Malignant Pleural Effusion

Question 1

Define a pleural effusion [1]

Answer 1

accumulation of fluid in pleural cavity

Question 2

List the typical presenting symptoms of pleural effusion [7]

Answer 2

1. Shortness of breath
2. Fever
3. Weight loos
4. Lethargy (lack of energy)
5. Cough
6. Chest pain
7. Haemoptysis

Question 3

What are the signs associated with pleural effusion? [6]

Answer 3

1. clubbing
2. ascites
3. lymphadenopathy
4. reduced breath sounds
5. stony dull to percussion
6. reduced vocal or tactile fremitus

Question 4

Describe the Light’s criteria for identifying exudate [4]

Answer 4

1. fluid protein : serum protein ratio = >0.5
2. fluid LDH : serum LDH ratio = >0.6
3. fluid LDH >2/3 maximum serum normal

Any 1 of 3 = exudate

Question 5

List the causes of transudate pleural effusion [5]

Answer 5

1. Heart failure
2. Cirrhosis
3. Renal failure
4. Hypothyroidism
5. Hypoalbuminemia

Question 6

List the causes of exudative pleural effusion [11]

Answer 6

1. Malignancy
2. Infection
3. Empyema
4. TB
5. Haemothorax
6. Autoimmune
7. Pulmonary embolism
8. Post CABG? MI
9. Drug induced
10. Pancreatitis
11. Chylothorax

Question 7

Define chylothorax [1]

Answer 7

accumulation of lymphatic tissue in the pleural cavity

Question 8

What investigations should you carry out for a suspected pleural effusion? [3]

Answer 8

1. Imaging
2. Bloods
3. Sampling
   
   • As few interventions as possible
   • Never drain an undiagnosed effusion
   • Local anaesthetic thoracoscopy

Question 9

How much fluid needs to be present in a pleural effsuion for it to show up on a CXR? [1]

Answer 9

at least 500ml

Question 10

Describe the common features of pleural effusion on CXR [3]

Answer 10

1. uniformly white appearance
2. blunting of the costophrenic and cardiophrenic angles
3. a meniscus at the upper edge

Question 11

What is a thoracoscopy and what are its functions? [4]

Answer 11

1. direct visual examination of the pleura with a thoracoscope
2. performed under local anaesthesia and mild sedation
3. can biospy areas which appear abnormal and give definitive effusion management

Question 12

When would it be appropriate to carry out a thoracoscopy? [1]

Answer 12

indicated in undiagnosed cytology negative pleural effusions

Question 13

What is the most common primary cause of malignant pleural effusions? [1]

Answer 13

mesothelioma

Question 14

Where does malignant pleural effusions commonly metastasise? [6]

Answer 14

1. Lung most common
2. Breast, ovarian
3. Also bowel, renal, lymphoma etc.

Question 15

How is a malignant pleural effusion diagnosed? [2]

Answer 15

1. Aspiration
2. Often need tissue for genetics

Question 16

How is a malignant pleural effusion managed? [4]

Answer 16

1. Management is symptom driven, patient centered
2. Chest drain +/- talc pleurodesis
   
   • talc pleurodesis = fusion of pleura = pleural space is gone
3. Indwelling pleural catheter
   
   • soft, flexible tube that runs under your skin to the area next to your lungs for recurrent pleural effusions
4. Patient choice unless talc failed/lung trapped

Question 17

What are the features of a complex parapneumonic effusion? [4]

Answer 17

1. pH <7.2
2. LDH >1000
3. Glucose <2.2
4. Loculated on ultrasound

Question 18

Define empyema [1]

Answer 18

collection of pus/bacteria in the pleural cavity

Question 19

What are the management options for an empyema? [4]

Answer 19

1. Drainage
2. IV antibiotics
3. Fibrinolytics - to dissolve fibrinous clots (aids drainage)
4. Surgery