6. Pleural Disorders

Pleural disorders refer to a group of medical conditions that affect the

Pleura

• thin membrane surrounding the lungs and lining the chest cavity

Common types of pleural disorders

• pleural effusion (fluid)

• empyema (pus)

• hemothorax (blood)

• chylothorax (lymph)

• pneumothorax (air)

• BP fistula (connection between the bronch tree & pulm)

Pleural Effusion definition

• accumulation of an abnormal quantity of fluid in the pleural cavity

Pleural effusion patho

• Pleural space normally has small amounts of fluid for lubrication

• fluid is produced by the parietal pleura and absorbed by lymphatic vessels in parietal pleura

• balance is normally maintained by hydrostatic pressure, oncotic pressure & lymphatic drainage

• Pleural effusion happens when this balance is disrupted

What are the 2 types of Pleural effusions?

1. Transudative

2. Exudative

What are transudative effusions?

• fluid accumulates because increase in pulmonary capillary hydrostatic pressure or decrease in capillary oncotic pressure

• thin and watery (low protein count)

PRESSURES

What are the common causes of transudative effusions?

• CHF

• Liver disease

• Kidney disease

• pulmonary embolism (increase work on heart = increase permeability

What is exudative transfusions?

• fluid accumulates cause increased vascular permeability or inflammation and malignancies

• higher protein count & higher cell count (WBC)

What are some common causes of exudative transfusions?

• Infections

• neoplasm

• trauma & surgery

• CT disease

• pulmonary embolism

• idiopathic

30-50% of pts with what develop pleural effusions?

Pulmonary embolisms

A Small pulmonary embolism can cause what type of effusion and why?

Transudative

• due to back pressure

A Large pulmonary embolism can lead to what kind of effusion and why?

Exudative

• infarction & inflammation

What is empyema?

Accumulation of pus

• from infection

What is hemothorax?

Blood in pleural space

• penetrating or blunt chest trauma

What is chylothorax?

• chyle in pleural cavity

  • trauma or cancer occluding thoracic duct

  • Also could happen in neonates due to congenital malformities

What are some symptoms we may see on assessment of a pts with pleural effusion?

• Dyspnea (SOB)

• Chest pain

• Splinting

• Increased RR

• Cough

• Use accessory muscles

• CV effects (in severe)

  • JVD, Altered BP, decreased CO

What will we see on inspection of a pt with pleural effusion?

• decreased chest expansion on the affected side

• tracheal or mediastinal shift (in large effusions)

What will we see on palpation of a pt with pleural effusion?

Decreased tactile fremitus

What will we see on percussion of a pt with pleural effusion?

Dull or flatness over area of fluid

What will we hear on ausculation of a pt with pleural effusion?

• diminished or absent BS over effusion

How do we diagnose pleural effusion?

1. CXR

• blunting of costophrenic angle

• entire side of lung will be obstructed

• mediastinal shift or depressed diaphragm

2. CT or U/S

• capable of detecting small amounts of fluid

• U/S to guide thoracentisis

• CT also evaluates pleura and lung

What is thoracentesis?

• remove fluid from pleura

• fluid then examined for blood, pus, cell count, protein, pH (differntiates between transudative vs exudative)

What is a pleural biospy?

• small sample of parietal pleura removed for lab testing

• used when the cause of effusion remains unclear

Treatment of pleural effusion?

1. treat underlying problem that caused the effusion

2. Removal of fluid (Chest tube or thoracentesis)

3. Pleurodesis- Tetracyline (Chronic)

• inject into cavity and will cause adhesion of pleural surfaces = no sliding of lining

How is a pneumothorax classified?

1. How gas gains entrance to pleural space

• open

• closed

• tension

2. How they occurred

• spontaneous

• traumatic

• iatrogenic

What is a spontaneous pneumo?

Cause:

• spontaneous idiopathic rupture (no underlying cause)

• secondary to underlying lung condition

Air entry:

• From inside the lung through a tear in the visceral pleura

• as lung collapses = seals off the leak (air cannot leave since the hole is closed off)

Affects:

• one lung is impaired/atelectasis

What type of pneumo is this?

Spontaneous

What would we see on clinical assessment of a pt with a spontaneous pneumo?

• laboured respirations with dyspnea

• tachycardia (since decreased CL, J receptors & Chemoreceptors kick in)

• pleural pain

• asymmetrical chest movement

• absent breath sounds on affected sided

• hyper resonance

• mediastinum will shift towards affected side as lung collapses

What is the treatment for sponatenous pneumos?

Thoracentesis

• 4th or 5th ICS midaxillary, towards apex

What is a traumatic pneumo?

Cause:

• penetrating wound to chest

• gunshot, stabbing, impaling object

Air entry:

• from outside of body through opening in thorax and parietal pleura

• air enters with every inspiration and leaves with each expiration

Affects:

• may also affect the unaffected lung as it becomes compressed by mediastinal shift on inspiration

What type of pneumo is this?

Open/ Traumatic

What would we see on clinical assessment of pt with traumatic pneumo

• sucking nose

• tracheal swing with each inspiration and exhalation causing decreased BP

• hypoxic

• laboured respirations with dyspnea

• tachycardia

• pleural pain

• asymmetrical chest movement

• hyper resonance

• absent breath sounds on affected side and decreased on unaffected

What is the treatment for traumatic pneumo?

• cover with clean occlusive dressing taped only on 3 sides - don’t want to seal or tension pneumo can result

• chest tube, intubate/ventilate

• surgical repair

What is a tension pneumo?

Causes:

• open puncture through thorax or a closed tear in lung surface

• both with a flap or one way valve

Air entry:

• air enters the pleural cavity with each inspiration and the flap closes on expiration

• pressure builds up in thorax with each breath

Effect:

• Atelectasis - unaffected lung compressed by mediastinal shift

• mediastinal shift and increased intrathoracic pressure reduce venous return

What type of pneumo is this?

Tension

What do we see on assessment on a patient with a tension pneumo?

• BS are absent on affected side

• Tracheal & mediastinal deviation to the unaffected side

• shock

• JVD

• cyanosis & severe hypoexmia

• laboured respirations with increasing dyspnea

• tachycardia

• pleural pain

• asymmetrical chest movement

• hyperresonance

• pulsus paradoxis

What is the treatment for tension pneumo?

• Needle decompression 2nd ICS midclavicular

• After = chest tube and suction

If a pneumo is small what can we do?

• py may need only bed rest or limited physical activity

• reabsorption of gas usually within 30 days

What is a bronchopleural (B-P) Fistula?

abnormal connection between the bronchial tree & pleural cavity

• air leaks continuously into cavity = peristent pneumo

What are the causes of BP fistual?

• post-surgical

• infection

• trauma

What are the clincal signs of a BP fistula?

• persistent air leak

• pneumothorax

• resp distress

What is the treatment for BP fistula?

• surgical repair

• endoscopic procedures

• supportive care

If we are draining fluid with a chest tube, where do we cut and direct?

• 4-6th ICS midaxillary line

• Aimed down

If we are draining air with a chest tube, where do we cut and direct?

• 2-3rd ICS anterior chest midcalvicular (tension)

• 4-6th midaxillary (simple pneumo)

• Aiming UP

Why do we place a Chest tube above the ribs?

to avoid blood vessels and hilar regions

When do we remove a chest tube?

48 hours after air leak no longer seen in water seal chamber