Pleural Disorders - Exam 2

Question 1

What is the pleura? ______ is attached to the chest wall. _____ covers the lungs, blood vessels, bronchi and nerves

Answer 1

the serous membrane lining the thorax (chest wall) and enveloping the lungs

parietal= attached to the chest wall

visceral= covers the lungs, blood vessels, bronchi and nerves

Question 2

Which pleura has nerve endings?

Answer 2

parietal pleura

Question 3

What is the pleural cavity? What is the pleural fluid?

Answer 3

the thin serous fluid-filled (potential space) between the two pulmonary pleura

fills the pleural space/cavity; helps the two layers of pleura glide smoothly past each other during breathing

Question 4

Is pleural fluid normally seen on imaging?

Answer 4

pleural fluid is NOT normally seen on imaging, only if there is a problem

Question 5

What is pleurisy? What is pleural effusion?

Answer 5

Pleurisy - Inflammation of the pleura that causes sharp pain with breathing

Pleural Effusion - Excess fluid in the pleural space

Question 6

What medications can lead pleurisy?

Answer 6

procainamide, hydralazine, and isoniazid

Question 7

What AI disorders lead to pleurisy? What GI disorders lead to pleurisy?

Answer 7

lupus (SLE), rheumatoid arthritis,or scleroderma

pancreatitis, peritonitis, cholecystitis

Question 8

a localized, sharp, stabbing, fleeting pain that is worsened by inspiration, sneezing or coughing

What am I?
What does it radiate towards?

Answer 8

pleurisy

radiation of pain to ipsilateral scapula may occur if diaphragmatic pleura is affected

Question 9

What will you hear on PE in pleurisy?

Answer 9

pleural friction rub and decreased breath sounds

Question 10

If CT is indicated, what kind do you need to order?

Answer 10

chest CT with contrast or CT angiography

Question 11

Name 3 reasons you would want to admit a pt for pleurisy

Answer 11

hypoxemic (O2 sat of <90%)
parenteral pain control is needed
underlying etiology requires hospitalization

Question 12

What is the tx for pleurisy?

Answer 12

NSAIDs!! indomethacin 25 mg BID-TID (short course - < 7-10 d)

cough suppressant (codeine, dextromethorphan, tessalon perles)

Question 13

What does using cough suppressant put you at risk for?

Answer 13

pneumonia due to build up on airway secretions that are NOT coughed out due to cough suppressant

Question 14

What is a pleural effusion? How much fluid is normal?

Answer 14

a collection of fluid in the pleural space resulting from a disruption in the normal pleural homeostasis

leaves 5–15 mL of fluid in the normal pleural space (1 teaspoon or 1 tablespoon)

Question 15

What are the 5 pathophys processes that account for most pleural effusions?

Answer 15

Question 16

What is the pathophsy behind transudate fluid?

Answer 16

A fluid that passes through a membrane (capillary wall), which filters out all the cells and much of the protein, yielding a watery solution. A transudate is a filtrate of blood caused by an imbalance in hydrostatic and colloid osmotic pressure

Question 17

What is the pathophys behind exudative fluid?

Answer 17

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

Question 18

transudate want to think ?????

exudate want to think ?????

Answer 18

transudate think imbalance in pressure

exudate think inflammation or infection

Question 19

**______ falls under both transudate and exudate

Answer 19

pulm embolism

Question 20

What are the 3 MC s/s of a pleural effusion?

Answer 20

dyspnea, cough and pleuritic chest pain

Question 21

a small pleural effusion will present like ???

a large pleural effusion will present like ????

Answer 21

small= less symptoms with normal physical exam

larger= more symptomatic with abnormal physical exam findings

Question 22

What are 2 important questions to ask you pt when considered about a pleural effusion?

Answer 22

When did it start? has it gotten worse?

Question 23

What are 3 things that will be DECREASED over the area that has the pleural effusion?

Answer 23

Diminished or absent breath sounds
Dullness to percussion
Decreased tactile fremitus

also have diminished or delayed chest expansion on the side with the effusion

Question 24

What is a common CXR finding with pleural effusion?

Answer 24

blunting of the costophrenic angle is evident if there is > 175 ml (appx 6 oz) of fluid present

Question 25

What is a helpful diagnostic imaging for pleural effusions?

Answer 25

CXR first then chest CT CT is helpful when determining the underlying pathology

Question 26

What are the 2 treatment options for pleural effusions?

Answer 26

observation vs thoracentesis

Question 27

What are the indications for pleural effusion observation?

Answer 27

benign cause (overt CHF, viral pleurisy, recent thoracic or abdominal sx) small amount of pleural fluid and there is a secure clinical diagnosis

Question 28

What is the correct needle placement in a thoracentesis in a supine or posterior position? upright or seated?

Answer 28

supine/posterior: Midaxillary line between the 7th and 9th rib insert needle just superior to rib to avoid neurovascular bundle upright/seated: midscapular line between the 7th and 9th rib insert needle just superior to rib to avoid neurovascular bundle

Question 29

What are the diagnostic indications for thoracentesis?

Answer 29

- new onset pleural effusion without a clinical apparent cause - atypical presentation of pleural effusion in a heart failure pt (unequal bilateral effusions, CHH pleural effusions should be equal and bilateral)

Question 30

What are the therapeutic indications for thoracentesis?

Answer 30

Symptom relief Evidence of loculation on imaging Risk of pleural thickening/restrictive functional impairment

Question 31

**What are the absolute contraindications for thoracentesis?

Answer 31

uncooperative patient cutaneous disease over the proposed puncture site

Question 32

What are the relative contraindications for thoracentesis?

Answer 32

bleeding diathesis or systemic anticoagulation (use US guidance is preferred) small volume of fluid (< 1 cm thickness on a lateral decubitus film)

Question 33

What is a caution with thoracentesis? What are they at risk for?

Answer 33

mechanical ventilation - risk of tension pneumothorax if lung is punctured

Question 34

What are the 7 complications of thoracentesis?

Answer 34

pain at the puncture site cutaneous or internal bleeding pneumothorax empyema re-expansion pulmonary edema malignant seeding of the thoracentesis tract adverse reactions to anesthetics used in the procedure

Question 35

Under what conditions does the risk of pneumothorax increase for a thoracentesis?

Answer 35

use of a needle larger than a 20 gauge and a lack of US guidance

Question 36

What 5 lab values are part of the initial pleural fluid evaluation?

Answer 36

pleural fluid LDH pleural fluid protein serum LDH, albumin and globulin (proteins)

Question 37

What are the normal serum lab values for albumin, globin and LDH? What makes up total serum protein?

Answer 37

total serum protein = albumin + globulin

Question 38

**What is Light's criteria? What does it indicate?

Answer 38

if ONE criteria is met fluid is exudative

Question 39

What is the management for a pleural effusion?

Answer 39

thoracentesis can be transiently therapeutic for severe dyspnea tube thoracostomy indicated in empyema, complicated effusion, large or unstable hemothorax

Question 40

When is a tube thoracostomy indicated for pleural effusion?

Answer 40

empyema, complicated effusion, large or unstable hemothorax aka especially if bloody or pus in the pleural fluid

Question 41

complicated pleural effusions are often associated with _______, ______ and ______

Answer 41

pneumonia, lung abscess or bronchiectasis

Question 42

What does a hemothorax put you at risk for?

Answer 42

risk of hemorrhage and fibrous tissue formation

Question 43

At what point should you order a repeat chest xray in a pleural effusion?

Answer 43

repeat CXR when drainage decreases to < 100 mL/day to ensure complete drainage has occurred

Question 44

What is a pleurodesis? When is it commonly used?

Answer 44

Instillation of an irritant (sclerosing agent¹) to cause inflammatory changes that result in bridging fibrosis between the visceral and parietal pleural surfaces, effectively obliterating the potential pleural space commonly used in limited life expectancy when the goal of therapy is to palliate symptoms

Question 45

What is a pneumothorax? What are the 5 pneumothorax classifications?

Answer 45

The abnormal presence of air or gas in the pleural cavity 1. Primary spontaneous pneumothorax 2. Secondary spontaneous pneumothorax 3. Traumatic pneumothorax 4. Iatrogenic pneumothorax 5. Tension pneumothorax

Question 46

What is a primary spontaneous pneumothorax? What pt population?

Answer 46

occurs in the ABSENCE of an underlying lung disease most common in frequently in smokers and tall, thin, males between 10 and 40 years old

Question 47

What is the etiology of a primary spontaneous pneumothorax?

Answer 47

eitology is unknown but possibility a sign of early lung dz with rupture of subpleural apical blebs

Question 48

What are 2 risk factors for primary spontaneous pneumothorax?

Answer 48

Positive family history and cigarette smoking are risk factors

Question 49

What is a secondary spontaneous pneumothorax?

Answer 49

a complication of preexisting pulmonary disease presenting s/s are more severe due to impaired baseline lung function

Question 50

What is a catamenial pneumothorax?

Answer 50

- recurrent spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation. It is thought to be related to endometrial tissue affecting the pleura.

Question 51

What is the MC cause of iatrogenic pneumothorax?

Answer 51

positive pressure mechanical ventilation

Question 52

What is a tension pneumothorax caused by? What are the 2 MC causes? Why is it considered an emergency?

Answer 52

results from air entering pleural space but not escaping MC cause: CPR or positive-pressure mechanical ventilation Life-threatening due to cardiopulmonary compromise

Question 53

**What are the unstable vital signs?

Answer 53

Question 54

tachypnea, pleuritic chest pain, dyspnea, SOB, diminished breath sounds, decreased tactile fremitus What am I?

Answer 54

pneumothorax

Question 55

What will a tension pneumothorax present like?

Answer 55

**severe respiratory compromise and **CV collapse marked tachycardia, hypotension unable to speak full sentences **tracheal deviation displacement of the PMI

Question 56

What is the imaging work-up needed for pneumothorax?

Answer 56

CXR: PA, expiratory and lateral decubitus views then Chest CT with or without contrast- more sensitive and helpful to identify pathology

Question 57

What is the management of a primary spontanous pneumothorax?

Answer 57

#1 priority is airway stablization!! #2 oxygen supplementation #3 then consider therapeutic options : supplemental oxygen with observation, needle/catheter aspiration, chest tube or catheter thoracostomy

Question 58

What are the indications for supplemental oxygen and observation as a tx for pneumothorax?

Answer 58

very small pneumothorax (≤ 3 cm at the apex or ≤ 2 cm at the level of the hilum) stable vital signs first PSP no pleural effusion ALL OF THE ABOVE MUST BE MEET

Question 59

What are the criteria to be considered a small pneumothorax?

Answer 59

(≤ 3 cm at the apex or ≤ 2 cm at the level of the hilum)

Question 60

What is the oxygen goal for a very mild primary spontaneous pneumothorax? Then what do you do?

Answer 60

Oxygen at 6 L with goal of SpO2 of >96% repeat CXR after 6 hours

Question 61

What are the indications to do aspiration as a tx for primary spontaneous pneumothorax? What kind of aspiration is preferred?

Answer 61

large pneumothorax : (≥ 3 cm at the apex or ≥ 2 cm at the hilum) stable vital signs first PSP provider with expertise in aspirations catheter is preferred over needle due to many complications when needle is used

Question 62

Where is aspiration procedure done? What materials do you need? How much air should be removed?

Answer 62

2nd ICS in the midclavicular line Air is aspirated using a 60 mL syringe and a one way valve/stopcock 2.5-4 L should be removed until resistance is met

Question 63

After aspirating the pt and not meeting resistance after _____, What does that make you think? What is the next step?

Answer 63

Lack of resistance after 4 L = persistent air leak indication for chest tube

Question 64

After the successful aspiration of pneumothorax, What do you need to do next? What do you do if the pneumothorax persists?

Answer 64

observe patient and repeat CXR at 4 hours, if stable remove catheter and repeat CXR at 2 hours if recurrence occurs insert chest tube and admit

Question 65

What are the indications for a chest tube?

Answer 65

failure of observation or aspiration recurrent PSP complete collapse or mediastinal shift bilateral pneumothorax unstable vital signs lack of expertise in aspiration technique severe symptoms concurrent pleural effusion requiring drainage complex, loculated pneumothorax

Question 66

Where do you place a chest tube? What material is commonly used?

Answer 66

4th or 5th intercostal space in the anterior axillary or midaxillary line-> use the nipple as an anatomical landmark catheter is attached to water-seal system or light wall suction

Question 67

What french size is commonly used for a chest tube? What french size if using a catheter?

Answer 67

tube: greater than 16mm catheter: less than 14mm, less pain but increased risk for plugging or kinking

Question 68

What is the secondary spontaneous pneumothorax treatment?

Answer 68

maintain airway oxygen supplementation tube or catheter thoracostomy and admission

Question 69

What is the management for a tension pneumothorax? What confirms the dx? What do you do next?

Answer 69

1st line: A large-bore needle (14-16 gauge) inserted into the pleural space through the 2nd anterior ICS (between ribs # 2-3) at the midclavicular line OR 5th ICS in the anterior or midaxillary line __________________ If large amounts of gas escape from the needle after insertion, the diagnosis is confirmed Leave needle in place until a thoracostomy tube can be inserted