Crr Week 6: Pleural Diseases (Mccaffree)

Front 1

What are the 2 types of exudative pleural effusions?

Back 1

1. Malignant pleural effusion
2. Parapneumonic effusion

Front 2

List the 3 general types of pleural diseases.

Back 2

1. Pneumothorax
2. Pleural effusions
3. Hemothorax

Front 3

In general, what causes a pneumothorax?

Back 3

Spontaneous rupture of weak areas on the surface of the lung, allowing air to leak into the pleural space

Front 4

List the 3 classifications of pneumothorax.

Back 4

1. Spontaneous pneumothorax
2. Traumatic pneumothorax
3. Iatrogenic pneumothorax

Front 5

List 2 causes of primary spontaneous pneumothorax

Back 5

1. Subpleural bullae
2. Airway inflammation

Front 6

Secondary pneumothorax results from what kind of disease?

What is the most common cause?

Back 6

Parenchymal lung disease:

1. COPD <-- Most common
2. Pneumonia
3. Carcinoma
4. Mesothelioma
5. Sarcoidosis
6. Tuberculosis
7. Cystic fibrosis

Front 7

What is the difference between a bullae and a bleb?

Back 7

Bullaes are outpouching of the pleura and are connected to airways. Blebs exist within the visceral pleura and are NOT connected to airways

Front 8

List 4 clinical presentations of spontaneous pneumothorax. Which is the most common?

Back 8

1. Sudden onset of pleuritic chest pain <-- MOST COMMON
2. Dyspnea
3. Tachycardia
4. Diminished breath sounds

Front 9

What happens to arterial blood gases as a result of pneumothorax?

Back 9

1. Hypoxemia
2. Acute respiratory alkalosis

Front 10

What causes acute respiratory alkalosis in the case of pneumothorax?

Back 10

Hyperventilation
(as a result of decreased PO2)

Front 11

What type of pneumothorax is present if the mediastinum resides at the midline and the hemidiaphragms are at equal heights?

Back 11

Non-tension pneumothorax

Front 12

List 6 complications of pneumothorax.

Back 12

1. Recurrence
2. Reexpansion pulmonary edema
3. Failure to reexpand
4. Bronchopleural fistula
5. Pneumomediastinum, pneumopericardium, and subcutaneous emphysema
6. Tension pneumothorax

Front 13

What are the 2 goals of management for resolving pneumothorax?

Back 13

1. Remove air from pleural space
2. Decrease the likelihood of recurrence

Front 14

List the management options for treating pneumothorax.

Back 14

1. Observation +/- oxygen
2. Aspiration
3. Chest tube +/- pleurodesis
4. Surgery (VATS, Thoracotomy)

Front 15

What might be a good treatment option for someone who has recurrent pneumothorax?

Back 15

Pleurodesis
(Inflammatory agent causes attachment of visceral and parietal pleuras to obliterate pleural space)

Front 16

How should you manage a small primary spontaneous pneumothorax (<15%) if the patient is asymptomatic?

Back 16

1. High flow oxygen for 6 hours
2. Repeat CXR
3. If no bigger, discharge home.
4. Return in 24 hours for reassessment and repeat CXR

(Return ASAP if dyspneic)

Front 17

How should you manage a PSP >15% if the patient is hemodynamically stable?

Back 17

1. Aspiration
2. Follow-up CXR in 6 hours

Front 18

What are the indications for managing pneumothorax with a chest tube?

Back 18

1. Bilateral pneumothorax
2. Significant symptoms
3. Persistant air leak
4. Need for positive pressure ventilation
5. Tension pneumothorax

Front 19

Describe how tension pneumothorax affects blood flow

Back 19

Pressure causes decreased venous return as both IVC and SVC are restricted
(decreased preload)

Front 20

What signs will you see on an CXR that indicate tension pneumothorax?

Back 20

1. Mediastinal shift to contralateral side
2. Depressed hemidiaphragm

Front 21

List some signs and symptoms associated with tension pneumothorax

Back 21

1. Tachycardia
2. Low BP
3. Decreased lung sounds
4. Tracheal deviation
5. Increased difficulty breathing
6. Jugular vein distension

Front 22

If a patient presents with JVD, tracheal deviation, decreased blood pressure, tachycardia, and decreased lung sounds-- what would you suspect?

Back 22

Tension pneumothorax

*Emergency!

Front 23

How do you manage tension pneumothorax?

Back 23

Needle decompression

Front 24

Where do you insert the needle when performing needle decompression?

Back 24

Insert needle OVER the third rib, in between the 2nd and 3rd rib, along the mid-clavicular line

*Listen for air escaping
(Used to manage tension pneumothorax)

Front 25

What other treatment modality should be considered if a patient's pneumothorax is managed with a chest tube?

Back 25

Pleurodesis

Front 26

Who needs definitive management for pneumothorax with Video assisted thoroscopy surgery?

Back 26

1. Failure to reexpand after 3 days
2. >2 episodes on the same side
3. Recurrence after chemical pleurodesis
4. Occupation of the patient

Front 27

If after a simple aspiration is performed and the patient experiences complete reexpansion-- what should be done?

If there is recurrence of pneumothorax, what should be done?

Back 27

The patient can be discharged

If recurrence --> another aspiration or chest tube

Front 28

If the lung is not reexpanding after invasive aspiration as been performed, what is going on, and what should be done?

Back 28

It is likely that there is an air leak and patient should be hospitalized and monitored for an air leak for 3 days

*If air leak resolves --> consider pleurodesis or surgery
*If air leak does NOT resolve --> VATS, thoracotomy

Front 29

How are secondary spontaneous pneumothorax treated?

Back 29

1. Chest tube
2. Suction if persistent air leak or failure to reexpand with underwater seal
3. Pleurodesis to prevent recurrence
4. Maybe surgery

Front 30

How is traumatic pneumothorax managed?

Back 30

Chest tube

Front 31

How is iatrogenic pneumothorax managed?

Back 31

(caused by central line)

*managed with chest tube

Front 32

For initial fluid evaluation of a pleural effusion, what lab values are checked?

Back 32

1. Protein (fluid and serum)
2. LDH (fluid and serum)
3. Glucose or pH
4. Cell evaluation, gram stain, culture
5. Cytology and ADA if TB suspected

Front 33

Which lab tests are most useful in determining if fluid is transudate or exudate?

Back 33

1. Protein (fluid and serum)
2. LDH (fluid and serum)

Front 34

What F/S protein ratios are indicative of transudate and exudate fluids?

Back 34

Transudate --> <0.6
Exudate --> >/= 0.6

Front 35

What LDH values are indicative of transudate and exudate fluids?

Back 35

Transudate = <2/3
Exudate = >2/3

Front 36

What F/S LDH values correspond to transudate and exudate fluids?

Back 36

Transudate --> <0.5
Exudate --> > or = 0.5

Front 37

List 5 causes of transudate effusions.

What is the most common?

Back 37

1. Congestive heart failure <-- MOST COMMON
2. Cirrhosis (ascites)
3. Nephrotic syndrome
4. Hypoproteinemia
5. Renal failure/ volume overload

Front 38

What are the 2 most common causes of exudate effusions?

Back 38

1. Infections
2. Malignancies

Front 39

How do you treat transudate effusions?

Back 39

1. Treat underlying problem
2. Diurese

Front 40

How do you treat exudate effusions?

Back 40

1. Treat underlying problem
2. Specific therapy geared towards pneumonia or malignancy

Front 41

How are empyema and complicated parapneumonic effusions treated?

Back 41

Chest tube

Front 42

How is a non-complicated parapneumonic effusion treated?

Back 42

1. Simple observation
2. Antibiotics

Front 43

What sort of lab values and characteristics indicate a complicated parapneumonic effusion?

Back 43

Glc < 40
pH < 7.2
LDH > 1000
Loculated
(+) gram stain or culture

Front 44

How do you treat chronic empyemas?

Back 44

(these are empyemas that are present for more than 2 weeks)

Treat like an abscess:
1. Surgical decortication
2. Open drainage-- rib resection

Front 45

What is the most effective pleurodesis agent?

Back 45

Talc slurry

Front 46

What are some possible complications of pleurodesis?

Back 46

1. Pain
2. Fever
3. Infection
4. Fatal pneumonitis (rare; with talc instillation)

Front 47

In general, is VATS or pleurodesis a more superior treatment?

Back 47

VATS
(less recurrences)

Front 48

How do you relieve dyspnea experienced with malignant pleural effusions?

Back 48

Dry tap

Front 49

How are malignant pleural effusions treated?

Back 49

1. Chest tube
2. Pleurodesis
3. Repeat therapeutic thoracentesis
4. Chemo-responsive tumors may require occassional tapping