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Medical Studies 1 > 9.3 & 9.4 Pleural Effusions > Flashcards

9.3 & 9.4 Pleural Effusions Flashcards

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USMLE® Step 1 flashcards
1
Q

Define pleural effusion

A

Abnormal/excess fluid in pleural space

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2
Q

Describe the three broad mechanisms of pleural effusion

A
  • Transudative
  • Exudative
  • Disruption of fluid-containing structure within thoracic cavity
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3
Q

List some of the most common causes of pleural effusion. Which is the most common?

A
  • Heart failure (most common)
  • Malignancy
  • Infection
  • Post-surgical
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4
Q

Is pleural effusion more common in men or women? Does this differ between aetiologies?

A
  • Overall, same
  • However, differs between aetiologies
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5
Q

Is pleural effusion more common in adults or children?

A

Adults

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6
Q

What % of pleural effusion cases are considered idiopathic?

A

25%

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7
Q

What symptoms do patients commonly present with when they have pleural effusion? Why?

A
  • Shortness of breath (increased weight of fluid, mechanical strain on diaphragm and chest wall)
  • Chest pain (usually due to parietal pleura inflammation)
  • Cough (mechanical effects detected by airways)
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8
Q

True or false: pleural effusion patients never present with abnormal examination findings

A
  • False
  • Sometimes they do, sometimes they don’t
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9
Q

List some common examination findings for pleural effusion

A
  • Clubbing (cancer)
  • Tar staining (smoking -> cancer)
  • Enlarged lymph nodes (infection)
  • Chest wall scars
  • Radiation burns and mastectomy (cancer?)
  • JVP (heart failure)
  • Evidence of arthropathy (rheumatological causes)
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10
Q

Chest expansion findings pleural effusion

A

Reduced expansion ispilateral to effusion

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11
Q

Percussion findings pleural effusion

A

“Stony” dull

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12
Q

Auscultation findings pleural effusion

A

Absent or reduced breath sounds

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13
Q

Investigations for suspected pleural effusion

A
  • Observations (RR, HR, BP, SpO2)
  • Blood test (WCC, CRP, Troponinin, D-Dimer)
  • ECG
  • CXR
  • CT
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14
Q

Describe various pleural fluid sampling/drainage procedures for pleural effusion

A

Diagnostic thoracentesis: Small volume of pleural fluid aspirated

Therapeutic thoracentesis: larger volume (usually >500mL) drained

Chest drain insertion: thoracostomy

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15
Q

What is the recommended first line treatment approach for pleural effusion? Why?

A
  • Large volume aspirate (don’t leave tube in) -> 1-1.5L
  • It enables testing of fluid for aetiology, tests how quickly fluid will refill, gauges symptomatic benefits, and helps to identify a non-expansile lung
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16
Q

What type of pleural effusion does low viscosity, straw-coloured fluid often suggest?

A

Transudate (but it can still be paucicellular exudate)

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17
Q

What does serosanguinous fluid suggest in pleural effusion?

A

No real diagnostic value

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18
Q

What does frank blood fluid in pleural effusion suggest?

A

Usually from malignant effusion, but could have other causes as well

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19
Q

What does milky/turbid pleural effusion suggest?

A

Infection/chylothorax

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20
Q

What does putrid smelling pus on pleural effusion suggest?

A

Infection. Likely from anaerobes

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21
Q

What does urine-smelling pleural effusion indicate?

A

Urinothorax

22
Q

Is the criteria for classifying pleural effusions more likely to misdiagnose transudates or exudates? Why?

A
  • More likely to mis-classify transudates as exudates
  • This is because exudates are more severe
23
Q

Light’s criteria are the most common criteria used to classify pleural effusions. What are the criteria, and how many need to be fulfilled for it to be exudative?

A
  1. If pleural fluid protein > 0.5 of serum protein
  2. If pleural fluid LDH > 0.6 of serum LDH
  3. If pleural fluid LDH >2/3 of laboratory normal value
24
Q

What does low pH of pleural fluid in pleural effusion suggest?

A

Malignancy and/or infection

25
Q

Under normal circumstances, can glucose diffuse across the pleura? How does this impact glucose levels?

A
  • Yes, it can diffuse freely
  • Usually, pleural fluid glucose levels are same as blood glucose levels
26
Q

Under what circumstances could pleural fluid contain low glucose?

A
  • Increased utilization
  • decreased diffusion due to pleural thickening
27
Q

What is the role of cell count testing in pleural effusion?

A

Differentiate between infection/inflammation and malignant aetiology.

28
Q

What is the role of cytology testing in pleural effusion?

A

Tests for malignancy

29
Q

What ages are pleural infection more common in, and is it more common in men or women?

A
  • More common in elderly and childhood.
  • More common in men (twice as common)
30
Q

Mortality rates of pleural infection, including normal and immunocompromised/elderly:

A

Overall: 20%
Elderly/immunocompromised: 30%

31
Q

List the four aetiologies of pleural infection (hint: it kind of resembles those of pneumonia)

A
  • Community-acquired
  • Hospital-acquired
  • Iatrogenic
  • Other
32
Q

List some types of pleural infection whose aetiology falls under “Other”

A
  • Oesophageal leak/rupture
  • Spontaneous bacterial empyema
  • Translocation from abdominal/sub-diaphragmatic infection
33
Q

Additional exam findings in pleural effusions associated with pleural infection

A
  • Patients may look unwell
  • Diaphoretic
  • Fever
34
Q

In what % of infective pleural effusion is fluid culturing positive?

A

Only 50-60%

35
Q

Uncomplicated vs complicated para-penumonic effusion

A
  • Both have no pus
  • Uncomplicated has normal pH/glucse, whereas complicated has abnormal
  • Complicated may also have culture positive readings and septations, uncomplicated has neither
36
Q

Describe the two main pillars of pleural infection management, and what is done for both

A

Pillar 1: Eradicate infection
- Broad-spectrum antibiotic

Pillar 2: Removed infected fluid
- Chest tube
- Fibrinolytics + mucolytics

If these don’t work:
- Surgery

37
Q

Which agent is used for lysis of pleural adhesions? What type of drug is it?

A

Alteplase (thrombolytic)

38
Q

Which agent is used to decrease viscosity of infected pleural fluid

A

Pulmozyme

39
Q

Roughly what percentage of pleural effusions are malignant?

A

22% -> 1/5 is close enough to remember

40
Q

What % of cancers are complicated by malignant pleural effusion?

A

15%

41
Q

Strictly speaking, which cancers can cause malignant pleural effusion?

A

Literally any of them, if they spread

42
Q

List the four most common cancers that cause malignant pleural effusion, and specify the most common

A
  • Lung cancer (most common)
  • Breast cancer
  • Mesothelioma
  • Lymphoma
43
Q

Is malignant pleural effusion more common in lung cancer or mesothelioma?

A

Mesothelioma (90% vs 50%)

44
Q

Are the examination findings for malignant pleural effusion very consistent?

A
  • No
  • They can vary widely depending on what stage of disease the patient is in
45
Q

Investigations for malignant pleural effusion

A
  • Vitals
  • Comprehensive bloods
  • Imaging (CXR, Thoracic ultrasound, CT, +/- PET scan)
  • Pleural fluid sampling
  • Pleural biopsy
46
Q

Describe pleural fluid characteristics in malignant pleural effusion

A
  • Clear, blood-stained, or cloudy
  • No smell
  • pH may be normal or low
  • Protein: usually high
  • LDH: normal/elevated
47
Q

Does malignant pleural effusion always require intervention?

A
  • No
  • Sometimes, systemic therapy will reduce the effusion
48
Q

Management options for malignant pleural effusions

A
  • Thoracentesis
  • Intercostal catheter (temporary)
  • Indwelling pleural catheter - long-term
  • Surgical (Video-assisted surgery, decortication, pleurodesis)
49
Q

Describe indwelling pleural catheters

A
  • Stay in patient
  • Intermittently, nurse can come to patient’s house and drain the fluid
50
Q

What % of malignant pleural effusion cases show re-accumulation following drainage?

A

70-90%

51
Q

What occurs during video-assisted thoracoscopy surgery (VATS)

A
  • Drain fluid
  • Take biopsies
  • Administer talc
  • Place a drain into patient
52
Q
A

Medical Studies 1 (90 decks)

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