Pleural effusion

Question 1

Causes of pleural effusion

Answer 1

Heart, liver or renal failure 
Pneumonia 
Pulmonary embolism 
Cancer 
TB

Question 2

Symptoms of pleural effusion

Answer 2

Progressive breathlessness
Pleuritic pain
Symptoms of underlying condition

Question 3

Signs of pleural effusion

Answer 3

Reduced chest wall movements on the affected side 
Stony dull percussion note 
Diminished or absent breath sounds 
Decreased vocal resonance 
Bronchial breathing just above effusion

Question 4

Which patients are more likely to present with pleural effusion

Answer 4

Heart, liver or renal failure
Cancer
TB
Pleural infection

Question 5

Diagnosis of pleural effusion

Answer 5

Chest radiography

Question 6

Management of pleural effusion

Answer 6

Refer(or admit) the person for drainage of effusion and further IX of underlying cause

Question 7

When does a transudative effusion occur

Answer 7

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

Question 8

When does an exudative pleural effusion occur

Answer 8

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

Question 9

What is the light criteria

Answer 9

Consists of measurement of the lactate dehydrogenase(LDH) and protein concentration in the pleural fluid and serum

Question 10

When is a pleural effusion considered exudative

Answer 10

Pleural fluid -to-serum protein ratio > 0.5

Pleural fluid-to-serum LDH ratio > 0.6

Pleural fluid LDH concentration > 2/3 upper limit of normal for serum LDH

Question 11

Most common causes of transudates

Answer 11

Heart failure
Cirrhosis
Hypoalbuminaemia
Peritoneal dialysis

Question 12

Less common causes of transudates

Answer 12

Hypothyroidism
Nephrotic syndrome
Mitral stenosis
Pulmonary embolism(more likely to be exudate)

Question 13

Common causes of exudates

Answer 13

Pneumonia

Malignancy

Question 14

Less common causes of exudates

Answer 14

Pulmonary infarction(from PE) 
Autoimmune disease(RA)
Asbestos exposure 
Pancreatitis 
Dressler's syndrome 
TB

Question 15

Causes of chylothorax

Answer 15

Neoplasm(lymphoma, metastatic carcinoma)
Trauma(operative and penetrating injuries) 
TB 
Sarcoidosis 
Cirrhosis 
Amyloidosis

Question 16

What is pseudochylothorax

Answer 16

Accumulation of cholesterol crystals in a long-standing pleural effusion

Question 17

Causes of pseudochylothorax

Answer 17

TB
Rheumatoid arthritis
Poorly treated empyema

Question 18

Tracheal deviation in pleural effusions

Answer 18

With a large unilateral effusion, it is displaced away from the lesion

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

Question 19

What does mediastinal shift in the presence of an effusion suggest

Answer 19

A large effusion that is in excess of a litre

Question 20

What type of pleural aspiration may be carried out if the pleural effusion is small or loculated

Answer 20

Ultrasound-guided pleural aspiration

Question 21

Which additional test can be carried out for a suspected empyema

Answer 21

Centrifuge to differentiate from chylothorax

Question 22

Which additional test can be carried out if a chylothorax is suspected

Answer 22

Cholesterol and triglyceride levels

Centrifuge; presence of cholesterol crystals and chylomicrons

Question 23

Which additional test can be carried out if a haemothorax is suspected

Answer 23

Haematocrit

Question 24

Use of pleural aspiration in bilateral pleural effusions

Answer 24

Aspiration should not be performed for bilateral effusions in a clinical setting strongly suggestive of transudate unless atypical features present

Question 25

Causes of bloody pleural fluid

Answer 25

``` Malignancy Pulmonary embolus with infarction Trauma Benign asbestos pleural effusions Post-cardiac injury syndrome ```

Question 26

Purpose of pleural fluid haematocrit

Answer 26

If haematocrit of fluid is more than half of patient's peripheral blood haematocrit, this confirms haemothorax < 1% haematocrit of pleural fluid is insignificant

Question 27

Normal pleural pH

Answer 27

7.6

Question 28

Causes of pleural pH < 7.2 with a normal blood pH

Answer 28

Pleural infection and empyema Rheumatoid disease and SLE TB Malignancy Oesophageal rupture

Question 29

Why should pleural cytology specimen be repeated if negative

Answer 29

Malignant effusions are diagnosed by pleural fluid cytology alone in only 60% of cases

Question 30

Causes of low pleural glucose levels

Answer 30

``` Empyema Rheumatoid disease SLE TB Malignancy Oesophageal rupture ```

Question 31

Management options for pleural effusions where aspiration has failed

Answer 31

Pleurodesis Pleurectomy Surgically implanted pleuroperitoneal shunts

Question 32

Management options for pleural effusions where aspiration has failed

Answer 32

Pleurectomy | Surgically implanted pleuroperitoneal shunts

Question 33

What is pleurodesis

Answer 33

Injection of a sclerosant to cause adhesion of the visceral and parietal pleura and to prevent reaccumulation of effusion

Question 34

Commonly used sclerosing agents

Answer 34

Tetracycline Sterile talc Bleomycin

Question 35

When is pleurodesis commonly used

Answer 35

Management of recurrent malignant effusions

Question 36

What might pleural fluid with low glucose indicate

Answer 36

Rheumatoid arthritis | TB

Question 37

What might pleural fluid with raised amylase indicate

Answer 37

Pancreatitis | Oesophageal perforation