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STEP 2 Pulmonary > Pulmo. Pleural effusion/empyema (09-30) (1) > Flashcards

Pulmo. Pleural effusion/empyema (09-30) (1) Flashcards

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1
Q

2 types: transudate and exudate

A

.

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2
Q

transudate causes.
Increased hydrostatic pressure?

A

CHF

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3
Q

transudate causes.
Decreased oncotic pressure? 3

A

nephrotic syndrome, gastrosis (kwashiorkor), and cirrhosis (hepatic hydrothorax).

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4
Q

transudate causes.
Decreased intrapleural pressure

A

pulls fluid from the vascular membrane to the
pleural space.
▪ Atelectasis.

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5
Q

transudate causes.
also constrictive pericarditis

A

.

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6
Q

exudate causes. 3 in general

A

malignancy
pneumonia
tuberculosos

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7
Q

exudate and transudate both in what disease?

A

PE

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8
Q

exudate causes from table?6

A

infection (Tb, pneumonia)
malignancy
connective tissue disease
PE
pancreatitis
post CABG (coronary artery bypass grafting)

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9
Q

transudate patho?

A

hydrastotic or oncotic pressure

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10
Q

exudate patho?

A

inflammation

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11
Q

exudate. light criteria.
pleural/serum protein?

A

> 0,5

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12
Q

exudate. light criteria.
pleural/serum LDH?

A

> 0,6

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13
Q

exudate. light criteria.
pleural LDH >2/3 upper limit of normal of serum LDH

A

.

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14
Q

exudate causes. Empyema characteristics?

A

purulent fluid, neuropjil predominant, + gram stain/culture

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15
Q

exudate causes. Chylothorax characteristics?

A

milky white fluid, incr. triglycerides

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16
Q

exudate causes. malignancy characteristics?

A

abnormal cytology

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17
Q

exudate causes. tuberculosis characteristics?

A

+acid-fast bacterium stain/culture

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18
Q

Pleural effusions. 2 diagnostic?

A

xray and thoracenthesis

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19
Q

Pleural effusions.
xray findings?

A

▪ Obliteration of the costophrenic angle.
▪ Horizontal meniscus if large.
▪ Can be chylothorax, hemothorax (hematocrit >50% of peripheral
blood), or effusion.

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20
Q

Pleural effusions.
xray: if <1cm watch and wait

A

.

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21
Q

Pleural effusions.
xray: if septations and lobes involved (loculated)?

A

Septations and lobes involved (loculated): thoracentesis (+/- tPA).
▪ Thoracentesis fails -> thoracotomy.

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22
Q

Pleural effusions.
xray: CHF?

A

CHF (BNP>500): do diuresis.
▪ Fails –> thoracentesis.

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23
Q

Pleural effusions.
Thoracentesis. Send 4 tubes. for what?

A
  1. Cell count and differentials
  2. Cytology
  3. Glucose, pH, LDH, protein
  4. Gram stain and culture
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24
Q

Pleural effusions.
Thoracentesis.
Cell count and differentials. Pneumonia, TB, cancer?

A

Pneumonia; PMNs

TBC/malignancy: lymphocytes

Cancer: RBCs

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25
Pleural effusions. Thoracentesis. Cytology?
malignancy; lung, breast cancer, and lymphoma
26
Pleural effusions. Thoracentesis. Glucose < 60 in what cases?
o Rheumatoid pleurisy. o Complicated parapneumonic effusions or empyema. o Malignant effusion. o Tuberculous pleurisy. o Lupus pleuritis. o Esophageal rupture.
27
Pleural effusions. Thoracentesis. Glucose < 30 in what cases?
o Rheumatic effusion. o Empyema.
28
Pleural effusions. Thoracentesis. Triglycerides for chylothorax. in what cases seen?
Seen in cardiothoracic surgery, congenital malformations, down syndrome, noonan syndrome, and malignancy.
29
Pleural effusions. Thoracentesis. Chylothorax, what lab findings?
triglycerides, cholesterol, chylomicrons, and fat-soluble vitamins, HYPONATREMIA.
30
Pleural effusions. Thoracentesis. chylothorax management?
drainage, limitation of dietary fat, and possible thoracic duct ligation.
31
Pleural effusions. Thoracentesis. Chylothorax to differentiate from empyema?
To differentiate it from empyema: do centrifugation; chylothorax remains uniform and empyema becomes a clear supernatant overlying a precipitate.
31
Pleural effusions. Thoracentesis. what lab for TB?
Adenosine deaminase for TB.
32
Pleural effusions. Thoracentesis. what lab for pancreatitis?
Amylase: pancreatitis or esophageal perforation.
33
Pleural effusions. Thoracentesis. normal pH, what in transudate and exudate?
Normal pleural pH: 7.60. o Transudate: 7.40-7.55. o Exudate:7.30-7.45
34
Pleural effusions. Thoracentesis. gram stain and culture for what?
Bacteria or fungi or TB.
35
Parapneumonic effusions table. Uncomplicated etiology?
Sterile exudate in pleural space
36
Parapneumonic effusions table. complicated etiology?
bacterial invasion of pleural space
37
Parapneumonic effusions table. Uncomplicated. pleural fluid analysis. 3 - pH, WBC, glucose
pH >= 7,2 WBC =<50k glucose >= 60 mg/dl
38
Parapneumonic effusions table. Complicated. 3 - pH, WBC, glucose
pH < 7,2 WBC >50k glucose ><60 mg/dl
39
Parapneumonic effusions table. Uncomplicated. Pleural fluid gram stain and culture?
negative
40
Parapneumonic effusions table. Complicated. Pleural fluid gram stain and culture?
can be positive/Negative* *negative is typically a false negative due to ow bacterial count. Both (stain and culture) are typically positive in empyema
41
Parapneumonic effusions table. Uncomplicated. treatment?
antibiotics
42
Parapneumonic effusions table. Complicated. treatment?
antibiotics + drainage
43
Parapneumonic effusions table. Uncomplicated. Pathophysiology?
Inflammatory fluid from pneumonia --> pleural space
44
Parapneumonic effusions table. Complicated. Pathophysiology?
Bacterial invasion into pleural fluid
45
Parapneumonic effusions table. Uncomplicated. LDH ratio?
> 0,6
46
Parapneumonic effusions table. Complicated. LDH ratio?
> 0,6
47
Parapneumonic effusions table. Uncomplicated. glucose?
decr./normal
48
Parapneumonic effusions table. Complicated. glucose?
decreased
49
Parapneumonic effusions table. Empyema. pathophysiology?
Bacterial colonization --> purulent fluid
50
Parapneumonic effusions table. Empyema. pleural fluid analysis?
pH < 7,2 decr. glucose LDH > 0,6
51
Parapneumonic effusions table. Empyema. pleural fluid gram stain and culture?
positive
52
How to differentiate empyemas from complicated effusions?
by the presence of gross pus or bacteria on Gram stain.
53
what LDH indicated bacterial invasion of the pleural space?
LDH >1000 indicates bacterial invasion of the pleural space.
54
What treatment may be required for empyema and complicated effusions?
Most complicated effusions and all empyemas require drainage in addition to antibiotics (2-4 weeks).
55
Treatment. empyema?
Empyema: chest tube placement and systemic antibiotic treatment. Doesn’t resolve → thoracoscopic debridement.
56
Management of pleural effusions algo. 1st: penumonia and effusion on XRAY --> Small effusions AND no resp. distress or hypoxia ->?
oral abs close monitoring
57
Management of pleural effusions algo. 1st: penumonia and effusion on XRAY --> Moderate/large effusion OR respiratory distress OR hypoxia -->
Ultrasound IV abs drainage
58
Empyema table. etiology?
bacterial invasion of pleural space resulting in fibrinopurulent consolidation Usually due to progression of a complicated parapneumonic effusion
59
Empyema table. mos?
oral anaerobic bacteria (likely most common) Strep. pneumonia Staph. aureus
60
Empyema table. clinical? symptoms
Symptoms of pneumonia (fever, dyspnea, pleuritic chest pain)
61
Empyema table. clinical? onset
insidious presentation (eg 1-2 weeks or more), weight loss
62
Empyema table. clinical? labs
lab evidence of inflammation (leukocytosis, thrombocytosis)
63
Empyema table. management - all mentioned IN ADDITION TO ABS. 3
Chest tube drainage when possible (ie empyema is free flowing) Intrapleural fibrinolytic durgs (tPA/DNase) may assist drainage Surgical decortication for highly fibrotic, loculated effusions
64
Empyema table. tPA/DNase - tissue plasminogen activator/recombinant deoxyribonuclease
.

STEP 2 Pulmonary (30 decks)

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