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24 Cards in this Set
- Front
- Back
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Pleuritis
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- Parietal pleura contains many pain fibers, so any inflamm can cause pain
– “pleuritic pain” worse with deep breathing |
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Pneumothorax definition
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- 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 |
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Pneumothorax causes
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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 |
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Pneumothorax treatment
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- put a chest tube in for suction until the lung heals up
– use a pleural vac |
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Tension Pneumothorax
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- 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 |
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Pleural effusions radiology
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- 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 |
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Pleural effusions diagnostic thoracentesis
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- 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 |
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Pleural effusions theraputic thoracentesis
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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
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Pleural effusions thoracentesis safe tapping
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- 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 |
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defining transudates and exudates
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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 |
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transudative effusions
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- 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 |
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exudative effusions
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- huge differential dx & tx options
– from ↑ perm of pleural microcirculation due to inflam or impaired lymp drainage |
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cell count in exudative effusions (lymphos, eos, basos, neutros, mesos)
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- 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 |
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Hemothorax
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- 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 |
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Empyema
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- 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 |
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Chylothorax
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- exudative effusion from disruption of thoracic duct
- usually turbid |
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Simple parapneumonic effusions
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– reactive to a pneumonia & resolve w/ Abs
– benign course |
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borderline empyema
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- when pH > 7.1 & < 7.2, or glucose > 40 or LDH > 1000 and Gram (-)
– need RETAP |
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empyema Tx
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- 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 |
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TB effusions dx
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- 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 |
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TB effusions Tx
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- 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 |
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Malignant effusions general
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- more common causes of exudative effusions
– any tumor can mets to the pleura, esp lung, breast, lymphoma, ovary, stomach |
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Malignant effusions Dx (this is very long)
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- 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 |
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Malignant effusions Tx
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- 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 |
