What are the characteristics of pleuritic pain?
• Sharp, Stabbing, Localised.
• Exacerbated by Deep inspiration, Coughing, Movement.
• Relieved by Shallow Breathing.
What would you notice from tactile vocal fremetis for both pneumothorax and an effusion?
What would you notice when percussing both a pneumothorax and effusion?
• Pneumothorax would be hyperresonant.
• Effusion would be stony dull.
What would you expect to hear when auscultating a pneumothorax or effusion?
Reduced breath sounds as there is a layer of insulation. With an effusion you may hear increased bronchial breathing above the effusion.
What does a 'pleural rub' sound like and how is it caused?
• Creaking with respiration, best heard at the begininning and end of the resp cycle.
• Caused by the stick/slip vibration between the visceral and parietal pleurae, which are roughened by fibrinous exudate.
What is Hamman's sign? (Pneumothorax)
• Precordial bubbles/crackles. Synchronised with heart beat not resp.
• "Mediastinal Crunch"
• Caused by cardiac contraction forcing air through folds of pleura.
What is Hippocratic succussion?
This a splashing sound heard when shaking the chest during an effusion, due to fluid-air interaction.
What are the two degrees of spontaneous pneumothorax?
•1˚ - Congenital pleural bleb.
-Typically tall, thin, smoker.
•2˚ - Acute of chronic lung disease.
What are some of the iatrogrogenic causes of a pneumathorax?
Central venous access, nerve block, liver and lung biopsies.
At which size does a pneumothorax become classed as 'large'?
Visible rim >2cm or hemithorax >20%
What is the presentation of a pneumothorax?
• Sudden onset unilateral, pleuritic pain.
• Increased RR, Increased HR.
• Reduced expansion, hyperresonant, reduced breath sounds.
• Slight hypoxia and cyanosis.
What are the four stages of management of a pneumothorax?
1) Allow to resorp spontaneously.
2) Needle Aspiration
3) Chest Drain
What size tube should you use to drain air or pleural fluid?
What is 'Swinging' (Chest drain) and why might it not be present?
• Swinging is the normal oscilation of the water level due to respirtation.
• Block or clot in the system, fully re-expanded lung.
At what point should you remove a chest drain?
• No swinging.
• No bubbling >24hr
• <100ml/day drainage
• X-ray shows reinflated lung.
What is a tension pneumothorax?
• Increased plueral pressure on affected side.
• Causes complete collapse of lung, mediastinal/tracheal deviation away from affected side.
• Compresses other lung, leading to hypoxia and cyanosis.
What are the complications of a tension pneumothorax?
• Compresses heart and occludes vena cavae.
- Hypotension, tachycardia.
- Neck vein distension.
- Cardiac arrest.
What is the presentation of a tension pneumothorax in addition to a normal pneumothorax?
• Normal pneumothorax; Increased RR, Increased HR, Pleuritic pain, dyspnoea, hypoxia slight cyanosis.
• Tension pneumothorax;
- Tracheal shift.
- Neck vein distension.
- Severe hypoxia and cyanosis.
- Decreased BP (Shock: Cold and Clammy)
What is the management of a tension pneumothorax?
Thoracocentesis (14g venflon into affected side)
What is subcutaneous emphysema?
• In a tension pneumothorax, the pressure in the pleural cavity may be so high that air is forced into the tissues.
- This causes massive oedema and airway obstruction.
• This results in subcutaneous crepitus-
- "Crunching Snow"
What is the definition of a pleural effusion?
Fluid in the pleural space.
What are the two types of fluid that can be present in a pleural effusion and what are they?
• Exudate and Trandudate.
• Exudate, any fluid that filters from the circulatory system into lesions or areas of inflammation.
• Transudate, is a fluid with a low protein concentrate, that results from increased fluid pressures.
What are the main causes of a transudate effusion?
• Heart failure
• Renal failure
• Hepatic failure
What are the main causes of an exudate pleural effusion?
• Post operative
• Pulmonary embolus
What is the presentation of a plueral effusion?
• Increasing SOB +/- dry cough.
• Unilateral pleuritic chest pain.
• Increased RR.
• Reduced breath sounds, reduced fremitis, stony dull percussion, reduced expansion.
• Slight hypoxia and cyanosis.
What investigation can be performed for a pleural effusion?
• Chest XR
• Diagnostic Tap
How would a pleural effusion present on a chest X-Ray?
• Blunting of the costophrenic angle.
• Tracheal shift if large.
• May also identify undelying causes.
How would a pleural effusion present on a USS?
• One large pocket of fluid or several pockets.
What tests should a diagnostic tap be sent for once 50ml has been aspirated?
• pH (<7.2 indicates complicated parapneumonic effusion, empyema or malignancy).
• Protein / LDH /Glucose
• AFB / TB Culture / General Culture
'Light's Criteria' defines a fluid as an exudate if it fits one of what three definitions?
1) The ratio of pleural fluid protein to plasma protein is >0.5.
2) The ratio of pleural fluid LDH to plasma LDH is >0.6. (Lactate dehydrogenase)
3) The pleural fluid LDH is greater than 0.6 the times of the normal upper limit for serum.
If a pleural fluid has been identified as a transudate what investigations should then be performed?
If the pleural fluid is identified as an exudate which investigations should be performed?
• CT Thorax
What is the management of a pleural effusion?
1) Transudate - Treat the cause.
2) Exudate -
- Malignant - Drain and pleurodesis.
- Haemathorax - Large bore chest drain + surgery
- Emyema - Chest drain and IV antibiotics.