L14 Pleural Disease

Card Set Information

Author:
jknell
ID:
200096
Filename:
L14 Pleural Disease
Updated:
2013-02-12 18:13:01
Tags:
Pulmonary II
Folders:

Description:
Pulmonary II
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user jknell on FreezingBlue Flashcards. What would you like to do?


  1. Anatomy of Pleura
    • Mesothelial cells (mesoderm origin)
    • Connective tissue (blood and lymph vessels)
    • 1-2 cells thick

    • Visceral Pleura:
    • -covers lung
    • -separates lobes of lung from each other

    • Parietal Pleura:
    • -lines chest wall, diaphragm and mediastinum
    • -stomata between mesothelial cells
    • -sensory nerve endings


  2. Pleural Space
    -potential space

    ~10 mL of pleural fluid to provide lubrication during respiration (made and drained by parietal pleura)

    -Negative pressure created by outward force of chest wall and inward force of lung
  3. Pleural Vasculature


    • Visceral Pleura
    • -supplied by bronchial artery
    • -drained by pulmonary veins

    • Parietal Pleura
    • -supplied by intercostal artery
    • -drained by systemic veins
    • -stomata --> lymphatics
  4. Pleural Fluid
    Production = Absorption (15-20mL/day)

    • Balance between:
    • -hydrostatic forces
    • -oncotic forces
    • -membrane permeability
    • -(Starling Equation)

  5. Pleural Effusion Etiology
    • 1. Transudate
    • -imbalance of hydrostatic pressure
    • -imbalance of oncotic pressure
    • *often secondary to non-pulmonary pathophysiology

    • 2. Exudate
    • -increase in mesothelial or capillary permeability
    • -often inflammatory
  6. Causes of Transudates
    • 1. Congestive Heart Failure
    • -increased pulmonary venous pressure
    • -liquid leaks out of pulmonary capillaries into interstitium, then into pleural space

    • 2. Hyperproteinemia
    • -reduced oncotic pressure
    • -nephrotic syndrome

    • 3. Excessive Salt/Water intake
    • -hospitalized patients

    • 4. Hepatic hydrothorax
    • -portal HTN --> ascites
    • -ascites pass through diaphragm down pressure gradient (often R-sided)

    • 5. Pulmonary Embolism
    • -without infarction
  7. Causes of Exudates
    • 1. Malignancy
    • -direct involvement of pleural space
    • -lymphatic obstruction of drainage

    • 2. Infection
    • a) TB
    •      -cavitary rupture
    • b) Pneumonia
    •      -parapneumonic effusion (sterile)
    •      -empyema (infected)

    • 3. Autoimmune CT Disease
    • -SLE
    • -RA

    4. Post-CABG

    • 5. Sympathetic Effusion
    • -pancreatitis
    • -subphrenic abscess

    • 6. Hemothorax
    • 7. Esophageal rupture
    • 8. PE with infarction
    • 9. Benign asbestos-related pleural effusion (BAPE)
  8. Pleural Effusion Clinical Features
    • Symptoms:
    • 1. Pleuritic Pain
    • 2. Fever (if infectious)
    • 3. Dyspnea (if large)
    •      -hypoxemia (if large)
    •      -hypercapnia very rare
    • 4. Asymptomatic

    • Physical Exam:
    • 1. Dullness (clavicle trick)
    • 2. Decreased breath sounds
    • 3. Egophony at superior edge of effusion
    • 4. Pleural friction rub
    • 5. Tracheal shift (if under high pressure)
    • 6. Asymmetric chest rise
  9. Pleural Effusion Diagnosis
    • 1. Imaging (CXR, CT, U/S)
    • 2. Invasive Procedures
  10. Pleural Effusion Imaging
    • 1. CXR
    • -blunting of phrenic angles
    • -meniscus (tracking along lateral wall)
    • -straight lines if hydropneumothorax

    • 2. CT
    • -small pleural effusion

    • 3. U/S
    • -low echogenicity
    • -"dark" pockets
  11. Pleural Effusion Invasive Diagnostic Procedures
    • 1. Thoracentesis
    • 2. Tube thoracostomy (chest tube)
    • 3. Pleuroscopy
    • 4. Video-assisted thoracic surgery (VATS)
    • 5. Closed pleural bx (good for TB)
  12. Pleural Fluid Evaluation
    • Light's Criteria:
    • 1. LDH
    • -pleural > 0.6 Serum
    • -pleural > 2/3 ULN Serum
    • 2. Total Protein
    • -pleural > 1/2 serum

    ** only need to meet 1/3 criteria to = exudate

    • Other Tests:
    • -cell count
    • -pH
    • -glucose (infections)
    • -TGs
    • -Amylase (ruptured esophagus)
    • -Serum-pleural albumin gradient (diuresis)
  13. Loculations
    • -fibrous bands of tissue
    • -can lead to effusions that "defy gravity"
    • -seen in long standing effusions (almost always exudative)

    • Commonly seen in:
    • -malignant effusions
    • -prior empyema
    • -prior hemothorax
  14. Pleural Effusion Treatment
    • 1. Treat the underlying cause
    • 2. Diuresis

    • 3. Thoracentesis
    • -short term tx of sx

    4. Tube thoracostomy

    • 5. Surgery with decortication
    • -esp for loculations
    • 6. Pleurodesis
    • -instill irritating agents (talc, tetracycline derivative) into pleural space
    • -induces inflammation and scars visceral and parietal pleura together

    • 7. Pleur X catheter
    • -recurrent (esp due to malignancy)
    • -don't need to go into hospital
  15. Pneumothorax
    • 1. Air entry from outside the body (parietal pleura)
    • -trauma
    • -iatrogenic (tubes, catheters, incisions)
    • -hydropneumothorax with lung entrapment

    • 2. Air entry from within the body (visceral pleura)
    • -ruptured bleb, bulla, cyst
    • -esophageal rupture (achalasia)
    • -bronchial fracture (hit steering wheel in MVA)
    • -spontaneous primary pneumothorax

    Tension pneumothorax can occur with mechanical ventilation
  16. Pneumothorax Pathophysiology
    -consequences range from none to acute cardiovascular collapse

    -accumulation of substantial amount of air can collapse underlying lung parenchyma

    • -usually under atmospheric pressure
    • -if under positive pressure = tension pneumothorax
    • -may lead to shifting of the mediastinum and trachea

    • Cardiovascular Collapse
    • -in extreme cases
    • -fall in CO and BP
    • -due to inhibition of venous return
  17. Pneuthorax Clinical Features
    • Symptoms:
    • -sharp, acute onset chest pain
    • -minimal discomfort
    • -pleuritic pain
    • -dyspnea
    • -asymptomatic
    • -SICK (hypoxemia, hypotension, midline shift)

    • Physical Exam:
    • -decreased breath sounds
    • -hyperresonance (tympany)
    • -tracheal deviation (tension)
    • -hypotension (tension0
    • -hypoxemia
  18. Pneumothorax Treatment
    -Most resolve spontaneously (pressure in pleural space higher than pressure in mixed venous blood)

    • 1. 100% FiO2 by face mask
    • -washes nitrogen out from blood creating a diffusion gradient for the gas in the pleural space

    • 2. Needle Decompression
    • -2nd intercostal space
    • -emergency only

    • 3. Thoravent
    • -trochar with catheter

    4. Pigtail Chest Tube

    5. Surgical or large bore chest tube

    6. Pleurodesis

What would you like to do?

Home > Flashcards > Print Preview