Pleural Disorders Flashcards
(61 cards)
1
Q
the serous membrane lining the thorax (chest wall) and enveloping the lungs
A
pleura
2
Q
which pleura is attached to the chest wall?
A
parietal
the parietal and visceral pleura are continuously connected
3
Q
which pleura covers the lungs, blood vessels, bronchi and nerves?
A
visceral pleura
the parietal and visceral pleura are continuously connected
4
Q
the thin serous fluid-filled (potential space) between the two pulmonary pleura
A
pleural cavity
Radiographically not visualized unless there is pathology
5
Q
fills the pleural space/cavity; helps the two layers of pleura glide smoothly past each other during breathing
A
Pleural fluid
6
Q
3 Disorders of the Pleura
A
- Pleurisy - Inflammation of parietal pleura that causes sharp pain with breathing
- Pneumothorax - Buildup of air or gas in the pleural space
- Pleural Effusion - Excess fluid in the pleural space
7
Q
pain fibers are located in the _____, when it becomes inflamed, what happens?
A
parietal pleura
the normal gliding between the 2 pleura incites pain
8
Q
a common cause of noncardiac chest pain
A
pleuritis / pleurisy
9
Q
9 causes of pleurisy
A
- Respiratory Infection
- viral (ex: influenza)
- bacterial(ex: pneumonia or TB)
- fungal - Lung cancer near the pleural surface
- Trauma: Rib fracture
- medications
- procainamide, hydralazine, and isoniazid - PE
- CHF
- Autoimmune disorder
- lupus (SLE), rheumatoid arthritis,or scleroderma - GI disorders
- pancreatitis, peritonitis, cholecystitis - Idiopathic
10
Q
- chest pain localized, sharp “knifelike”, fleeting pain that is worsened by inspiration, sneezing or coughing
- radiation to ipsilateral scapula
- cough, SOB , fever, myalgias, headache, nasal congestion (infectious etiology)
- abd pain, N/V (GI etiology)
- orthopnea, paroxysmal nocturnal dyspnea (PND), peripheral edema (CHF related)
- pleural friction rub, decreased breath sounds
what is the possible dx?
A
Pleurisy
- worsened by inspiration, sneezing or coughing - “pleuritic chest pain”
- radiation of pain to ipsilateral scapula may occur if diaphragmatic pleura is affected
11
Q
testing for pleurisy
A
- EKG - normal unless cardiac etiology
- CXR - findings will depend on underlying etiology
- Rib X-ray series - rule out rib fx if history of trauma
- labs (case based) - CBC, cardiac enzymes, BNP, pancreatic enzymes inflammatory markers (ESR, CRP), ANA/RF (autoimmune workup)
- CT chest with contrast / CT angiography of the chest
12
Q
management for pleurisy
A
- Treat underlying cause (if identified)
- Decide on pt disposition - Admit if:
- hypoxemic (O2 sat of <90%)
- parenteral pain control is needed
- underlying etiology requires hospitalization -
NSAIDs or other analgesics
indomethacin 25 mg BID-TID (short course - < 7-10 d) - Cough suppressant - any OTC cough suppressant
- Codeine 30-60 mg TID - good option for pain and cough suppression
- Dextromethorphan combination products
- Tessalon Perles
- Be cautious of retention of airway secretions with cough suppressants - Antibiotics (if indicated)
13
Q
complications with pleurisy
A
pleural effusion - pain will improve transiently due to separation of pleura; SOB and cough will worsen
14
Q
a collection of fluid in the pleural space resulting from a disruption in the normal pleural homeostasis
A
Pleural Effusion
15
Q
Pleural fluid homeostasis is achieved via
A
- A constant movement of fluid from the capillaries of the parietal and visceral pleural into the pleural space
- Absorption of pleural fluid occurs through parietal pleural lymphatics
- The resultant homeostasis leaves 5–15 mL of fluid in the normal pleural space
16
Q
Five pathophysiologic processes account for most pleural effusions
A
- Increased production of fluid d/t increased hydrostatic or decreased oncotic (osmotic) capillary pressures (Transudates)
- Increased production of fluid d/t abnormal capillary permeability (Exudates)
- Decreased lymphatic clearance of fluid from the pleural space (Exudates)
- Infection (Empyema)
- Bleeding (Hemothorax)
17
Q
A fluid that passes through capillary wall, which filters out all the cells and much of the protein, yielding a watery solution
a filtrate of blood caused by an imbalance in hydrostatic and colloid osmotic pressure
what type of pleural effusion?
A
transudate
18
Q
A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues. The altered permeability of blood vessels permits the passage of large molecules and solid matter through their walls
what type of pleural effusion?
A
exudates
19
Q
causes of transudate pleural effusion
A
- Heart failure (> 90% of cases)
- Cirrhosis with ascites
- Nephrotic syndrome
- Peritoneal dialysis
- Myxedema
- Atelectasis (acute)
- Constrictive pericarditis
- SVC obstruction
- Pulmonary embolism
20
Q
cause of exudate pleural effusion
A
- Pneumonia (parapneumonic effusion)
- Cancer (MC) - lung and breast, lymphoma, leukemia
- Pulmonary embolism
- Bacterial pneumonia (MC)
- Tuberculosis
- Connective tissue disease
- Viral infection
- Fungal infection
- Rickettsial infection
- Parasitic infection
- Asbestos
- Meigs syndrome
- Pancreatic disease
- Uremia
- Chronic atelectasis
- Trapped lung
- Chylothorax
- Sarcoidosis
- Drug reaction
- Post–MI syndrome
21
Q
A detailed history should be obtained to help narrow ddx for pleural effusions, what do you have to ask for history?
A
- recent illness - URI, pneumonia
- chronic medical conditions
- liver, heart, kidney, cancer, alcoholism - trauma
- recent travel
- increased risk for PE
- TB endemic areas - Occupational hx - asbestos
- Medication hx - past/present
- TB exposure
- live or work in a homeless shelter
- migrant farm camp
- prison/jail
- nursing home
22
Q
Most common presenting symptoms of pleural effusion
A
dyspnea, cough, pleuritic chest pain
23
Q
Other symptoms may be related to underlying condition for pleural effusion (ROS is vital)
A
- Lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea (CHF)
- Night sweats, fever, hemoptysis, and weight loss (TB)
- Hemoptysis, weight loss (malignancy)
- Fever, purulent sputum, pleuritic chest pain (pneumonia)
24
Q
Clinical presentation of pleural effusions are likely to be dependent on what?
A
effusion severity
smaller effusions - less sx with normal PE
larger effusion - more sx with abnormal PE findings
25
clinical presentation on PE of pleural effusion
1. over area of effusion
- Diminished or absent breath sounds
- Dullness to percussion
- Decreased tactile fremitus
2. Diminished/delayed chest expansion on the side of the effusion
3. trachea away from effusion
- only with large effusions d/t increased intrapleural pressure
4. Other findings depends on underlying etiology
- Peripheral edema, JVD, and _S3 gallop_ (CHF)
- Peripheral edema (nephrotic syndrome or pericardial disease)
- Jaundice, ascites (liver disease)
- LAN, palpable mass (malignancy)
26
imaging for pleural effusion
1. CXR
- PA: blunting of costophrenic angle if > 175 ml (appx 6 oz) of fluid present
- Lateral decubitus - more reliable for smaller effusions
2. CT chest
- more sensitive > CXR in identifying small effusions
--- Can identify 10 ml of fluid
- Helpful in determining underlying pathology (i.e. pneumonia, PE, tumors)
27
2 management options for pleural effusions
1. Observation: Requires serial imaging and PEs
2. Thoracentesis: a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall to remove fluid
- most often via ultrasound guidance
28
indications for observation management
1. Benign etiology is the most likely cause
- overt CHF, viral pleurisy, recent thoracic or abd surgery
2. Small amount of pleural fluid and there is a secure clinical dx
29
Thoracentesis Indications for pleural effusions
1. _Diagnostic Indications_
- New onset pleural effusion without a clinically apparent cause
- Atypical presentation of pleural effusion in a HF pt
--- Ex: unequal bilat effusions, pleurisy, fever, concern for CA or infection, echo inconsistent with HF, lack of improvement after appropriate acute tx of HF
2. _Therapeutic Indications_
- Symptom relief
- Evidence of loculation on imaging
- Risk of pleural thickening/restrictive functional impairment
--- s/p primary or reactivation of TB, hemothorax
30
CI (absolute and relative) for thoracenesis
1. _Absolute CI_
- uncooperative pt
- cutaneous disease over the proposed puncture site
2. _Relative CI_
- bleeding diathesis or systemic anticoagulation
--- US guidance by experienced operator is recommended if benefit outweighs risk
- a small volume of fluid (**<1 cm thickness on a lateral decubitus film**)
--- safe if US guidance is utilized
31
caution with thoracentesis
mechanical ventilation - risk of tension pneumothorax if lung is punctured
32
complications with thoracentesis
1. pain at the puncture site
2. cutaneous or internal bleeding
- results from a laceration of an intercostal artery or spleen/liver puncture
3. pneumothorax
- use of a needle larger than a 20 gauge and a lack of US guidance increases risk
4. empyema
5. reexpansion pulmonary edema
6. malignant seeding of the thoracentesis tract
7. adverse reactions to anesthetics used in the procedure
33
initial pleural fluid evaluation
1. pleural fluid LDH
2. pleural fluid protein
3. serum LDH, albumin and globulin (proteins)
34
If exudative fluid is found on initial pleural fluid evaluation, additional testing needed:
1. cell count (RBC, WBC with differential)
2. gram stain, C&S
3. cytology (looking for malignant cells)
4. amylase
5. glucose
6. marker for TB
35
Light’s Criteria: If one or more of the following is met the fluid is exudative:
Pleural fluid protein : serum protein > 0.5
Pleural fluid LDH : serum LDH > 0.6
Pleural fluid LDH > ⅔ the ULN serum value
36
management for pleural effusion
1. tx underlying condition
2. _thoracentesis_ - transiently therapeutic for severe dyspnea
3. _tube thoracostomy_ for: empyema, complicated effusion, large or unstable hemothorax
- empyema/complicated effusion can rapidly coagulate and organize to form fibrous peels that might require surgical decortication
--- complicated effusions are often associated with pneumonia, lung abscess or bronchiectasis
- hemothorax - risk of hemorrhage and fibrous tissue formation
- **repeat CXR when drainage decreases to < 100** mL/day to _ensure complete drainage_
4. Pleurodesis - d/t limited life expectancy, goal is to palliate sx
37
Instillation of an irritant (sclerosing agent) to cause inflammatory changes that result in bridging fibrosis between the visceral and parietal pleural surfaces, effectively obliterating the potential pleural space
what is this intervention?
pleurodesis
38
indications for pleurodesis
recurrent effusions - often related to malignancy
39
The abnormal presence of air or gas in the pleural cavity
Pneumothorax
40
Pneumothorax classifications
1. Primary spontaneous pneumothorax
2. Secondary spontaneous pneumothorax
3. Traumatic pneumothorax
4. Iatrogenic pneumothorax
5. Tension pneumothorax
41
occurs in the absence of an underlying lung disease most frequently in smokers
etiology is unknown - often a sign of early lung disease with _rupture of subpleural apical blebs_ (small cystic spaces under visceral pleura) in response to high negative intrapleural pressures
what type of pneumothorax
primary spontaneous pneumothorax
42
Primary spontaneous pneumothorax MC in who?
risk factors?
1. affects mainly tall, thin males between 10 and 40 years of age
2. Positive family hx and cigarette smoking are risk factors
43
a complication of preexisting pulmonary disease
presenting sx are often more severe due to an impaired baseline lung function
what type of pneumothorax?
Secondary spontaneous pneumothorax
44
preexisting pulmonary disease in Secondary spontaneous pneumothorax
COPD, asthma, cystic fibrosis, tuberculosis, Pneumocystis pneumonia, menstruation (catamenial pneumothorax), interstitial lung diseases
45
what is a Traumatic pneumothorax
penetrating or blunt trauma
blunt - rib fractures
penetrating - stab wound, gunshot wound
46
positive pressure mechanical ventilation
interventional procedures
what type of pneumothorax?
what types of procedures?
Iatrogenic pneumothorax
thoracentesis, pleural biopsy, subclavian or internal jugular vein catheter placement, percutaneous lung biopsy, bronchoscopy with transbronchial biopsy
47
results from air entering pleural space but not escaping
Life-threatening due to cardiopulmonary compromise
what type of pneumothorax?
Tension pneumothorax (EMERGENT)
the pleural cavity pressure > atmospheric pressure
48
MCC of tension pneumothorax
CPR or positive-pressure mechanical ventilation
49
sx of pneumothorax
1. Onset: at rest, activity, trauma
2. Pleuritic chest pain
- ranging from mild-severe
3. Tachypnea
4. Dyspnea/SOB
50
PE findings of pneumothorax
1. _Diminished breath sounds_ and _decreased tactile fremitus_ on the affected side
2. Small pneumothoraces may only demonstrate mild tachypnea
3. **Tension pneumothorax** may cause:
- severe **rsp compromise and CV collapse**
--- marked tachycardia, hypotension
--- unable to speak full sentences
- **tracheal deviation**
- displacement of the PMI
51
imaging for pneumothorax
1. **_PA CXR is usually diagnostic_**
- _expiratory or lateral decubitus_ - shows small pneumothorax *not visible on inspiratory films*
2. _Chest CT_
- **more sensitive > CXR**
- often helpful in identifying associated pathology (if present)
52
Management of Primary Spontaneous Pneumothorax (PSP)
1. Airway stabilization
2. Oxygen supplementation
3. Determine need for removal of air from pleural cavity
- Therapeutic Options
--- Supplemental oxygen w/ observation: 6 L, SpO2 >96%; Repeat CXR after 6 hrs
--- Needle/catheter aspiration of intrapleural air
--- Chest tube or catheter thoracostomy
4. Aspiration - Needle or catheter
- needle is less preferred d/t complications
5. Tube/Catheter Thoracostomy - “chest tube”
53
Indication for supplemental oxygen and observation for primary spontaneous pneumothorax:
(all of the following must be present)
1. very small pneumothorax (≤ 3 cm at apex or ≤ 2 cm at lvl of hilum)
2. stable vital signs
3. first PSP
4. no pleural effusion
54
Indications for aspiration for Primary Spontaneous Pneumothorax
1. large pneumothorax
- (≥ 3 cm at the apex or ≥ 2 cm at the hilum)
2. stable vital signs
3. first PSP
4. provider with expertise in aspirations
55
how to do procedure of aspiration for Primary Spontaneous Pneumothorax
_Procedure_ - **2nd ICS in the midclavicular line**
1. Air is aspirated using a 60 mL syringe and a one way valve/stopcock
2. 2.5-4 L should be removed until resistance is met
3. After successful aspiration
- observe patient and repeat CXR at 4 hours, if stable remove catheter and repeat CXR at 2 hours
- Discharge if pneumothorax remains resolved, if recurrence occurs insert chest tube and admit
56
while doing an aspiration on a pneumothorax you feel a lack of resistance after 4 L, what does this mean/next step?
persistent air leak = chest tube
57
indications for Tube/Catheter Thoracostomy - aka “chest tube”
1. failure of observation or aspiration
2. recurrent PSP
3. complete collapse or mediastinal shift
4. bilateral pneumothorax
5. unstable VS
6. lack of expertise in aspiration technique
7. severe sx
8. concurrent pleural effusion requiring drainage
9. complex, loculated pneumothorax
58
how does a Tube/Catheter Thoracostomy work?
1. Catheter more prevalent
- easy to place, less painful, and as effective for the drainage of air compared to tube thoracostomy
2. _Imaging assisted_ indicated if pneumothorax is _loculated_
3. _Location_: **4th / 5th ICS in anterior axillary or midaxillary line**
4. Tube/catheter is attached to water-seal system or light wall suction
59
difference between tube vs catheter CT
Tubes
- ≥ 16 French diameter
- larger and require surgical incision
- more painful, less risk of plugging/kinking
Catheters
- ≤ 14 French diameter
- smaller, can be introduced with guidewire
- less pain, increase risk for plugging or kinking
60
Management of Secondary Spontaneous Pneumothorax
1. Maintain airway
2. Oxygen supplementation
- use cautiously in those at risk for oxygen-induced hypercapnia
3. _Tube / catheter thoracostomy and admission_
4. Consult pulmonology
- definitive tx with pleurodesis recommended
61
Management for Tension Pneumothorax
**_Needle decompression_**
1. A large-bore needle (14-16 gauge) inserted into pleural space thru **2nd anterior ICS** (between ribs 2-3) at **midclavicular line**
- Some also recommend **5th ICS** in **anterior or midaxillary line**
2. If large amounts of gas escape from the needle after insertion, the diagnosis is confirmed
3. Leave needle in place until a thoracostomy tube can be inserted
