Respiratory emergency

Question 1

Definition of pleural effusion

Answer 1

abnormal accumulation of fluid in pleural cavity.

Not a diagnosis, an indicator of a pathologic process that may be in origin.

Question 2

Definition of hemothorax

Answer 2

Accumulation of blood in pleura space

Question 3

Name the 3 types of Pleural effusion.

Answer 3

1) transudative pleaural effusion
2) Exudative pleural effusion
3) hemothorax.

Question 4

list examples of transudative pleural effusion

Answer 4

1. cardiac failure
   2) hypoalbuminemia

Question 5

Name examples of exudative pleural effusion

Answer 5

bacterial pneumoniass
TB
uremia

Question 6

causes of haemothorax

Answer 6

traumatic:
- blunt trauma
- penetrating trauma

Nontraumatic:
- neoplasia
- blood dyscrasia
- PE with infarction
- torn pleural adhesions in association with spontaneous penumothorax.

Question 7

Definition of neoplasia

Answer 7

uncontrolled/ abnormal growth of cells/ tissues in the body

Question 8

What is the difference between small effusions and large effusions? for pleural effusions.

Answer 8

small: min. of 300mls in the pleural cavity to be seen in xray

large: interferes with lung expansion with reduction in vital capacity
hypoxia and hypercapnia.

Question 9

clinical features of pleural effusion. small and large.

1 general.
1 small.
4 large

Answer 9

acute pleural pain, dyspnea

small effusion:
no findings

large effusions:
decreased chest movement
shift of mediastinum structure
dullness on percussion and absent breath sounds

Question 10

what is thoracostomy

Answer 10

chest tube placement

Question 11

what is the treatment for hemothorax if it is equal or greater than the amt required to obscure the costophrenic sulcus

Answer 11

thoracostomy

Question 12

when should surgical exploration for traumatic haemothorax be considered?

Answer 12

• massive haemothorax: greater than 1000ml of blood is evacuated immediately after thoracostomy
• bleeding from chest continues 150-200mls for 2-4 hours
• persistent blood transfusion required to maintain haemodynamic stability

Question 13

what is pneumothorax?

Answer 13

collection of air in pleura cavity

Question 14

types and causes of pneumothorax

Answer 14

Spontaneous
 Rupture of bulla(e) on surface of lungs
 Bronchial asthma, COPD, tuberculosis

Chest trauma
 Negative pleural pressure will allow air to enter

Question 15

clinical features of pneumothorax:

almost similar as haemothorax/

Answer 15

Asymptomatic in small pneumothorax

 Acute pleural pain, dyspnea in large pneumothorax
 Decreased chest movements
 Shift of mediastinal structures
 Hyper-resonance on percussion and absent breath sounds

Question 16

what is tension pneumothorax?

Answer 16

Life-threatening condition
 The accumulation of
air under pressure in the pleural space.

Associated with formation of a one-way valve at
point of rupture in the lung
 Air becomes trapped in pleural cavity and builds up
 Prevents lung from inflating fully

Question 17

complications of pneumothorax:

Answer 17

1) Venous return and cardiac output decrease with
hypotension and tachycardia

2) Hypoxemia due to alveolar collapse

3)Reexpansion pulmonary edema
 Occurs following rapid lung reexpansion particularly:
 From low lung volumes
 Long duration pneumothorax
 High pressure gradient across lung
 May be related to reperfusion injury
 Lung reexpansion should be slow
* First, just waterseal, no suction
* If lung fails to reexpand, then apply suction

4)DEADLY - Bronchopleural fistula (BPF)
is a sinus tract between the main stem, lobar, or
segmental bronchus and the pleural space

Question 18

WHAT IS Bronchopleural fistula and why isit deadly?

Answer 18

a sinus tract between the main stem, lobar, or
segmental bronchus and the pleural space
, allows continuous flow of air entry into the pleural space, making things worse.

Question 19

how to diagnose pneumothorax?

Answer 19

Chest radiography
– Requires good quality film
– In ICU, 30% of pneumothoraces are missed due to:
* Low-quality film
* Supine position of patient on AP film
* Air hidden behind thoracic or mediastinal structures

2) Radiographic appearance
 Mediastinal shift, diaphragmatic depression, flattened ribs

3) CT may be used to confirm size and presence of
pneumothorax.

Question 20

management of pneumothorax: SOS

Answer 20

1. Oxygen
   – Should be administered to all patients
   – Supplemental O 2 speeds absorption of air from pleural space
2. Observation of stable patients
   – Primary: observe 4 hours, if no enlargement: home
   – Secondary and iatrogenic: hospitalize and observe carefully,
   * If there is any deterioration (SpO 2 , RR, etc) - drain
3. Simple aspiration
   – Small catheter placed in pleural space
   – Connect to three-way stopcock
   – Slowly evacuate until no more air can be removed
   – This works as many leaks heal between time of leak and its
   drainage.
   – If 4 L air is removed without resistance, chest tube placement is
   required

4.Chest tubes
– Resolution is mostly determined by lung healing
– Small bore: placed via small incision in second intercostal space
(ICS), midclavicular line or laterally, fifth–seventh ICS
* Connected to underwater seal or Heimlich valve
– Large bore: placed via blunt dissection, usually connected to
“three-bottle” chest drainage system
– Chest tubes are sutured in place

5.Pleurodesis: consider with recurrent
pneumothoraces
Pleurodesis is a procedure per formed to obliterate the pleural
space to prevent recurrent pleural ef fusion or pneumothorax or
to a treat persistent pneumothorax .

Question 21

where are chest tubes usually inserted in terms of anatomical positions?

Answer 21

second intercostal space
(ICS), midclavicular line or laterally, fifth–seventh ICS

Question 22

Pleurodesis:

Answer 22

procedure to stick your lung to the chest wall.

Question 23

PULMONARY EDEMA

Answer 23

Life threatening emergency in which excess fluid
accumulates in lungs
 Characterized by extreme breathlessness
 Due to alteration of capillary forces in the alveolar wall

Question 24

causes of pulmonary edema

Answer 24

1) ↑ Venous hydrostatic pressure
 LVF (most common cause)
2. ↓ Plasma osmotic pressure
 Hypoalbuminemia

3. Altered alveolar capillary membrane
   permeability
    Acute respiratory distress syndrome (ARDS

Question 25

pathphysiology of pulmonary edema

Answer 25

↑ pulm capillary pressure
 Engorged vessels, lungs less compliant
 ↑ resistance of small airways
 Tachypnoea, wheezing
 If pressure ↑ > 25mmHg (normal 15)
 ↑ filtration of fluid into interstitial space , causing interstitial edema
 Gas exchange worsens
 Xray changes –Kerley B lines
PATHOPHYSIOLOG