Chapter 22


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Chapter 22

  1. 1. CHAPTER 22 Pleural Diseases Hey Buddy, got a Match? (Answers in glossary) 1. B 2. D 3. F 4. B 5. G 6. C 7. H 8. E 9. K 10. L 11. I 12. M 13. N 14. J 15. P 16. O 17. Q THE PLEURAL SPACE 18. The pleural spaces of the buffalo are connected. Humans are separate. For the buffalo this meant that puncture of either lung resulted in collapse of both lungs. Humans are put in this situation following lung volume reduction surgery and bilateral lung transplantation surgery. P. 504 19. The space is about 10-20 microns in width and is filled with a small amount of pleural fluid. NOTE: Egan says 10-20 mm. Is that likely under normal circumstances? The seventh edition of Egan says 10-20 microns! P. 504 20. Normal pressure is negative relative to atmospheric pressure and results in a net movement of fluid into the pleural space when it is in communication with adjacent sites. P. 504 21. The weight of the lung and gravity are pulling the lung down so that the visceral pleura at the top is pulled away from the parietal pleura, thus increasing negative pressure. The opposite effect occurs at the base. P. 504 PLEURAL EFFUSIONS 22. P. 505-506 Condition Mechanism A. CHF Elevated pulmonary venous pressure forces fluid into the interstitium and reduces removal of fluid via intercostal veins. B. Hypoalbuminemia Low protein levels allow fluid to leak out of vessels into the interstitial space. C. Liver disease Ascites forces fluid into the pleural space via small holes in the diaphragm. D. Lymph obstruction Normal drainage is slowed by blocked lymphatics. E. CVP line Accidental placement into the pleura. Copyright © 2004 Mosby, Inc. All rights reserved.
  2. 2. 23. CHF. P. 506 24. Inflammation in the lung or pleura. P. 507 25. P. 507-508 Effusion Cause A. Parapneumonic Increased lung H20 and pleural fluid from inflammation. Complicated effusions have fibrin clots. B. Malignant Cancer metastasized into the pleura. C. Chylothorax Rupture or blockage of the thoracic duct. D. Hemothorax Bleeding into the space-usually after trauma. 26. Restriction, especially decrease in FVC. P. 509 27. The costophrenic angles. P. 509 28. In the lateral decubitus film the patient lies on the affected side. P. 509 29. Ultrasound is good but CT is the most sensitive (with contrast) P. 510 30. P. 510 A. Intercostal artery laceration B. Infection C. Pneumothorax 31. P. 511 Figure 22-3 A. Fluid collection chamber-keeps fluid out of the water seal B. Water seal-prevents air leak back into the lung C. Suction chamber-standardizes pressure applied to the chest PNEUMOTHORAX 32. P. 511 A. Sharp chest pain (nearly every patient) B. Dyspnea (two thirds of all cases) 33. Iatrogenic pneumothorax. Often not treated. Common causes include needle aspiration lung biopsy, thoracentesis, and cvp catheter placement. P. 512 34. Penetrating chest trauma (noniatrogenic) is usually caused by knife or gunshot wounds. Blunt trauma can fracture ribs which tear the lung, or may rupture the alveoli. Treatment for penetrating trauma is usually a chest tube, unless uncontrolled bleeding occurs. Blunt trauma may or may not require a chest tube. P. 511-512 35. Transillumination. P. 512 36. Compare the 2 major types of spontaneous pneumothorax. Primary spontaneous pneumothorax occurs without lung disease. Probably rupture of a small bleb. Usually occurs in tall, slender, young males. 90% are smokers. Secondary spontaneous pneumothorax occurs in COPD patients who have emphysema, or in hyperinflated asthmatics or cystic fibrosis patients. Some pulmonary fibrosis patients may experience spontaneous pneumothorax. P. 512 37. P. 513 A. Definition—Air in the pleural space at greater than atmospheric pressure. B. Radiographic finding—Mediastinal shift away from the affected side, diaphragm depression, and rib expansion. C. Clinical signs—Hypotension, hypoxemia, tachycardia, decreased breath sounds, and hyperresonance to percussion D. Treatment—Needle decompression, then a chest tube. Copyright © 2004 Mosby, Inc. All rights reserved. 2
  3. 3. 38. Mortality rate is low (7%) with early recognition. Delay by as little as 30 minutes raised mortality to over 30%. P. 513 39. Most of the gas in a pneumothorax is nitrogen. Oxygen replaces the nitrogen and is absorbed since this increases the pressure gradient for nitrogen from the pleural space into the tissues. P. 514 40. Large prolonged air leak. Positive pressure ventilation adds air to the pleural space. Lowering tidal volumes, lowering PEEP, positioning, double-lumen tube ventilation, and adding PEEP to chest tubes may help (among others). P. 516 CASE STUDIES Case 1 41. A. “I think Mrs. Dink has a right-sided pleural effusion because 1. hypoxemia P. 509 2. chest x-ray shows opacification on the right P. 509 3. dull percussion note; check out Chapter 14, Bedside Assessment. 4. shift of structures to the left 5. CHF commonly causes effusions P. 506 42. Administer oxygen. 43. Thoracentesis to drain the effusion may be necessary, but it is more important to treat the underlying CHF. P. 506 Case 2 44. A. “I think Mr. Fink has a pneumothorax because 1. chest x-ray—dark area without lung markings (Chapter 18) 2. increased resonance to percussion (Chapter 14) 3. pain on inspiration P. 511 4. history of tall, thin, young male P.512 5. breath sounds (Chapter 14) 45. Put him on oxygen. All patients with pneumothorax should be placed on oxygen. Besides the respiratory distress and mild hypoxemia, O2 helps resolve the pneumothorax. P. 486 46. If the pneumothorax is small, it may resolve without treatment. Otherwise, simple aspiration may be successful (P. 514), or insertion of a chest tube (P. 515). WHAT DOES THE NBRC SAY? 47. B. Chest x-ray P. 514 48. A. A water seal P. 511 49. D. Pneumothorax P. 513 50. B. Lateral decubitus chest film P. 509 51. A. Pulmonary edema in the right lung P. 485 52. D. Lung compliance measurement-Note that this answer is not in the text, per se, although you can work this out by deduction! Remember both conditions would reduce compliance. 53. B. Initiate oxygen therapy—This is a tough choice as well, and no clear answer is given in the text. I chose to give oxygen therapy first, since it is appropriate for pneumothorax or cardiac problems. P. 486 Obviously the physician needs to be notified, and a chest x-ray may be Copyright © 2004 Mosby, Inc. All rights reserved. 3
  4. 4. appropriate, but these actions are not immediately therapeutic. On the other hand, pneumothorax in these patients is very serious and should be treated and not merely observed. P. 509 54. C. Recommend a chest x-ray—The text recommends insertion of a chest tube, but also points out that deceleration injuries may cause airway trauma that is immediately life-threatening, and is associated with fracture of anterior ribs 1-3. P. 512 FOOD FOR THOUGHT 55. Ascites is fluid accumulated in the abdomen. It restricts downward movement of the diaphragm. P. 506 56. No more than 1,000 ml should be removed at one time. P. 513-514 57. Subcutaneous emphysema is the presence of air in the soft tissues, and under the skin. It means that alveolar disruption has occurred, probably from barotrauma. It may or may not occur with a pneumothorax. P. 513 mini clini Copyright © 2004 Mosby, Inc. All rights reserved. 4