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24 Cards in this Set

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- Parietal pleura contains many pain fibers, so any inflamm can cause pain
– “pleuritic pain” worse with deep breathing
Pneumothorax definition
- Entry of air into the pleural space
– can be a rent in the lungs from a biopsy or due to areas of gas trapping
– compromises chest wall
– air sucked in by negative pleural P
– esp w/ tall people
Pneumothorax causes
1) Iatrogenic – central lines, mechanical ventilation, lung biopsy
2) Abnormal lungs w/ areas of blebs, bullae (cysts in the lungs)
3) Abnormal airways w/ air-trapping from ball-valve effect like asthma
Pneumothorax treatment
- put a chest tube in for suction until the lung heals up
– use a pleural vac
Tension Pneumothorax
- medical emergency!
– Air escapes into pleura causing buildup of positive P in thoracic cavity
– May occur when pt is on a mechanical ventilation with air buildup, which causes compromise of venous return to VC & shock
– Pts need immediate decompression
Pleural effusions radiology
- should not see pleura on normal CXR
– might see blunting of costophrenic angle on upright film
– Elevation or flattening of hemi diaphragm on upright film
– Diffuse haziness of hemi thorax on supine film
- If large, will cause shift of mediastinum to contra-lateral side
Pleural effusions diagnostic thoracentesis
- differentiate transudate & exudate, sort out an exudates
- can tell you if you need a gram stain, AFB, amylase, cholesterol, TG level, pH, or adenosine deaminase
Pleural effusions theraputic thoracentesis
Can relieve sense of dyspnea by allowing expansion of lung, improving length (tension relationship of chest wall muscles & diaphragm), and it creates more normal chest wall
Pleural effusions thoracentesis safe tapping
- use lateral decubitus film to show fluid is present, free flowing, and uniformly > 1 cm
– also use ultrasound or CT to identify & locate loculated effusions
– Post-tap X-ray if pt develops coughing, chest pain or dyspnea
– contraindications are uncooperative pt, bleeding diathesis and anticoagulation, Mechanical Ventilation, and too little fluid
defining transudates and exudates
for exudates
1) pleural-fluid protein / serum protein > 0.5
2) pleural-fluid LDH > 0.6
3) pleural fluid LDH level > 2/3 upper limits of normal
- For transudates difference b/t albumin in serum minus pleural fluid is > 1.2
transudative effusions
- limited dx possibilities & tx options
– transudate means CHF from ↑ pulmonary venous Ps
– usually resolves in 48 hours after diuresis
– Nephrosis (low oncotic pressures)
– Atelectasis (↑ negative pleural pressure)
– Ascites can also preferentially form in pleural space, hepatic-hydrothorax
exudative effusions
- huge differential dx & tx options
– from ↑ perm of pleural microcirculation due to inflam or impaired lymp drainage
cell count in exudative effusions (lymphos, eos, basos, neutros, mesos)
- if > 50% lymphos, cancer or TB
– if > 10% eos, blood or air in pleural space, drug rx, asbestos, paragonimiasis
– if > 10% basos, leukemic infiltration
– if > 50% neutros, acute process
– if > 5% mesos, TB less likely
- Malignancy, trauma
- pleural fluid hct 50% of blood hct
– Will coagulate & may lead to loculation w/ complications of fibrothorax & possible empyema
– If small, may defibrinate & stay free flowing
- exudative effusion from bacterial infections
- failure to recognize & drain can lead to unresolved sepsis & fibro thorax
- defined by pH < 7.1, glucose < 40, (+) Gram stain
- exudative effusion from disruption of thoracic duct
- usually turbid
Simple parapneumonic effusions
– reactive to a pneumonia & resolve w/ Abs
– benign course
borderline empyema
- when pH > 7.1 & < 7.2, or glucose > 40 or LDH > 1000 and Gram (-)
– need RETAP
empyema Tx
- thoracostomy & Abs
– thrombolytics if loculated or stops draining despite fluid on X-ray
– decortication if unable to achieve drainage & lung is trapped in fibrinous peel
– untreated may -> empyema necessitans or bronchopleural fistula -> bigtime sepsis
TB effusions dx
- 90-95% lymphos
- fluid protein level > 4.0
– no meso cells
– pleural adenosine deaminase > 40 U/L
– MTB DNA may be detected by PCR
– closed pleural biopsy has a 60 % yield
TB effusions Tx
- If not treated, > 50% will develop active pulmonary or extra pulmonary TB
– < 40% have + cultures b/c the effusions usually immunologic Rx to organism
– use anti-TB meds in 6 – 12 wks
Malignant effusions general
- more common causes of exudative effusions
– any tumor can mets to the pleura, esp lung, breast, lymphoma, ovary, stomach
Malignant effusions Dx (this is very long)
- cytology is 70% + for adeno, 10% for mesothelioma, and 20% for others – flow cytometry helpful for lymphoma – measuring tumor markers is probably worthless
- lymphos 50-70%, pH < 7.3, glucose < 60
- the lower the ph and glucose, the more the burden
- visceral pleura most involved, so you many need open biopsy instead of closed
Malignant effusions Tx
- therapeutic thoracentesis for palliation
– chest tube drainage & talc slurry 90% effective unless lung trapped
– thorascopy & talc poudrage > 90% effective unless lung trapped
– a pleuroperitoneal shunt is especially good for chylothorax