Pathophys 19: Respiratory Chest Pain
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18 terms
Terms | Definitions |
|---|---|
 Somatic sensory fibers | these nerves innervate the parietal not visceral pleura |
| Pleural space | has a net pressure difference of -7 to -9cm of H2O -> favors movement of fluid into this space from the lungs (lymphatics take it away) |
| Physical exam signs in pleural effusion | decreased/absent tactile fremitus, dullness to percussion, diminished breath sounds over area of effusion, bronchial breath sounds and egophony can often be heard just above effusion due to presence of atelectatic lung -> shifting dullness is virtually pathognomonic -> if unilateral need diagnostic thoracocentesis, if bilateral may not be required (usually due to CHF) |
| Exudative pleural effusion | pleural protein / serum protein > .5, pleural LDH/serum LDH > .6, pleural fluid LDH is greater than 2/3 of the upper limit of normal for the serum LDH -> due to alteration of LOCAL factors that influence movement of fluid across pleural space (inflammation/infection can widen or cause cell gaps, tumors can obstruct flow of lymphatics) -> parapneumonic effusions, neoplastic disease, TB, collagen vascular disease, pulmonary emboli, GI disease, drug reactions, post-surgical effusion, chylothorax, hemothorax |
| Transudative pleural effusion (clear) | occurs due to alteration of SYSTEMIC factors that influence movement of fluid across the pleural space (excess water, insufficient protein - decreased colloid osmotic pressure) -> CHF, cirrhosis, nephrotic syndrome, pericardial disease, peritoneal dialysis (renal failure) |
| Parapneumonic effusion | pleural effusion associated with infectious pneumonia, lung abscess, or bronchiectasis -> may be translucent -> straw colored fluid to frank pus -> exudative stage (microvascular extravasation) -> fibropurulent stage (invasion of pleura by bacteria) -> organization stage (fibroblasts move into exudate and produce inelastic peel which encases the lung -> treat with AB and drain |
| Low glucose in pleural fluid | complicated parapneumonic effusion, malignant, tuberculous, rheumatoid, paragonimias, hemothorax, Churg-Strauss syndrome |
| High amylase in pleural effusion | acute pancreatic disease, chronic pancreatic disease, esophageal rupture, malignant pleural effusion |
| Esophageal rupture | spontaneous or after endoscopy -> excruciating chest pain, unquenchable thirst, fever -> subcutaneous emphysema, pneumothorax and pleural effusion -> pleural fluid amylase is elevated and contains food particles -> explore and drain mediastinum |
| Chronic pancreatic pleural effusion | cachectic, sinus tract from pancreas through diaphragm into mediastinum -> massive pleural effusion and marked elevation if pleural fluid amylase -> need operation to decompress pancreas |
| Low pleural fluid pH | seen in malignancy, rheumatoid pleuritis, TB, hemothorax, urinothorax, paragonimias and the Churg-Strauss syndrome (measure with blood gas machine) |
| Tuberculous pleuritis | If pleural fluid ADA > 70 units or gamma interferon is high it is diagnostic -> granulomas on pleural biopsy, |
| Collagen vascular diseases (Rheumatoid pleuritis) | elderly man with rheumatoid nodules -> pleural fluid is low glucose, high LDH, low pH |
| Neoplastic disease | almost always exudate, can be grossly bloody -> use cytological examination of pleural fluid -> gold standard is pleural biopsy |
| Mesothelioma | chest pain or dyspnea, CXR nearly always shows a unilateral effusion -> median survival is a year after diagnosis -> resection in early disease, usually associated with asbestos -> may show right sided nodular circumferential pleural thickening exceeding 1cm in thickness |
| Pneumothorax | presence of air or gas in the pleural space -> intrapleural pressure is normally negative compared to intra-alveolar and atmospheric pressures during inspiration -> can be spontaneous, tension, trauma, iatrogenic -> common in patients with bullous emphysema |
| Signs of pneumothorax | tactile fremitus diminished on affected sign, hyper-resonance on affected side to percussion, diminished or absent breath sounds on affected side of auscultation, if large enough may shift the mediastinum to the opposite side |
| Treatment of pneumothorax | prevent death, relieve symptoms and prevent recurrence -> observation, oxygen, drainage by needle aspiration, drainage by chest tube, pleurodesis by chest tube or surgery, surgical resection of disease and pleurodesis |
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