Pleural Disease - Clin Med 2

What does this refer to

• Accumulation of fluid in the pleural space due to the manifestation of underlying disease

  • Nearly half of all pleural effusions in the United States are accounted for by a combination of lung cancer and breast cancer

Pleural effusion

What does this refer to

• Recent respiratory infections or fever, specifically ask about pneumonia

• History of CHF, renal or liver impairment, pulmonary hypertension, PE, malignancies (or red flag symptoms), occupational history, medication use

History of Pleural Effusion

What does this refer to

• Fluid accumulation in the pleural space is a common occurrence caused by both benign and serious conditions.

• United States alone, it is estimated that approximately 1.5 million cases of pleural effusions are diagnosed annually, with 16% requiring thoracentesis

Epidemiology of Pleural Effusion

What does this refer to

Pathophysiology of Pleural Effusion

What does this refer to (Classification of Pleural Effusion)

• Imbalance of fluid forces (hydrostatic)

• Protein forces (oncotic) external to pleural space.

Transudative

What does this refer to (Classification of Pleural Effusion)

• Disease process

  • Systemic

  • Focal

Exudative

What does this refer to

• Vary with etiology

• Small amount of fluid is usually asymptomatic

• MC symptoms are dyspnea, cough, and pleuritic chest pain

Presentation of Pleural Effusion

What does this refer to

• Vary depending on etiology

  • Specific to respiratory system

  • Nonspecific

  • Small amount usually asymptomatic

• Three most common symptoms are dyspnea, cough, and pleuritic chest pain.

• Exertional dyspnea (rapid)

  • Severity correlates with effusion size

• Cough

  • Nonspecific mild and nonproductive

  • Severe-(infective)

    • Fever, sweating and fatigue

• Pleuritic Chest Pain

  • Degree of inflammation

Signs and Symptoms of Pleural Effusion

What does this refer to

• Large effusion may result in contralateral tracheal shift, asymmetric chest expansion, and tachypnea

• Decreased or absent tactile fremitus, dullness to percussion over the fluid area, and uni- or bilaterally diminished or absent breath sounds

• Pleural friction rub heard on auscultation if inflammatory process or post thoracentesis

Physical Examination of Pleural Effusion

What does this refer to

Differential Dx of Pleural Effusions

What does this refer to

• Chest US or CXR, possible CT

• Thoracentesis and fluid analysis

Diagnostic Studies of Pleural Effusions

What does this refer to

Exudates

What does this refer to

• Varies by primary condition

• Symptomatic patients may require a large-volume thoracentesis and/or insertion of a pleural drain

• Asymptomatic patients and patients with transudative pleural effusions, in general, do not require tube thoracostomy or pleural interventions but are closely followed (every 3 to 6 weeks) for clinical and radiographic observation.

Management of Pleural Effusion

What does this refer to

• Treat underlying disorder

• Possibly Abx Therapy, Diuretics, ultrafiltration, & Anticoagulation

• Symptomatic

  • Thoracentesis

    • +/- insertion of pleural drain

Treatment for Pleural Effusion

What does this refer to

• Water on the lungs

• Common and several diseases can cause this effusion

  • Heart failure most common

• Severity/seriousness depends on primary cause

• Treatment based on symptoms

• Recurrent effusions, may need meds to stop fluid

• Fluid accumulation ongoing could be cancer.

Patient Education of Pleural Effusion

What does this refer to

• Abnormal collection of gas, usually air, in the pleural space and subsequent collapse of the lung

Pneumothorax

What does this refer to

• 2 forms

• Nonspontaneous (Traumatic and iatrogenic)

  • Known precipitating factors

• Spontaneous (Primary and Secondary)

  • No obvious precipitating factors

• male-to-female ratio of 3.3:1

• average age of 34 years old for males and 40 for females

• Tall, thin, male

• Connective tissue disorders

• Smoking

• Scuba diving, high altitudes and flying

Epidemiology of Pleural Disease

What does this refer to

• A ________ is the presence of air or gas in the pleural space due a breach in the visceral or parietal pleura, either by trauma or spontaneous rupture.

• opposing forces provide a slight suction on the lung to keep it expanded throughout the respiratory cycle

• Air enters the pleural space from loss of integrity of the chest wall or alveolar sac

• The exact pathogenesis of spontaneous alveolar rupture is unclear

Pathophysiology of Pneumothorax

What does this refer to

• Clinical presentation and medical history vary depending on the type of pneumothorax

• The chest pain typically resolves within 24 hours

Primary Spontaneous Pneumothorax

What does this refer to

• Varied based on type

• Development closely correlated with underlying disease

• Abrupt onset of dyspnea and pleuritic chest pain on ipsilateral side

• History of significant risk factors including recent accident or trauma, smoking, malignancies, COPD, infection (especially HIV, Pneumocystis jiroveci, toxoplasmosis and Kaposi sarcoma), illicit drug use, air travel should be considered.

• A history of prior pneumothorax is important as the recurrence rate is high

History of Primary Spontaneous Pneumothorax

What does this refer to

• Varied based on severity and cause

  • Chest tightness.

  • Easy fatigue.

  • Rapid heart rate.

  • Bluish color of the skin caused by lack of oxygen.

  • Nasal flaring.

  • Chest wall retractions.

• MC are chest pain and dyspnea

• Usually thin, tall adolescent males is typically greatest risk

Presentation of Primary Spontaneous Pneumothorax

What does this refer to

• Ranging from normal to severe distress

• Possible unequal breath sounds, hyperresonance with percussion on ipsilateral side, decreased tactile fremitus, tachycardia, pulsus paradoxus, hypotension, jugular venous distention

Physical Examination of Primary Spontaneous Pneumothorax

What does this refer to

• CT

• High index of suspicion in an unstable patient requires immediate needle decompression

Diagnostic Studies for Primary Spontaneous Pneumothorax

What does this refer to

• Observation and supplemental oxygen for all patients

• Additional considerations

  • Treatment of the underlying lung disease, simple aspiration, tube or catheter thoracostomy, thoracoscopy, mechanical ventilation

Management of Primary Spontaneous Pneumothorax

What does this refer to

Differential Dx of Primary Spontaneous Pneumothorax

What does this refer to

• Diagnosis of pneumothorax is based on clinical suspicion and the history and physical examination are key to the diagnosis

• Clinical interpretation of the presenting signs and symptoms is crucial for the correct diagnosis

• Unstable patients with a clinical high suspicion of a pneumothorax require urgent decompression with needle decompression or tube thoracostomy before imaging.

• In stable patients, the presence of the pneumothorax should be confirmed by imaging, which will also provide information on the extent and possible cause.

Evaluation of Primary Spontaneous Pneumothorax

What does this refer to

Diagnostic tests for pneumothorax

What does this refer to

• Observation and supplemental oxygen therapy are recommended for all patients with a ________. Oxygen therapy accelerates the rate of pleural air absorption. In asymptomatic patients with small ________, oxygen administration is usually the only treatment needed.

• Observation

• Supplemental oxygen

• Treatment of the underlying lung disease

• Simple aspiration

• Tube or catheter thoracostomy

• Thoracoscopy

• Mechanical ventilation

• Treatment of a pneumothorax depends not only on the clinical setting but also on the etiology and associated comorbidities

Treatment for pneumothorax

What does this refer to

Patient education for pneumothorax

What does this refer to

• Condition in which the pleura becomes inflamed. Sharp chest pain that worsens with deep breathing (coughing, sneezing, and chest wall movements)

• Viral infx most common but can be pneumonia (MRSA)

• Treat with NSAIDS such as ibuprofen

Pleuritic Chest Pain

What does this refer to

• Innervated by somatic nerves (which senses pain due to trauma/inflammation

  • Inflammation then triggers local pain receptors

  • Phrenic nerve innervated the diaghragm (which causes the referred pain ipsilateral neck/shoulder)

Pathophysiology of Parietal Pleura

What does this refer to

• Diaphoresis

• Nausea

• Palpitations

• Pain-Sharp pain and stabbing is typical for noncardiac chest pain

  • Near the diaphragm, get referred pain to neck and/or shoulder

Presentation of Pleuritic Chest Pain

What does this refer to

• Audible raspy breathing on auscultation

• Tachycardia

• Tachypnea

Physical Exam of Pleuritic Chest Pain

What does this refer to

• Pericarditis

• Costochondritis

• Pneumonia

Differential Dx ofPleuritic Chest Pain

What does this refer to

Differential Diagnosis of Pleuritic Chest Pain

What does this refer to

Outpatient Diagnosis of Pleuritic Chest Pain.

What does this refer to

Serious Etiologies of Pleuritic Chest Pain and Associated Red Flags

What does this refer to

• Most are viral infx

  • Pain and symptoms resolve in 2-4 weeks

  • NSAIDS

  • Corticosteroids-for intolerant to NSAIDS

• Nonviral Infection

  • Treat based on cause

    • Abx treatment

    • Colchicine for familial Mediterranean Fever

      • Refractory cases interleukin-1 or 6 inhibitor

Treatment of Pleuritic Chest Pain

What does this refer to

• More likely to occur with malignancy, renal failure and rheumatoid pleurisy

  • Pleurodesis

• Follow up

  • Very important with smokers, ones with persistent, or older than 50yo

    • Resolution of the abnormality @ 6weeks post-treatment

Recurrent Cases of Pleuritic Chest Pain

What does this refer to

SOB

What does this refer to

• _____________ present with overlapping symptoms that can sometimes cloud the diagnosis. Compare and contrast the pathophysiology, historical features, physical examination findings, and diagnostic studies of COPD and interstitial lung disease.

Chronic obstructive lung disease and interstitial lung disease

What does this refer to

• ______________ is a heterogeneous group of disorders. Compare and contrast the findings found on CXR and CT scan with idiopathic pulmonary fibrosis, sarcoidosis, connective tissue interstitial lung disease, and eosinophilic interstitial lung disease.

Interstitial lung disease

What does this refer to

• ____________ is a cardiovascular manifestation of pulmonary disease leading to hypertrophy or dilatation of the right ventricle. List the pulmonary conditions that lead to cor pulmonale.

Cor Pulmonale