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3: MED1 Y3 - Respiratory [18] > [6] Pleural Effusion > Flashcards

[6] Pleural Effusion Flashcards

1
Q

What is a pleural effusion?

A

When the volume of fluid in the pleural space is substantially greater than normal

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2
Q

What kind of disease can pleural effusions be caused by?

A

Disease that is pulmonary, pleural, or extrapulmonary

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3
Q

What covers the lungs?

A

A thin serious layer, called the visceral pleura

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4
Q

What covers the chest wall and pericardium?

A

The parietal pleura

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5
Q

How are the visceral and parietal pleura related?

A

The parietal pleura is a reflection of the visceral pleura, and they are connected at the lung hila

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6
Q

What is the space inbetween the visceral and parietal pleura called?

A

The pleural space

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7
Q

What is found in the pleural space?

A

A very small amount of fluid

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8
Q

What is the purpose of the fluid in the pleural space?

A

It lubricates movement between the layers

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9
Q

What can pleural effusions be classifed as?

A

Transudates or exudate

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10
Q

Other than transudates and exudates, what can accumlate in the pleural space?

A
  • Blood
  • Pus
  • Chyle
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11
Q

What is it called when blood accumulates in the pleural space?

A

Haemothorax

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12
Q

What is it called when pus accumulates in the pleural space?

A

Empyema

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13
Q

What is it called when chyle accumulates in the pleural space?

A

Chylothorax

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14
Q

When does a transudative pleural effusion occur?

A

When there is disruption of the hydrostatic and oncotic forces operating across the pleural membranes

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15
Q

When does an exudative pleural effusion occur?

A

When there is increased permeability of the pleural surface and/or capillaries, usually as a result of inflammation

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16
Q

How are pleural effusions divided into transudative and exudative?

A

On the basis of the Light criteria

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17
Q

What does the Light criteria consist of?

A

The measureent of lactate dehydrogenase (LDH) and protein concentration in the pleural fluid and serum

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18
Q

What are the Light criteria?

A

Fluid is considered exudative if one of the following is present;

  • Pleural fluid-to-serum protein ratio is >0.5
  • Plueral fluid-to-serum LDH ratio is >0.6
  • Pleural fluid LDH concentration > 2/3 upper limit of normal serum LDH
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19
Q

What are the most common causes of transudate pleural effusions?

A
  • Heart failure
  • Cirrhosis
  • Hypoalbuminaemia
  • Peritoneal dialysis
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20
Q

What are the less common causes of pleural effusion?

A
  • Hypothyroidism
  • Nephrotic syndrome
  • Pulmonary embolism
  • Mitral stenosis
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21
Q

What are the most common causes of exudate pleural effusions?

A
  • Pneumonia
  • Malignancys
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22
Q

What are the most common malignancies causing pleural effusion?

A

Lung cancer in men, breast cancer in women

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23
Q

What kind of pleural effusoins are most commonly due to malignancy?

A

Large, unilateral pleural effusions

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24
Q

What are the less common causes of exudate pleural effusions?

A
  • Pulmonary infarction, resulting from pulmonary embolism
  • Autoimmune disease, especially RA
  • Asbestos exposure
  • Pancreatitis
  • TB
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25
Q

What is a chylothorax?

A

The presence of chyle in the pleural space

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26
Q

What does a chylothorax usually occur due to?

A

Disruption of the thoracic duct

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27
Q

What are the causes of a chylothorax?

A
  • Neoplasm
  • Trauma
  • TB
  • Sarcoidosis
  • Cirrhosis
  • Amyloidosis
28
Q

What neoplasms can cause a chylothorax?

A
  • Lymphoma
  • Metastatic carcinoma
29
Q

What trauma can cause a chylothorax?

A

Operative and penetrating injuries

30
Q

When are pleural effusions symptomatic?

A

An effusion has to be quite large before it causes any symptoms, however most malignant effusions are symptomatic

31
Q

What are the symptoms of a pleural effusion?

A
  • Shortness of breath, especially on exertion
  • Cough
  • Pleuritic chest pain
32
Q

What other history features should be noted with pleural effusion?

A
  • Loss of weight, which may suggest malignancy
  • Smoking and haemoptysis, which might suggest lung cancer
  • History of another malignancy
33
Q

How is a pleural effusion investigated?

A
  • Examination
  • CXR
  • Other imaging, including CT, MRI, and ultrasound
  • Pleural fluid analysis
34
Q

What may be seen on inspection on examination in pleural effusion?

A
  • Signs of lung pathology
  • Chest expansion may be reduced, bilaterally or unilaterally
  • Dyspnoea
  • Signs of underlying cause
35
Q

What signs of lung pathology may be seen on examination in pleural effusion?

A
  • Nicotine staining on dfingers
  • Accessory muscles of respiration use
  • Finger clubbing
36
Q

What signs of an underlying cause may be seen on examination in pleural effusion?

A
  • Signs of weight loss
  • Rheumatoid changes in hands
37
Q

Describe chest expansion in pleural effusion

A

It is reduced on the side of the effusion

38
Q

How is the trachea deviated in pleural effusion?

A

With a large, unilateral effusion, the trachea is deviated away from the lesion

If there is associated collapse, the trachea is deviated towards the lesion

39
Q

What may be found on palpation in examination in pleural effusion?

A

May be decreased tactile vocal fremitus

40
Q

What may be found on percussion in pleural effusion?

A

Effusion will cause stony dullness on percussion. Laterally, it will rise upwards towards the axilla

41
Q

What will be found on ausculatation in pleural effusion?

A
  • Breath sounds diminished or absent over effusion
  • Vocal resonance lost over pleural effusion, except at it’s upper surface
42
Q

What is the first-line investigation in suspected pleural effusion?

A

CXR

43
Q

How big must a pleural effusion be to be visible on a CXR?

A

About 200ml to be seen on a PA, or 50ml to cause costophrenic blunting on lateral view

44
Q

Other than detecting fluid, what can a CXR be useful for in pleural effusion?

A

May suggest an underlying cause, e.g. heart failure

45
Q

What is the advantage of ultrasound over CXR in pleural effusion?

A

It is much more sensitive than CXRs in detecting pleural effusions, and can detect even very small effusions

46
Q

What things are looked at when interpreting pleural fluid analysis

A
  • If it is transudate or exudate
  • Pleural fluid haematocrit
  • pH
  • Cytology
  • Lipids
  • Glucose
47
Q

What is classification of transdate or exudate in pleural fluid analysis based on?

A

Pleural protein content

48
Q

What can bloody pleural fluid be caused by?

A
  • Malignancy
  • Pulmonary embolus with infarction
  • Trauma
  • Benign asbestos pleural effusions
49
Q

What can pleural fluid haematocrit help determine?

A

If a pleural effusion is a haemothorax

50
Q

What can pH help determine in the analysis of pleural fluid?

A

If pleural effusion is a haemothorax

51
Q

What is the normal pH of pleural fluid?

A

Around 7.6

52
Q

What can cause a pleural pH of <7.2 with normal blood pH?

A
  • Pleural infection and empyema
  • Rheumatoid disease and SLE
  • TB
  • Malignancy
53
Q

What is the importance of cytology in pleural fluid analysis?

A

It is required to diagnose malignant effusions

54
Q

Why are lipids looked at in pleural fluid analysis?

A

Determine if chylothorax

55
Q

Where may low pleural glucose levels be found?

A
  • Empyema
  • Rheumatoid disease and SLE
  • TB
  • Malignancy
56
Q

What should the management of pleural effusion be aimed at?

A

The underlying disease

57
Q

When should aspiration be avoided in pleural effusion?

A

If transudate is confirmed

58
Q

How are small effusions that are not causing respiratory problems managed?

A

Observation

59
Q

What is the advantage of tapping in pleural effusion?

A
  • It can give symptomatic relief
  • Useful for diagnosis
60
Q

What is the disadvantage of tapping pleural effusions?

A

Effusion is likey to reform

61
Q

Where may repeated tapping be used in pleural effusion?

A

In pallative care

62
Q

How can controlled drainage of an effusion be achieved?

A

Insertion of a chest drain

63
Q

When are chest drains removed in pleural effusion?

A

If/when the underlying disease is treated

64
Q

In what kind of pleural effusions are chest drains often needed?

A
  • Empyema
  • Haemothorax
65
Q

What is pleurodesis?

A

The injection of sclerosant to cause adhesion of the visceral and parietal pleura, and to help prevent reaccumulation of the effusion

66
Q

What are some commonly used sclerosing agents in pleurodesis?

A
  • Tetracycline
  • Sterile talc
  • Bleomycin
67
Q

Where is pleurodesis most commonly used in pleural effusion?

A

In the management of recurrent malignant effusions

3: MED1 Y3 - Respiratory [18] (15 decks)

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