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CPCs > CPC 3 - Pleural Effusion > Flashcards

CPC 3 - Pleural Effusion Flashcards

1
Q

What is the mechanism of pleural fluid?

A 
Increased hydrostatic pressure;
Decreased oncotic pressure;
Increased permeability of pleura;
Increased pulmonary interstitial fluid;
Movement from other cavities (peritoneal);
Vascular rupture into thorax;
Rupture of thoracic duct.
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2
Q

What do you do once you have identified pleural effusion as a transudate?

A

Treat the cause

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3
Q

What do you do if patient returns to clinic after being treated for pleural effusion?

A 
Pleural aspiration and send fluid for:
Biochemistry
Microbiology
Cytology
Flow cytometry
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4
Q

What criteria must be met for pleural fluid to qualify as exudate?

A

Lights Criteria
Pleural fluid is an exudate if one or more of the following criteria are met:
Pleural fluid protein divided by serum protein is >0.5;
Pleural fluid lactate dehydrogenase (LDH) divided by serum LDH is >0.6;
Pleural fluid LDH >2/3 the upper limits of laboratory normal values for serum LDH

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5
Q

What is the difference between exudate and transudate?

A

Pleural fluid protein >30 g/l has indicated an exudate and

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6
Q

What can pleural fluid NT-proBNP be used for?

A

Pleural fluid NT-proBNP correlates with blood NT-proBNP, level of >1500 shown to discriminate cardiac failure from other causes of transudative effusions

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7
Q

What can pleural fluid pH be used for?

A

pH

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8
Q

What can pleural fluid glucose be used for?

A

Low level

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9
Q

What can amylase in pleural fluid indicate?

A

Useful in suspected cases of oesophageal rupture or effusions associated with pancreatic diseases

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10
Q

What can mesothelin, Fibulin-3, and Osteopontin levels in pleural fluid indicate?

A

All independently shown to help differentiate malignant from non malignant pleural effusions in patients with asbestos exposure

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11
Q

What are potential organisms that can be present in pleural fluid that are community acquired?

A

Strep spp. (52%)
Staph aureus (11%)
Gram -ve aerobes (9%) (enterobacteriaceae, E. Coli)
Anaerobes (20%) (Fusobacterium spp., Bacteroides spp., Peptostreptococcus spp., mixed)

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12
Q

What are potential organisms that can be present in pleural fluid that are hospital acquired?

A

Staphylococci (MRSA - 25%; S. aureus - 10%)
G-ve aerobes (17%) (E. coli, Pseudomonas aeruginosa, Klebsiella spp.)
Anaerobes (8%)

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13
Q

What are the cytology/characteristics of pleural effusion due to acute inflammation?

A

Mainly neutrophils
Usually underlying pneumonia
Frank pus indicates empyema
Reactive mesothelial cells may mimic malignancy

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14
Q

What are the cytology/characteristics of pleural effusion due to eosinophilic effusion?

A

> 10% eosinophils
Usually a reaction to air or blood in the pleural space
Rarer causes include: drug reactions; parasite infection; pulmonary infection; Churg-Strauss syndrome

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15
Q

What are the cytology/characteristics of pleural effusion due to lymphocytic effusion?

A 
Mainly lymphocytes
Broad differential diagnosis
Inflammatory disease (eg. rheumatoid)
Infection (including mycobacterial)
Malignancy (solid or lymphoma)
Others (after CABG)
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16
Q

What are the cytology/characteristics of pleural effusion due to malignant effusion?

A

Primary or secondary
Solid or haematological
use immunohistochemistry to define cell type
Definitive diagnosis or mesothelioma rarely possible
Squamous cell carcinoma may not shed cells into fluid

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17
Q

What does pleuritic chest pain indicate?

A

Inflammation or irritation of the parietal pleura.

The parietal pleura contains sensory nerve endings that can detect pain.

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18
Q

What are the basic functions of pleura?

A

Pleural fluid originates in parietal pleural tissue.

The parietal pleura and visceral pleura glide over each other without separation.

The visceral pleura absorbs fluid, which then drains into the lymphatic system and returns to the blood.

The pleural space typically contains 10-20ml of fluid at one time.

19
Q

What is the definition of pleural effusion?

A

The accumulation of fluid the the pleural space. It occurs whenever the rate of fluid formation and rate of resorption are mismatched.

20
Q

What imaging of CXR is used to confirm presence of pleural effusion?

A

PA and lateral CXR.
Look for homogenous density, density in dependent portion (costophrenic angle in PA view), Meniscus sign (dense homogenous opacity with a concave upper border; higher laterally than medially), loss of normal silhouette (obscures hemidiaphragm), +/- mediastinal shift.

21
Q

What is lost from view on a CXR in 50 ml, 175-200ml, and 500ml pleural effusion? What view is this seen in?

A

50ml - lateral view, obliteration of anterior or posterior CP angle

175-200ml - PA view, obliteration of lateral CP angle

500ml - PA view, obliteration of ipsilateral hemidiaphragm

22
Q

What is a loculated effusion?

A

When the fluid does not shift freely in the pleural space, usually due to adhesions between the visceral and parietal pleura (eg. haemothorax, infection (empyema))

No change by gravitational positioning

Lentiform opacity against chest wall (convex to the lung)

May mimic chest wall mass

23
Q

What to do once location of pleural effusion has been established?

A

Investigate aetiology, cause may be obvious from the clinical history or radiographic findings

Generally, all patients with unilateral plerual effusion (>1 cm in height on lateral decubitus X-ray, US or CT) of unknown origin should have thoracentesis

24
Q

What is a subpulmonic effusion?

A

When pleural fluid is located in the subpulmonic region in upright patients. lung floats on a layer of fluid.

The hemidiaphragm is flattened and inverted, without significant blunting of lateral costophrenic angle.

Apparent elevation of hemidiaphragm;
Lateral peak of hemidiaphgragm;
2cm between hemidiaphragm and gastric bubble

Can be confirmed by Decubitus film (lying down)

25
Q

What are the advantages of using US in imaging pleural effusions?

A

Lack of ionising radiation
Low cost and easy to repeat
Real-time bed side applications
Best method to detect small pleural effusions (from 5 ml)
More sensitive than CT to depict the internal structure (septa) of pleural collections.

26
Q

Anechoic US appearance of pleural effusions

A

US finding: Echo-free (black) spaces between pleural layers

Suggests transudate, sometimes exudate

27
Q

Complex non septated US appearance of pleural effusions

A

US finding: Echogenic material (bright) in anechoic fluid

Suggests exudate

28
Q

Complex septated US appearance of pleural effusions

A

Fibrin strands or septa floating in anechoic fluid

Suggests exudate

29
Q

Echogenic US appearance of pleural effusions

A

Homogeneously echogenic fluid

Suggests exudate, haemorrhage, empyema or chylothorax

30
Q

What are the advantages of CT for imaging pleural effusions?

A

Differentiates pleural from parenchymal lesions
Determines the precise location and extent of pleural disease
Differentiates between free and loculated fluid
More sensitive than US for differentiating fluid from pleural thickening
Exact placement of chest tubes and percutaneous biopsy

31
Q

What should be done before a CT of pleural effusion?

A

Administer contrast medium, and CT should be performed before complete aspiration of fluid (pleural abnormalities will be better visualised)

32
Q

What are common causes of exudative pleural effusions?

A

Parapneumonic effusion

Malignant neoplasm

33
Q

What are common causes of transudative pleural effusions?

A

Heart failure
Cirrhosis
Hypoalbuminemia
Peritoneal dialysis

34
Q

What are less common causes of exudative pleural effusions?

A 
Pulmonary infarction
RA
Benign effusion related to asbestos
Pancreatitis
Dressler's syndrome
Autoimmune disease
35
Q

What are less common causes of transudative pleural effusions?

A 
Nephrotic syndrom
PE
Mitral stenosis
Atelectasis
Hypothyroidism
36
Q

Congestive cardiac failure and pleural effusion?

A

Most common cause of transudative effusions.
Most often are bilateral (R>L).
If unilateral, are most commonly right-sided.
Usually, associated cardiac enlargement, with or without pulmonary venous hypertension.
Effusions improve quickly once diuretic therapy is started.

37
Q

What are CXR findings for congestive heart failure?

A 
Heart enlarged
Pleural effusions
Upper lobe diversion
Kerley B lines
\+/- Enlarge central pulmonary arteries
Also fissural fluid collections
38
Q

What percentage of pleural effusions in older patients are malignant?

A

25%

39
Q

Malignant effusions details?

A

The pleura may be involved by primary or secondary tumours

Secondary tumours account for about 90% of pleural neoplasms

Tumoral invasion of the pleura is produced by haematologic route, lymphatic invasion or by contiguity spread

40
Q

What is the appearance of malignant effusions on CXR?

A

Unilateral pleural effusion
Unilateral nodular/irregular pleural thickening
Rib destruction

41
Q

What is the appearance of malignant effusions on CT?

A

Nodular pleural thickening
Mediastinal pleural thickening
Parietal pleural thickening > 1cm
Circumferential pleural thickening

42
Q

What are the clinical features that are suggestive of malignant origin of pleural effusion?

A

Symptoms > 1m
Absence of fever
Blood-tinged fluid
Chest CT suggesting malignancy

43
Q

What are the primary sites causing metastatic pleural effusion?

A

Lung>breast>lymphoma/leukemia

Metastatic adenocarcoma positive cytology (70%);
Lymphoma (25-50%);
Squamous cell carcinoma (20%);
Sarcoma within pleura (25%).

CPCs (3 decks)

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