Mechanisms 3
Terms
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- Aqueous fluid
- absorbed by the visceral pleural capillaries
- Protein phase
- absorbed by the parietal pleural lymphatics
- Exudate
-
-more than 1/2 protein
-more than 6/10 lactate dehydrogenase
-formed by active abnormal cellular process - Causes of exudate
-
-infections: TB, fungus, penuemonia
-CA
-PE
-uremia
-drug reaction
-others - Transudate
-
passive movement of fluid resulting from 3 physiologic phenomina:
-increased hydrostatic pressure
-decreased plasma oncotic pressure
-increased neg. intrapleural pressure - causes of transudate
-
-CHF
-Nephrotic syndrome
-acute atelectasis
-PE - Empyema
-
a form of exudate
-fluid is turbid or purulent due to infx in the pleural space itself - Hemothorax
-
-gross blood in the pleural space
-usually due to chest trauma - Chylothorax
-
milky appearance due to cholesterol complexes
-should be centrifuged: if top is clear, its empyema, not its chylothorax - small effusions
- usually asymptomatic
- Large effusions
-
S/S
-dyspnea
-decreased breath sounds and femitus
-dullness to percussion
-massive: may push the trachea to opposite side - X-Ray findings
-
-thickening of interlobal and /or interlobular lung fissures
-loculate fluid
-crescentic line or meniscus - Transudate: treatment
- treat underlying condition
- Exudate treatment
- tube thoracostomy
- hemorthorax treatment
- usually one or more chest tubes
- Bronchiectasis
- the pathologic expansion of the bronchi or bronchioles resulting from chronic necrotizing infections caused by various conditions that destroy the bronchiole smooth muscle and elastic tissue
- Bronchiolectasis: S/S
-
-cough
-expectoration of copious purulent, sometimes fetid sputum
-flecks of blood, if not frank hemoptysis - causes of bronchiectasis
-
-Obstruction:
-tumor
-foreign body
-mucus impaction
-cystic fibrosis
-HIV / or other immunodef.
-Pneumonia - pathogeneis of bronchiectasis
-
obstruction and chronic infx
-usually effects lower lobes
-mixed flora - bronchiectasis: labs
- thin section CT shows dilated airways
- X-Ray: bronchiectasis
-
-shows increased bronchovascular markings from:
-peribronchial fibrosis
-intrabronchial
secretions - clinical sign
- finger clubbing
- Treatment: bronchiectasis
-
-ABX
-bronchodilators
-resp. therapy
-vibropercussion
-exercise & breathing ex.
-pursed lip breathing
-O2 therapy
-avoid smoking/sedatives/antitussives - Primary (ideopathic) Pulmonary HTN
-
-rare, mostly young women
-progressive dyspnea: death in 2-8 years
-unknown cause, see diffuse narrowing of pulomonary arterioles - Secondary pulmonary HTN
-
-vasoconstriction: chronic dyspnea
-loss of pulmonary vessels
-vascular obstruction
-increased pulm. venous pressure
-increased blood viscosity - Loss of pulmonary vessels: causes
-
-emphysema
-vasculitis
-pulmonary fibrosis
-autoimmune disease (RA,SLE) - Vascular obstruction
-
-pulmonar emboli
-tumors
-foreign bodies - increased pulmonary venous pressure
-
-increased mitral stenosis
-constrictive pericarditis - increased blood viscosity
- -polycythemia
- S/S pulmonary HTN
-
-dyspnea
-fatigue
-chest pain
-syncope on exertion - Pulmonary HTN: lab findings
-
-hypoxemia
-polycythemia in many cases
-ECG shows
-R atrial enlargement
-R ventricular strain
-RVH
-RAD
-V/Q scan: may show defects
-PFT's no routine changes - Pulmonary HTN: Treatment
-
-NO real effective treatment
-periodic phlebotomy if polycythema and hematocrit >60%
-prostacyclin - Pneumothorax
- seperation of the visceral and parietal pleurae by volume of air
- Primary spontaneous PTX
- occurs in the absence of underlying lung disease
- Secondary Spontaneous PTX
- occurs in complications of lung disease
- Traumatic PTX
-
-blunt or penetrating trauma
-iatrogenic causes
-subclavian or internal jugular vein catheterization
-thoracentesis
-percutaneous lung Bx
-pulm. barotrauma from mech. overventilation
- - Tension PTX
-
-air enters thorax during inspiration but does not exit on expiration
-positive interpleural pressure> ambient pressure
-may be due to trauma, CPR or mechanical ventilation - Primary PTX
-
-often tall, thin boys
-thought due to rupture of subpleural apical blebs due to high pleural pressure
-smoking increases risk - Secondary PTX
-
-associated with other lung diseases:
-pneumonia
-TB, CF
-Asthma - Catamenial PTX (secondary)
-
-assoc. with onset of menses +/- 3 days
-assoc. with intrathoracic endometriosis - PTX general S/S
-
-chest pain, minimal to severe on affected side
-perhaps mild tachycardia
-if large:
-breath sounds, fremitus decreased
-asymmetric chest expansion
-hyperresonance or tympany on chest percussion - Diagnosis of PTX:
-
suspect if:
-severe dyspnea & marked tachycardia
-tracheal or mediastinal shift
-systemic hypotension
-widespread percussion hyperresonance or tympany - LABS for PTX
- -ABGs show hypoxemia & acute resp. alkalosis
- CXR for PTX
-
-viscereal pleural line = defninitive dx
-may see pleural effusion, blunting of costophrenic angle
-may see shift of tracheal air column TOWARD a NL PTX
-may see shift of tracheal column & mediastinum AWAY from a tension PTX - Possible complications of PTX
-
-subcutaneous emphysema
-pneumonmediastenum on CXR - PTX treatment: Small (<15% of hemithorax)
-
-may only observe
-O2 supplementation may increase rate of air reabsorption
-Aspiration
-thoracostomy
-serial CXRs q24 hr to follow - PTX treatment: Large
-
-admit to hospital
-thoracostomy with underwater seal drainage and suction until lung expands on serial CXR