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Flashcards in Pleural Disorders Deck (74)
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1

What does the parietal pleura line? 3


What does it contain and what do they do?

Lines the thoracic cavity, including the thoracic cage, mediastinum, and diaphragm

Contains sensory nerve endings that can detect pain
Pleuritis can be painful

2

What does the visceral pleura line?

Does it detect pain?

Lines the entire surface of the lung

Contains NO sensory nerve endings that detect pain

3

What is the pleural space?

A potential space between the parietal pleura and visceral pleura, filled with pleural fluid.

4

Serous fluid that allows for the parietal pleura (outer lining) and visceral pleura (inner lining) to glide over each other without separation is what?

What does it provide? 2

What is it produced by and absorbed by?

Pleural fluid

Provides lubrication and surface tension

Pleural fluid is produced by the parietal pleura and absorbed by the visceral pleura as a continuous process.

5

Mechanics of Pulmonary Ventilation

1. Lungs are surrounded by _____ ____ that lubricates movement of lungs within the cavity

Continual suction of excess fluid into ______ _______ acts like a glue to hold the lungs to the thoracic wall (allows for smooth movement)

Pleural pressure is a pressure _______that holds the lungs open (more _____ pressure with inspiration)

1. pleural fluid


lymphatic channels

negative
negative

6

Intrapulmonary pressure
is what?

As the chest expands on inspiration the intrapulmonary pressure becomes more _______, which causes air to be sucked into the lungs

the pressure within the alveoli

negative

7

Intrapleural pressure is what?

negative pressure may be lost if fluid collects in the pleural space, making the lung unable to _____ _____?

Negative pressure is created in the pleural space as the thoracic cage enlarges and the lungs recoil during normal inspiration

expand fully

8

What is pleuritis?

Is a localized inflammation of pleural surfaces that produces sharp localized pain.

9

Describe the pain that is associated with pleuritis?

Take home….pleuritic pain is sharp, stabbing pain with “splinting” on inspiration

10

Clinical Picture of Pleuritis

Localized, pleuritic chest pain increased with _____ _______ and ______ and may be associated with ______ ____.

Pleural rub is a ____ ______ best heard during inspiration and expiration at site of the chest pain.

What kind of extrapulmonary pain is associated with pleuritis?

--deep inspiration and coughing
--pleural rub

--fine crackles


Ipsilateral shoulder pain

11

Causes of Pleuritis
4

1. Viral infection (Coxsackie B virus)
2. Thoracic trauma (fractured rib)
3. Secondary to pulmonary disorders e.g.
4. Secondary to systemic diseases e.g.

12

Pleuritis can be secondary to pulmonary disorders such as? 5

Can also be secondary to systemic diseases such as? 3

1. Bronchiectasis (common)
2. Pulmonary infarction
3. Pneumonia
4. Lung cancer
5. Tuberculosis


1. rheumatoid arthritis,
2. systemic lupus,
3. metastatic cancer

13

Diagnosis of Pleuritis
2

1. Chest X- ray
Normal unless primary lung disease

2. Diagnosis is typically clinical… May do a work-up to determine cause

14

Treatment of Pleuritis
3

Treatment of the primary cause of pleurisy

1. Symptomatic treatment of chest pain
2. Moderate analgesics……NSAIDS
3. Some patients may need short course of narcotics

15

What is pleural effusion?

When does it occur?

Results when fluid collects between the parietal and visceral pleural layers.

the normal flow of fluid is disrupted

16

What are two ways the normal flow of fluid is dirupted in pleural effusion?

1. Too much fluid produced
2. Not enough fluid removed

17

Clinical features of pleural effusion?
4

Clinical Features:
1. SOB
2. Cough
3. Pleuritic chest pain

4. Other signs and symptoms depends on etiology

18

Causes of Pleural Effusion?
12 (most most common to least common)

1. Congestive heart failure 500,000
2. Pneumonia 300,000
3. Malignancy 200,000
4. Pulmonary embolism 150,000
5. Viral 100,000
6. S/P CABG surgery 70,000
7. Cirrhosis with ascites 50,000
8. GI disease 25,000
9. Collagen-vascular disease 6,000
10. Tuberculosis 2,500
11. Asbestos 2,000
12. Mesothelioma 1,500

19

Diagnosis of Pleural effusion?
5

Diagnosis:
1. Careful History
2. Thorough exam
3. CXR
4. Chest CT
5. Pleural Fluid analysis

20

Radiologic Assessment

1. What positions would we order on pleural effusions?

What is indicative of the accumulation of between 250 - 500 ml of fluid?

What would a Lateral-Decubitus films show? (differenciate it from what?)

1. Chest X-Ray: PA and Lateral-Decub

2. blunting of either costophrenic angle

Lateral-Decubitus films (that allow fluid to shift to the dependent portion of the thoracic cavity) help differentiate fluid from pleural thickening and fibrosis

21

Whats a Sub-Pulmonic Effusion?

accumulation of fluid between the lung and the diaphragm which gives the false impression of an elevated hemi-diaphragm

22

Pleural Effusion Evaluation:
What is a Thoracentesis?


A WHAT in conjunction with WHAT should allow the clinician to diagnose the cause of an effusion in about 75 % of patients.

a simple bedside procedure that permits fluid to be rapidly sampled, visualized, examined microscopically, and quantified.


--A systematic approach to analysis of the fluid
--the clinical presentation

23

Pleural Fluid Analysis:
Two kinds?
What things are we analyzing in the effusion?
9

Transudate vs. Exudate

1. Gross Appearance
2. pH
3. Gram Stain, C & S
4. Cytology
5. LDH
6. Protein
7. Glucose
8. Cholesterol
9. Amylase

24

What is Light's Criteria? 3

How many must be met to be defined as an exudate?

If at least one of the following three criteria is present, the fluid is defined as an exudate

(please note that serum samples must be taken as well)

1. Pleural fluid protein/serum protein ratio > 0.5.
2. Pleural fluid LDH/serum LDH ratio > 0.6.
3. Pleural fluid LDH greater than two thirds the upper limits of the laboratory's normal serum LDH

25

Criteria for “Exudative Effusion”
3 criteria and their values?

1. Pleural Protein/Serum Protein ratio > 0.5

2. Pleural LDH/Serum LDH ratio > 0.6

3. Pleural fluid LDH > 200LDH (typically > than two thirds the upper limits of the laboratory's normal serum LDH)


only need 1 critical value to establish the diagnosis of exudate

26

Pleural effusion exudative causes?
11

1. Anything that causes inflammatory or infiltrative disease of the pleura (damaging capillary membranes)

2. Neoplasm (disruption causes increased permeability with lymphatic obstruction as well)
Lung Cancer, Breast Cancer,

3. Infection
Uncommonly associated with acute bacterial pneumonias (small and transient)

4. Empyema (not just disruption of the capillary membranes but the organisms have entered the pleural space)

5. Tuberculosis

6. Viral pneumonitis

7. Mycoplasmal pneumonia

8. Anything that causes inflammatory or infiltrative disease of the pleura (damaging capillary membranes)

9. Autoimmune disease

10. Pulmonary infarction (pulmonary embolus for example)

11. Intra-abdominal pathology (e.g. development of subdiaphragmatic abscess, pancreatitis)

27

What is responsible for 75% of all malignant pleural effusions?

Lymphoma

28

30

30

29

1. Describe a trandudative pleural effusion?

And what would cause it? 2 general. 3 examples

Transudative
1. straw-colored, clear, odorless fluid

2. Anything that causes

--increased hydrostatic pressure or
--decreased capillary colloid osmotic pressure such as…

1. Congestive Heart Failure (most common cause)
2. Severe hypoalbuminemia (nephrotic syndrome and liver failure)
3. Cirrhosis (associated with ascites)

30

What should we order when we find out if the pleural effusion is:
Transudate?
Exudate? 5

Transudate?
No further laboratory analysis indicated

Exudate?... Consider the following
1. WBC count with differential
2. Bacterial culture
3. Cytological examination
4. Glucose level
5. Amylase
Others