Pulmonology E1: Pleural Disorders

What innervates the parietal pleura?

Phrenic nerve (C3-C5)

Localized, sharp chest or shoulder pain exacerbated by respiratory movements (coughing/sneezing)

Pleuritis

PE findings of pleuritis

- Dullness to percussion

- Diminished breath sounds

- Pleural rub- heard in inspiration, expiration, and cessation of respiratory movements

Treatment for pleuritis

- Treat underlying condition
- Analgesics & NSAIDs
- Cold & warm compresses

What diagnostic workup should you always perform for pleuritis?

r/o ACS- EKG & troponin

What ribs are the hardest to break and signify a significant degree of trauma if fractured?

Ribs 1-3

What ribs are the most vulnerable?

Ribs 4-10

What ribs are more mobile and more difficult to break?

Ribs 11-12

When is surgical intervention used for a rib fracture?

If displaced or nonunion occurs

Treatment for rib fracture

Pain management

Pleural effusion caused by an alteration in hydrostatic or oncotic pressure
a. Transudative
b. Exudative

Transudative

Pleural effusion caused by increased mesothelial and capillary permeability
a. Transudative
b. Exudative

Exudative

Most common cause of transudative pleural effusion

CHF

Drug induced pleural effusion
a. Transudative
b. Exudative

Exudative

Pleural effusion associated with traumatic thoracic injuries- blunt or penetrating

Hemothorax

Each hemithorax can hold _______ of a patient's circulating blood volume

40%

Most empyemas are associated with what?

PNA due to the formation of parapneumonic effusion

PE findings of a pleural effusion

- Dullness to percussion

- Decreased breath sounds

- Decreased tactile fremitus

- Contralateral mediastinal shift

How much fluid is required in a pleural effusion to show blunting of the costophrenic angle?

200 mL

How much fluid is required in a pleural effusion to show blunting of the posterior gutter?

50 mL

What is Light's criteria used for?

To determine if the pleural effusion is transudative or exudative

Light's Criteria:
Pleural:Serum protein- < 0.5
Pleural:Serum LDH- < 0.6
Pleural fluid LDH- < 2/3 upper limit of normal

Transudative

Light's Criteria:
Pleural:Serum protein- ≥ 0.5
Pleural:Serum LDH- ≥ 0.6
Pleural fluid LDH- ≥ 2/3 upper limit of normal

Exudative

When performing a thoracentesis for pleural effusion treatment, what should you NOT do?

Do NOT take more than 1000 mL of fluid during a single attempt because it can lead to re-expansion of pulmonary edema

What procedure is performed for recurrent pleural effusions or pneumothorax?

Pleurodesis

Obliteration of the pleural space

Pleurodesis

How do you perform a chemical pleurodesis?

Agents, such as tetracycline, are used to stimulate inflammation of the pleural space

How do you perform a mechanical pleurodesis?

Thoracotomy or thoracoscopy

Simple pneumothorax

Does NOT shift mediastinum

Tension pneumothorax

Contralateral shift of the mediastinum

Open pneumothorax

Open wound in chest wall

Pathophys of a pneumothorax

Decrease in vital capacity and partial pressure of oxygen

Risk factors for a primary spontaneous pneumothorax (PSP)

Tall, thin body habitus
Marfan syndrome

Primary spontaneous pneumothorax (PSP) are common to have recurrences when?

Within the first year

PTX that occurs as a complication due to underlying lung disease

Secondary spontaneous pneumothorax (SSP)

What pneumothorax is considered a life threatening emergency?

Tension pneumothorax

When air in the pleural space builds up enough pressure to interfere with venous return, leading to hypotension, tachy, and severe dyspnea

Tension pneumothorax

Treatment for a tension pneumothorax

Needle decompression in the 2nd ICS MCL on the side of the PTX

Clinical signs of a tension pneumothorax

Tachycardia, hypotension, contralateral mediastinal shift

S&S of a tension pneumothorax

Sudden onset of one-sided CP and dyspnea

When do symptoms of a tension pneumothorax normally develop?

When a patient is at rest

PE findings of a large pneumothorax

- Diminished breath sounds

- Diminished tactile fremitus

- Hyperresonance on one side

What will a CXR of a pneumothorax reveal?

Visceral pleural line, lack of vascular markings

What will an US of a pneumothorax reveal?

Lack of lung sliding

Lack of lung sliding is seen on an ______ when evaluation a PTX

US

A visceral pleural line is seen on a ______ when evaluation a PTX

CXR

If a "sucking" wound is present with an open PTX, what should you do?

Place a 3 sided occlusive dressing

Treatment for a stable, small (<15%) PTX

Bed rest, symptomatic care, serial CXRs

Treatment for a stable, large (>15%) PTX

Chest tube to suction

Treatment for recurrent PTX

Pleurodesis

Most common cause of mesothelioma

Asbestos exposure

What is a serum biomarker used for evaluating mesothelioma?

Megakaryocyte potentiating factor (MPF)

A pleural effusion is seen in ______ of cases of mesothelioma

95%

What is the median survival rate of mesothelioma?

9-16 months