Pleural Diseases Kyphoscoliosis

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Pleural DiseasesKyphoscoliosis

• MODULE E
• Chapters 24 25

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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.

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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.

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Detection of Pleural Effusions

• X-ray
• PA Lateral Decubitus
• Ultrasound
• CT Scan

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Etiology

• Two Types of pleural effusions
• Transudates
• Exudates

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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.

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Etiology of Transudates

• Formation is the result of abnormal hydrostatic
  and oncotic pressures.

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Etiology of Transudates

• Congestive Heart Failure
• Left heart failure
• Hepatic Hydrothorax
• Peritoneal Dialysis
• Nephrotic Syndrome
• Pulmonary embolism
• Hypoalbuminemia

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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.

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Etiology of Exudates

• Malignant Pleural Effusions
• Malignant mesotheliomas
• Pneumonias
• Tuberculosis
• Fungal Diseases
• Diseases of GI tract

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Types of Pleural Effusions

• Hydrothorax
• Hydropneumothorax
• Empyema
• Chylothorax
• Hemothorax
• Loculated

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Hemothorax

• Blood in the pleural space.
• Chest trauma
• Iatrogenic hemothorax
• Pulmonary embolism with infarction
• Malignant disease
• Also referred to as serosanguineous.

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Empyema

• The accumulation of pus in the pleural cavity.
• Pyothorax
• Develops from inflammation.
• Thoracentesis will confirm the diagnosis and
  determine the organism.

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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.

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Chylothorax

• Chyle is a milky white fluid consisting mainly of
  fat particles.

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Loculated Pleural Effusion

• Confined or fixed to a single location by
  adhesions.
• Does not move when the patient lies on his/her
  side.

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Patient Assessment

• Chest pain decreased chest expansion
• Dyspnea/WOB/Cyanosis
• Cough
• Shift of the PMI and trachea
• Dull percussion note
• Diminished BS
• Tachypnea

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Pulmonary Functions

• Restrictive Disease
• Decreased lung volumes and capacities.
• Normal RV/TLC.
• NO TRAPPED GAS

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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)

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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

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Management of Pleural Effusions

• Oxygen therapy
• Thoracentesis
• Chest tube
• Pleurodesis
• Antibiotics
• Hyperinflation Protocol
• Cough/deep breathing, IS, IPPB, CPAP, PEEP

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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.

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Screening for Thoracentesis

• History of bleeding disorders
• Platelet count
• PT
• Use of anticoagulants
• Chest x-ray, ultrasound, CT scan

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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.

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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.

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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

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Complications of Thoracentesis

• Pneumothorax
• Infection/empyema
• Hemothorax
• Subcutaneous emphysema
• Air embolism
• Reexpansion Pulmonary edema

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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

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Disease of the Chest Wall
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• Kyphoscoliosis
• Kyphosis posterior curvature of the spine
• Humpback
• Scoliosis lateral curvature of the spine
• Kyphoscoliosis is a chronic disease

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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.

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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

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Clinical Manifestations

• Obvious thoracic deformity
• Tachypnea
• HR, CO, BP
• Cyanosis
• Weak cough with sputum production
• Clubbing

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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

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Pulmonary Functions

• Restrictive disease
• Decreased volumes and capacities.
• Normal flowrates.
• FEV1/FVC normal.

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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

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Chest X-ray

• Thoracic deformity
• Mediastinal shift
• Radiopaque or radiodense (white)
• Atelectasis
• Cardiomegaly if cor pulmonale is present

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Management

• Oxygen Therapy
• Bracing
• Body brace during formative years.
• Electrical stimulation
• Strengthen muscles around the spine.
• Surgery
• Harrington and Luque Rods into the spine.

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Management

• Sputum CS 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