Pneumothorax

Pleuritis

Pleural effusion

Air in the pleural space between the lung and chest wall results in a collapsed lung

-classified based on intrathoracic pressure

-can be either spontaneous or traumatic

pneumothorax

-Simple pneumo or Tension pneumo

Multiple rib fractures

Segment of chest moves oaridoxically

resp. distress or failure

requires intubation and mechanical ventilation

-Thin young males 3 times more likely than women

-Smokers, hereditary.

-changes in atmospheric pressure

-Males 15 cases/100,000/yr

-no underlying lung disease

-Underlying lung disease present:

1. airway disease

2. intersitital lung disease

3. necrotizing lung infections

4.cancer

5. catamenial pneumothorax

6. chest trauma

7. iatrogenic: central line, lung biopsy, ventillating pressure too high

-no external factors

1. Remove air

2. re-expand lungs

3. prevent recurrence

4. evaluate for underlying etiology

Rare recurrent pneumothorax associated with menses

-responds to ovulation supression medications

Asymptomatic

Dyspnea

Cough

Chest pain:

-Usually pleuritic

-aching

-may improve over time even without treatment

-tachycardia

-tachypnia

-hypotentiion (tension pneumo or hemopneumo)

-hypoxemia

-tracheal deviation

-sq emphysema

-asymm. chest movement

-hyperresonance on non collapsed lung side

-unilateral dec in breath sounds

-dec tactile fremitis

-dislacement of live and spleen

-unilateral lucenency

-line along edge of lung

-deviation of trachea and mediastinum if tension pneumothorax

-May be fluid present if hemopneumothorax

Sometimes air is trapped in the mediastinum

-with every heart beat you would hear a crunch

-if you felt the neck you would here a crunch

PE

Musculoskeletal chest pain

pleurisy

pulm infections

MI

exacerbation of underlying pulm disease

large pulm bleb

1. Specific to underlying disease

2. pulse oximetry

3. ABG (hypoxia or co2 retention with copd)

1. evaluate size

2. evaulate underlying pathophys

3. small uncomplicated (spontaneous or small truamatic) <15% size may be observed in hospital or as outpatient

4.should resolve at 1.5% a day

5. repeate cxr in 6hrs

6. supplemental O2

7. arrange follow-up

more symptomatic

-admit to hospital for O2

-require tube thoracostomy

-consult surgeon prior to elective procedure

-most resolve within 2 days or require further surgical tx

Always do an upright

-do an inspiratory image and expiratory image

++try to estimate the amount of lung involved

+++Surgical emergency

diagnosis always based on physical exam no need for xray

Small catheter (16 angiocath or fluid filled syringe) thoracostomy second interspace at mid-clavicular line

-Tube thoracostomy is definitive

-pleural sclerosis (tetracycline in pleural space- forms scar tissue b/c its irritating)

- fiberoptic repair of pleural

-Open thracotomy

"Inflammation of the pleura"

-caused by:

1. Viral (URI)

2.any inflammatory disease

1. unilateral chest pain that inc with inspiration = sharp and stabbing

2. Shortness of breath- can breath but it hurts

3. symps associated with viral infection: cough, sputum procuction, fever, malaise

-PE (r/oo with d-dimer)

-pneumonia

-pneumothorax

-epidemic pleurodynia (devils grip)

-chest wall pain

-herpes zoster

-MI

1. cxr

2. pulse oximetry or ABG

3. CBC

4. PE evaluation

5. EKG as indicated

Pleuritis treatment:

Diagnosis of exclusion

1. Anti-inflammatories (NSAIDS)

2.  Analgesics (Acetaminophen, Nacotic analgesics)

3. Symptomatic TX

4. Further evaluation

1. chest wall tender on compression

2. ENT symptoms

3. heart normal

4. Lungs: clear, wheezes or rales if underlying asthma, copd, or pneumonia, pleural friction rub

1.heart failure

2. malignancy

3. bact. infect

4. tB

5. viral infections

6. uremia

7. hypothryroidism

8.chirosis

9.nephrotic syndrome

10.collagen vascular disease

11. intra-abdominal causes

12. trauma

1. parapneumonic

Assoiciated with pneumonia, bronchiectasis, lung abscess

Complicated: require tube thoracostomy for drainage

Loculated: fluid confined by adhesions and not freely flowing

-ultrafiltrates of plasma

-very little protein

-inc in hydrostatic pressure in pulm vessels

-dec in oncotic pressure

etiology: chirosis and nephrotic

-large amounts of protein

-inc membrane permeability

-dec lymph drainage

Mixed transudate and exudate: PE

-etiology:

infections

malignancy

CT disorders

intra-abd causes

pul infart

uremia

fug interactions

post partum

1. hx of underlying disease (HF liver, uremia, malignancy)

2. chest pain -gradual

3. dyspnea with >500ml fluid

4.  tachycardia, hypxemia, hypotension (if severe)

5. lungs- dec breath sounds, dullness to percussion, dec tactile phremitus, localized pleaural friction rub, auscultatory percussion

5. mediastinal shift if massive

1. PA: 250-500 ml of fluid vidible, lat less fluid visible, supone hazzy

2. later decubitus: non-localized fluid will layer out

1. ultrasound

2. CT scan

3. MRI

1. evaluate for underlying cause

2. diagnose thoracentesis (cell count, gram stain, cytology)

3. lights criterial for exudate

4. therapeurtic throacentesis for circulatory or vascular compromise