Pulmonology Quiz 3b

eem8u's version from 2016-11-20 23:07

Pleural Disease

Question Answer
parietal pl. supplied by & drain into (blood)systemic arterial (from intercostals) >> systemic venous
visceral pl. supplied by & drain into (blood)systemic arterial (from BRONCHIAL artery) >> pulmonary venous system
lymphatics drain intoright lymphatic and THORACIC duct >> systemic venous system
sensory nerve endings foundin parietal pl.
stomata - location /structure / functionPARIETAL mesothelial c / openings on the cell w/ ONEWAY valves / pleural build formed > pleural fluid drained into lymph system


Pleural Effusion & Fluid physiology
Question Answer
pleural space normally contains _________ fluid10 cc of fluid (from parietal cells)
***avg rate of formation of pleural fluid15-20 mL/day
review starling forcesslide 21.8’
2 causes of pleural effusion1) increased entry of fluid 2) decreased exit of pleural fluid (e.g obstruction of stoma/lymphatics
transudate vs exudate - causealteration in driving pressure / alteration in permeability of pleural surface! (injured capillary beds)
***causes of Pl.Ef. - increased Pc“cardiogenic/hydrostatic” —> LEFT sided failure —> increased pulm capillary P —> liquid in interstitial —> liquid in pleura
causes of Pl.Ef. - COPc (decreased)hypoalbuminemia
***causes of Pl.Ef. - increased K (2)inflammatory / neoplastic


Diagnosis and Tx
Question Answer
how to perform thoracentesis*ABOVE the rib* b/c neuromuscular bundle runs below rib
normal pleural space contains predominantly ____ cellsMacrophages (75%)
***neutrophilic predominance in fluid indicatesacute disease, PE, pancreatitis, intra-­‐abdominal abscess, early tuberculosis
****lymphocytic predominance in fluid indicatesmalignancy, TB
pH and glucose in inflammatoryboth low (could be parapneumonic pl.ef.)
Light’s criteria measuresvascular permeability based on LDH - reflects degree of inflammation
***three criteria for EXUDATEhigh pl.fluid protein:serum protein (> 0.5) // high pl.fluid LDH :serum LDH (> 0.6) // pl.fluid LDH > 2/3 normal
How to use light’s criteriaif ANY of the three are met —> exudate


Transudate vs Exudative (and why)
Question Answer
****most common cause of transudate formationCHF
urinothoraxT (obstruction in urinary tract >> urine collection retroperitoneal)
ascitesT (same as cirrhosis)
PEE (causes infarction > inflammation )
CT diseaseE
***pancreatitisE - inflammation of diaphragm — leakage
malignant tumorE
CSFT (subarachnoid pleura fistula, as in shunt— csf hasVERY LITTLE protein)
CHFT (increased hydrostatic P - e.g. after shunt placement)
***nephrotic syndromeT (kidneys losing protein)
***end-stage liver diseaseT (liver can’t make albumin— hypoalbuminemia)
cirrhosisT (ascites fluid accumulation > through diaphragm )
how do malignancies cause effusions (2)1) formation of fluid altered 2) decreased clearance
****most common neoplasms in pl. ef.**Lung, breast, ovary, lymphoma
chyleE - thoracic duct rupture / know cranial vs caudal


Paraneumonic pleural effusion
Question Answer
****Paraneumonic effusion causes what kind of pl. efE (when pneumonia ****extends to pleura —> EMPYEMA
exudative stage - order, characteristics 1st, sterile pleural fluid (normal glucose and pH) — antibiotics alone are sufficient here
fibropurulent stage - order, characteristics2nd, bacteria invade >> leukocytes & bacteria (low pH and glucose! // HIGH LDH) >> fibrin deposition >> loculation formation
organization stage - order, characteristics 3rd, fibroblast growth over pleural surfaces >> considerable reduction in lung function
uncomplicated vs complicated glucose/pH normal levels (glucose > 40 mg/dL, pH > 7.2) vs low levels (glucose < 40, or pH < 7.2)


Other accumulations in plural space
Question Answer
****HCT of pleural fluid in hemothorax>50% of that of peripheral blood
most common cause of hemothoraxtrauma/iatrogenic (penetrating or non-­‐ penetrating trauma)
cause of chylothoraxthoracic duct disruption due to malignancy or cervical trauma
trace the normal route of chyleintestine >> intestinal lacteal vessels >> cisternal chili > thoracic duct (through aortic hiatus from R to L @ T5-7 > ascend posterior aortic arch > empties jugular )
right-­‐sided chylothorax whencaudal rupture (because of cross from R — L)
left-sided chylothorax whencranial rupture
hallmark of chyleelevated triglyceride (remains milky after centrifuge…)


Clinical Features of pleural effusion
Question Answer
1/3 of pleural volume accounted bydecrease lung volume
2/3 of pleural volume accounted bychest wall recoil outwards
***v/q changeshould be same b/c of equal loss of v/q (if lung is normal)
percussion / breath soundsdull/dampened
crackles? ego phony?yes b/c of possible atelectasis / yes b/c of consolidation
**REVEW chest x-ray21.30-39
volume of effusion for blunted costophrenic angle vs entire lung collapse200-300 mL vs 5 L
****explain pleurodesisuse irritating agent in pleural space to cause adhesion


Question Answer
2 common causes of entry through chest wall/parietal pleuraiatrogenic (needle/catheter) or trauma (knife/gunshot)
2 common causes of entry through visceral pleura1) rupture of sub pleural pocket (e.g. bleb/cyst/bulla) 2) necrosis of lung adjacent to pleura
spontaneous pneumothorax - primary vs sencodarydevelops without trauma, secondary occurs in underlying disease
***4 assc w/ primary spontaneousotherwise healthy, smoker, tall/thin, rupture of emphysematous bleb (in apex)
tension pneumothorax definedone-way valve (air can enter) — air remains under sub atmospheric pressure
tension pneumothorax - common causesPAP ventilation
***bleb defined as(not larger than 1 cm ) sub pleural thin wall / often found in young/ thing SMOKERS (but can be otherwise healthy)
****bulla defined as(more than 1 cm) sub pleural thin walled air >> focal areas of emphysema


Clinical Pneumothorax
Question Answer
breath soundsdecreased (or absent)
****percussionincreased! more resonant
tactile fremitusDecreased
resolutionmost often air resolves spontaneously w/ closure of sit
tx of 100% o2 - mechanismincrease o2 gradient in partial pressure of the food to increase gradient of gas absorption
****sum of partial pressure in capillary blood on room air~ 706 (N 2 573, H 2 O 47, CO 2 46, O 2 40)
****partial pressure of capillary blood with 100% oxygenless than 200 (b/c there is no more N2 taking up space)