malignancy
63
The pleural effusion is exudative and has a hemotocrit greater than 50% of systemic, what does it suggest?
Hemothorax
64
The pleural effusion is exudative and has a lymphocyte count greater than 50%, what does it suggest?
Lymphoproliferative disorder
| Other malignancy
65
The pleural effusion is exudative and has increased pleural eosinophil count, what does it suggest?
```
Air in the pleural space = PNEUMOTHORAX
Blood = HEMOTHORAX
Idiopathic
Drugs:Sulfasalazine, Nitrofurantoin, epival
Benign Asbestos-related pleural disease
```
66
Increased eosinophil (PFE, also called eosinophilic pleural effusion) happensat different rates in spont. pneumothorax ans hemothorax, elaborate:
In contrast to the rapid development of PFE after spontaneous pneumothorax, PFE is delayed following hemothorax, typically appearing by the tenth day,
67
The pleural effusion is exudative and has amylase level greater than Upper Lower limits of normal (ULN) for serum, what does it suggest?
Esophageal rupture
Pancreatitis
Malignancy
68
What does Elevated pleural fluid triglyceride levels (>1.24mmol/L) in exudative fluid suggest?
Chylothorax
69
If the values for pleural effision fluid falls between exudative and transudativem how can you differentiate?
Serum protein – pleural protein > 31 g/L
| = TRANSUDATE
70
What to do if diagnosis fails after 1st thoracentesis?
REPEAT THORACENTESIS
BRONCHOSCOPY – suspicion of lung cancer
CLOSED PLEURAL BIOPSY – suspicion of tuberculosis
71
What happens if 1st thoracentesis and other further diasgnostic tool cannot pinpoint a diagnosis?
Thorascopy (provides 92% diagnosis for NYD)
72
When would you to bronchoscopy for pleural effusion?
hemoptysis
| CT chest findings concerning for lung cancer
73
When would you do drainage for pleural effusions?
For transudative effusions, usually unsuccessful and rarely part of the management
For exudative effusions, often a necessary component of the treatment plan
74
What are some options for aggressive drainage?
```
Tube thoracostomy (chest tube insertion):
CT- or ultrasound-guided
```
Thoracic surgery referral:
Thoracoscopy
Open surgical drainage/decortication
75
What is pleurodesis?
Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae
76
How can pleurodesis be achieved?
Chest tube + Sclerosing agent
| Thoracoscopy + Rough pad
77
What would you do if fluid re-accumulate/continue to cause symptoms ?
Pleurodesis:
Surgical
Thoracostomy
Indwelling pleural catheter
78
What is the etiologies of pneumothorax?
Rupture of visceral pleura with secondary airleak from lung
Rupture of bronchus or trachea
Rupture of esophagus
Loss of integrity of chest wall
79
What are physiological effects of pneumothorax?
```
Apex to base pressure gradient
Lung compliance
FRC
Ventilation
Oxygenation
Progressive shift of the mediastinum
Decreased venous return to the heart → obstructive shock
```
80
What are some symptoms of pneumothorax?
Sudden
Chest pain
Shortness of breath
81
What are signs of PTX?
```
Tachypnea / tachycardia
Hypoxia
Hypotension
Elev. JVP
Dec breath sounds
Hyperessonance
Tracheal deviation
```
82
What are blebs?
Blebs – small, subpleural collection of air resulting from ruptured alveoli
- apex of upper/lower lobe
83
What are bullae?
large air filled spaces within the lung associated, with any form of emphysema
84
How to diagnose PSP?
Symptoms / signs
C- x-ray – PA film with insp. & exp. views
Quantification – nomograms vs. description
CT scan – only used in complicated pneumothorax
85
What is management for PSP?
Observation – select few; small asymptomatic p.; resolving; good follow up
Tube thoracostomy – most common & safe;can be ambulatory or in hospital; lung must be reexpanded
Chemical pleurodesis - tetracycline, talc
- only used if patient refuses surgery or is high risk
- induces pleural fibrosis and adhesions
86
What are some surgical therapy for PSP?
Resect blebs
Obliterate the pleural space
- apical pleurectomy
- pleural abrasion
87
What is the risk of recurrence based on the given therapeutic intervention?
Observation – 30%
Chest tube – 20-30 %
Chemical pleurodesis – 7-20%
Surgery – 2-5%
88
T or F: secondary spontaneous pneumothorax has higher motarlity
T
89
What is catamenial pneumothorax?
associated with menstration ( 48-72 hrs) in 20-30yrs old where air reaches chest from cervix via diaphragm pleural endometrial implants
90
Where is needle thorascotomy performed?
2nd intercostal space , mid clavicular line
91
What always follows needle thorascotomy?
Chest tube
92
Where is the chest tube placed?
mid axillary line, in line with nipple
