Pneumothorax, effusion + acute resp failure

Question 1

What is:
Sharp, localized, fleeting pain exacerbated by coughing, deep breathing, movement, sneezing

Radiation to ipsilateral shoulder

Answer 1

pleuritis

Question 2

What does this cause:
Acute inflammation of parietal pleura: bacterial, viral, or fungal infection/pneumonia
PE/ lung cancer
Lupus, metastatic cancer, mesothelioma

Answer 2

pleuritis

Question 3

How do you Dx pleuritis?

Answer 3

CXR - rule out other causes

Question 4

How do you treat pleuritis?

Answer 4

NSAIDs, codeine, other opioids

Question 5

Sudden onset of chest pain, dyspnea, cough, life-threatening or respiratory failure

Answer 5

pneumothorax

Question 6

What are risk factors for pneumothorax?

Answer 6

Drug use, increased pressure (diving, flying), airway disease, infection, lung disease

Question 7

What does this PE indicate:
Decreased breath sounds
Hyperresonance
Decreased or absent tactile fremitus
Mediastinal or tracheal deviation = tension
Increased JVP, pulsus paradoxus, HOTN

Answer 7

pneumothorax

Question 8

What type of pneumothorax: : no pre-existing lung disease
tall, thin boys + men 10 - 30 years w/ smoking + family hx

Answer 8

primary spontaneous pneumothorax

Question 9

What type of pneumothorax: pre-existing lung disease
more life-threatening, COPD, asthma, interstitial lung disease, TB, pneumocystis pneumonia

Answer 9

secondary spontaneous pneumothorax

Question 10

What type of pneumothorax: penetrating trauma, lung infections, CPR, + pressure mechanical ventilation
life-threatening, organs pushed to contralateral side

Answer 10

tension pneumothorax

Question 11

For unstable patients what imaging do you pick for a pneumothorax?

Answer 11

rapid bedside imaging w/ US: lung point, absence of lung sliding

Question 12

For stable patients what imaging do you pick for a pneumothorax?

Answer 12

CXR (TOC), showing visceral pleural line (companion lines), deep sulcus sign
CT, if dx is uncertain, loculated pneumothorax, or further trauma

Question 13

A small pneumothorax is <_

Answer 13

2 cm

Question 14

A large pneumothorax is _

Answer 14

> / 2 cm

Question 15

What values of the average intrapleural distance dictate a small or large pneumothorax?

Answer 15

<15% small, 50% large

Question 16

What’s the first step for pneumothorax?

Answer 16

stabilize patient
- RR <24
- HR>60 but <120
- normal BP
- O2>90%
- ability to speak in whole sentences

Question 17

What is treatment for a small primary pneumothorax?

Answer 17

6 hour observation
Repeat CXR to confirm no progression
Follow up in 24 hours

Question 18

What’s treatment for a large primary pneumothorax?

Answer 18

Needle aspiration followed by chest tube (second intercostal space at midclavicular line of the affected side) if fails
Attach to heimlich valve to prevent tension

Question 19

What’s treatment for a secondary pneumothorax?

Answer 19

Chest tube placement (large, severe, or from mechanical ventilation) + hospitalization
Thoracostomy (recurrence, bilateral, failure)

Question 20

How do you treat a tension pneumothorax?

Answer 20

Medical emergency → emergent chest decompression with a large-bore needle followed by immediate chest tube placement

Question 21

What can be seen as asymptomatic or pain referring to shoulder from pleural inflammation and dyspnea, cough?

Answer 21

pleural effusion

Question 22

What does this PE indicate:
absent or diminished movements on affected side
Fullness of chest w/ bulging intercostal spaces
Diminished breath sounds
decreased/absent tactile fremitus
Dullness to percussion
Absence of breath sounds
Absent vocal resonance
Pneumonia-like findings (crackles)

Answer 22

pleural effusion

Question 23

associated w/ bacterial pneumonia, bronchiectasis, or lung abscess

Answer 23

parapneumonic

Question 24

anatomically confined within a sac

Answer 24

loculated effusion

Question 25

accumulation of fluid between lung and diaphragm

Answer 25

subpulmonic effusion

Question 26

increased hydrostatic or decreased oncotic pressures (CHF, atelectasis, renal/liver disease)

Answer 26

transudative pleural effusion

Question 27

leaky capillaries from infection, malignancy, trauma

Answer 27

exudative pleural effusion

Question 28

A pleural effusion is classified by:

Answer 28

1) site 2) type 3) mechanism

Question 29

Protein <.5 LDH <.6 LDH <⅔ upper limit of normal for serum LDH

Answer 29

transudative pleural effusion

Question 30

Protein >.5 LDH >.6 LDH > ⅔ upper limit of normal for serum LDH

Answer 30

exudative pleural effusion

Question 31

Increased WBC count pleural effusion

Answer 31

empyema

Question 32

Pleural fluid: blood ratio >.5

Answer 32

hemothorax

Question 33

Light's criteria purpose

Answer 33

If any are true, pleural effusion is EXUDATIVE

Question 34

protein >.5 serum LDH >.6 pleural LDH > 2/3

Answer 34

light's criteria -- exudative

Question 35

elevated amylase in pleural effusion

Answer 35

pancreatic disease, malignancy, esophageal rupture

Question 36

elevated triglycerides in pleural effusion

Answer 36

chylothorax from thoracic duct disruption

Question 37

How do you diagnose pleural effusion?

Answer 37

CBC - leukocyte counts CXR: initial TOC PA: need fluid to diagnose, blunting of costophrenic angle (meniscus sign), diaphragm + heart poorly demarcated, shifts to uninvolved side Lateral decubitus: smaller effusions, free flowing vs. loculated - best CT scan: if minimal or loculated, US or CT for loculated or empyema

Question 38

pleural effusion TOC

Answer 38

chest xray

Question 39

What's the gold standard for diagnosis of pleural effusion

Answer 39

thoracentesis

Question 40

For all acute effusions + differentiation --

Answer 40

Analyze protein, LDH, pH, WBC, glucose, cytology, Gram stain Glucose <60 = TB, malignancy, rheumatoid arthritis, parapneumonic effusion Thoracentesis

Question 41

How do you treat a transudative pleural effusion?

Answer 41

treat underlying cause, diuretics + sodium restriction

Question 42

How do you treat an exudative pleural effusion?

Answer 42

drainage w/ consideration for placement of indwelling pleural catheter (pleurodesis for refractory >2 or 3)

Question 43

How do you treat an empyema?

Answer 43

antibiotics + drainage

Question 44

How do you treat a hemothorax?

Answer 44

drainage

Question 45

What type of acute respiratory failure is: Dyspnea, tachypnea, tachycardia, peripheral or central cyanosis Restlessness, confusion, AMS Tripoding, inability to lie supine, manifestations of stress response (HTN, diaphoresis), use of accessory muscles

Answer 45

hypoxic

Question 46

What type of acute respiratory failure is: Dyspnea + HA = classic Peripheral + conjunctival hyperemia, HTN, tachycardia, tachypnea, impaired consciousness, papilledema, myoclonus (spasms), asterixis COPD exacerbation - reduced air movement, wheezing, squeaking, rhonchi Acute asthma - wheezing, retractions Pulmonary edema - crackles

Answer 46

hypercapnic

Question 47

Respiratory dysfunction resulting in abnormalities of oxygenation or ventilation enough to threaten the function of vital organs

Answer 47

acute respiratory failure

Question 48

arterial hypoxemia caused by inflammatory lung injury or severe hypoventilation w/ escalating need for supplemental oxygen, acute or chronic From pneumonia, COPD, exacerbation, ACS, PE, sepsis, asthma, ARDS, interstitial lung disease, trauma

Answer 48

Type 1 = hypoxicemic

Question 49

imbalance between load on respiratory muscles + muscle pump capacity leading to PaCO2>45mmHG and pH<7.35 (lungs not functioning), acute, acute on chronic, chronic From obstructive, pulmonary edema, OHS, drug intoxication, neuromuscular disorders, chest wall disorders

Answer 49

Type 2 = hypercapnic

Question 50

What are rough guidelines for acute respiratory failure diagnosis?

Answer 50

PO2<60 (SpO2 <91%) in a nonCOPD and (SPO2<88% in COPD) PCO2>50mmHG

Question 51

What are diagnostic tools for acute respiratory failure?

Answer 51

Repeat vitals Continuous pulse ox ABG CXR EKG Troponin pro-BNP UDS Echo

Question 52

What's first line for acute respiratory failure?

Answer 52

ABCs: airway, breathing, circulation Oxygenation - low flow, simple face mask, high flow, non-invasive positive airway pressure, intubation Goal: >92% for non-COPD 88-92% w/ COPD

Question 53

Goal for oxygenation in ARF w/ non-COPD:

Answer 53

>92%

Question 54

Goal for oxygenation in ARF w/ COPD

Answer 54

88-92%

Question 55

What are these indications for: Respiratory muscle fatigue (current or impending) Hypoxia not corrected by nasal cannula, HFNC, or mask Pulmonary edema FIRST LINE FOR COPD in hypercapnic failure

Answer 55

NIPPV

Question 56

When is NIPPV contraindicated?

Answer 56

CI IF: significant secretions, facial trauma, burns, high risk of aspiration, AMS, long-term need

Question 57

What are these indications for: Hypercapnic encephalopathy (CO2 narcosis) Hypoxemia despite oxygen therapy Impaired airway protection Respiratory acidosis Refractory hypoxemia despite HFNC or biPAP Respiratory muscle exhaustion Apnea

Answer 57

intubation

Question 58

What are these indications for: apnea Acute hypercapnia Severe hypoxemia Progressive patient fatigue

Answer 58

mechanical ventilation

Question 59

When do you use ECMO in acute respiratory failure?

Answer 59

for cardiac failure or both cardiac/resp failures

Question 60

ARDS requirements are

Answer 60

Acute hypoxemia <1 week Ratio<300 P/F on ABG Diffuse BL infiltrates Swan cath or echo - PCWP <18 (NO CARDIOGENIC PULM EDEMA)

Question 61

hypoxemia is defined by

Answer 61

O2 <60 on ABG

Question 62

Hypercapnia is defined by

Answer 62

CO2 >50 on ABG

Question 63

Hypercapnia means

Answer 63

hypoventilation, commonly from a drug or obstructive disease process slowing ability to breathe

Question 64

Hypoxemia means

Answer 64

likely something is blocking ventilation like pneumonia, aspiration