Pleural Diseases
Kyphoscoliosis
MODULE E
Chapters 24 & 25
Pleural Space
• Visceral Pleura – attached to lungs.
• Parietal Pleura – attached to chest wall.
• Pleural space
• 5-10 mL of fluid secreted by the pleural cells.
• Minimizes friction as the two pleural surfaces
glide over each other during inspiration and
expiration.
Pleural Disease
• Pleural Effusion
• Accumulation of fluid in the intrapleural
space.
• Fluid accumulation separates the visceral and
parietal pleura and compresses the lungs.
• Atelectasis will develop.
• Compression of heart and great vessels.
• Decreased venous return.
• Restrictive lung disease.
Detection of Pleural Effusions
• X-ray
• PA & Lateral Decubitus
• Ultrasound
• CT Scan
Etiology
• Two Types of pleural effusions:
• Transudates
• Exudates
Transudates
• Fluid from the pulmonary capillaries moves
into the pleural space.
• The fluid is thin, watery, few cells, little
protein.
• Clear and light straw color.
• Protein content is less than 3 gm/dL.
• The pleural surfaces are not involved in
producing the fluid.
• pH greater than 7.30.
Etiology of Transudates
• Formation is the result of abnormal
hydrostatic and oncotic pressures.
Etiology of Transudates
• Congestive Heart Failure
• Left heart failure
•
•
•
•
•
Hepatic Hydrothorax
Peritoneal Dialysis
Nephrotic Syndrome
Pulmonary embolism
Hypoalbuminemia
Exudates
• Pleural Surfaces are diseased.
• Fluid has increased protein content greater
than 3 gm/dL.
• Increased cellular debris .
• Inflammatory process.
• pH less than 7.30.
Etiology of Exudates
•
•
•
•
•
•
Malignant Pleural Effusions
Malignant mesotheliomas
Pneumonias
Tuberculosis
Fungal Diseases
Diseases of GI tract
Types of Pleural Effusions
•
•
•
•
•
•
Hydrothorax
Hydropneumothorax
Empyema
Chylothorax
Hemothorax
Loculated
Hemothorax
• Blood in the pleural space.
•
•
•
•
Chest trauma
Iatrogenic hemothorax
Pulmonary embolism with infarction
Malignant disease
• Also referred to as serosanguineous.
Empyema
• The accumulation of pus in the pleural
cavity.
• Pyothorax
• Develops from inflammation.
• Thoracentesis will confirm the diagnosis
and determine the organism.
Chylothorax
• Thoracic Duct is a lymphatic channel that
runs from the abdomen through the
mediastinum and into the neck & empties
into the left subclavian vein.
• Disruption of the thoracic duct may cause
leakage of chyle into the pleural space.
• Malignancy, surgery and trauma.
Chylothorax
• Chyle is a milky white fluid consisting
mainly of fat particles.
Loculated Pleural Effusion
• Confined or fixed to a single location by
adhesions.
• Does not move when the patient lies on
his/her side.
Patient Assessment
•
•
•
•
•
•
•
Chest pain & decreased chest expansion
Dyspnea/WOB/Cyanosis
Cough
Shift of the PMI and trachea
Dull percussion note
Diminished BS
Tachypnea
Pulmonary Functions
• Restrictive Disease
• Decreased lung volumes and capacities.
• Normal RV/TLC.
• NO TRAPPED GAS
ABG
• Small pleural effusion
• Acute alveolar ventilation with hypoxemia
• pH: 7.50 PaCO2: 30 torr, PaO2: 60 torr
• Large pleural effusion
• Acute ventilatory failure with hypoxemia
• pH: 7.28 PaCO2: 55 torr, PaO2: 45 torr
• Metabolic acidosis may occur if there is
anaerobic metabolism ( lactic acid)
Chest X-ray Findings
• Blunting of costophrenic angle.
• Pleural meniscus sign.
• Mediastinal shift away from affected side.
• Depressed diaphragm.
• A minimum of 200 – 300 mL of fluid is
necessary to see a pleural effusion in an
upright film.
• Lateral decubitus film can pick up smaller
amounts of fluid (as little as 5cc of fluid).
• Atelectasis
Management of Pleural
Effusions
•
•
•
•
•
•
Oxygen therapy
Thoracentesis
Chest tube
Pleurodesis
Antibiotics
Hyperinflation Protocol
• Cough/deep breathing, IS, IPPB, CPAP, PEEP
Thoracentesis
• Insertion of a needle into the pleural space
to remove fluid or air.
• Removal of a specimen for biopsy.
• Therapeutically it can be used to treat a
pleural effusion.
Screening for Thoracentesis
• History of bleeding disorders
• Platelet count
• PT
• Use of anticoagulants
• Chest x-ray, ultrasound, CT scan
Procedure for Thoracentesis
• Sign a consent form.
• Administer analgesic.
• Position Patient; Disinfect skin with
betadine.
• Assist physician with sterile mask, cap,
gown and gloves.
• Anesthetize the skin with 2% Lidocaine.
• Insert needle until fluid level is reached.
Procedure for Thoracentesis
• Withdraw 100 – 300 mL of pleural fluid with
a syringe.
• Withdraw needle and suture or use
adhesive tape to close puncture hole.
• Monitor the vital signs/PO/assess WOB.
• Analyze the sample.
Analysis of Pleural Fluid
•
•
•
•
•
•
•
Color
Odor
RBC count
WBC count
Protein
Glucose
LDH
•
•
•
•
Amylase
pH
Gram and AFB stains
Aerobic, anaerobic,
TB and fungal cultures
• Cytology
Complications of
Thoracentesis
•
•
•
•
•
•
Pneumothorax
Infection/empyema
Hemothorax
Subcutaneous emphysema
Air embolism
Reexpansion Pulmonary edema
Complications of
Thoracentesis
• Pulmonary hemorrhage.
• Laceration of liver or spleen.
• Pain
• Mild pain for 24 hours after procedure
• Shoulder pain during the procedure,
indicates the tap is too low.
• Needle is piercing the diaphragmatic pleura
Disease of the Chest Wall
• Kyphoscoliosis
• Kyphosis – posterior curvature of the spine
• Humpback
• Scoliosis – lateral curvature of the spine
• Kyphoscoliosis is a chronic disease
Anatomic Alterations
• Deformity of the spine.
•
•
•
•
Compression of the lung.
Decrease lung expansion.
Atelectasis.
Hypoventilation
• Inadequate cough.
• Unable to mobilize secretions.
• Mediastinal shift – same direction as lateral
curvature.
Etiology
• 10% of the US population
• 1% have notable deformity
• Cause unknown in 80 – 85% of cases
• Idiopathic kyphoscoliosis
• Pathologic conditions
• Congenital vertebral defects
• Vertebral disease
• Neuromuscular diseases
Clinical Manifestations
•
•
•
•
•
•
Obvious thoracic deformity
Tachypnea
HR, CO, BP
Cyanosis
Weak cough with sputum production
Clubbing
Clinical Manifestations
• Chest Assessment
•
•
•
•
Shift of trachea and PMI
Dull percussion note
Diminished BS/Bronchial BS
Increased tactile and vocal fremitus
• Polycythemia (chronic hypoxemia/hypoxia)
• Cor Pulmonale
Pulmonary Functions
• Restrictive disease
• Decreased volumes and capacities.
• Normal flowrates.
• FEV1/FVC normal.
ABG
• Mild/moderate Kyphoscoliosis
• Acute alveolar hyperventilation with hypoxemia
• pH: 7.50 PaCO2: 30 torr, PaO2: 60 torr
• Severe Kyphoscoliosis
• Chronic ventilatory failure with hypoxemia
• pH: 7.28 PaCO2: 55 torr, PaO2: 45 torr
• Assess for CO2 retention
• Watch oxygen levels
Chest X-ray
• Thoracic deformity
• Mediastinal shift
• Radiopaque or radiodense (white)
• Atelectasis
• Cardiomegaly if cor pulmonale is present
Management
• Oxygen Therapy
• Bracing
• Body brace during formative years.
• Electrical stimulation
• Strengthen muscles around the spine.
• Surgery
• Harrington and Luque Rods into the spine.
Management
• Sputum C&S – antibiotics if needed
• Mobilization of Bronchial Secretions
• Hydration, CPT, Suctioning, IS, Bronchoscopy
Deep breathing/coughing,
• Hyperinflation Techniques
• Cough & deep breathing, IS, IPPB, PEEP,
CPAP
• Mechanical Ventilation - NPV