Pleural effusion Flashcards
Causes of pleural effusion
Heart, liver or renal failure Pneumonia Pulmonary embolism Cancer TB
Symptoms of pleural effusion
Progressive breathlessness
Pleuritic pain
Symptoms of underlying condition
Signs of pleural effusion
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
Which patients are more likely to present with pleural effusion
Heart, liver or renal failure
Cancer
TB
Pleural infection
Diagnosis of pleural effusion
Chest radiography
Management of pleural effusion
Refer(or admit) the person for drainage of effusion and further IX of underlying cause
When does a transudative effusion occur
When there is disruption of the hydrostatic and oncotic forces operating across the pleural membranes
When does an exudative pleural effusion occur
When there is increased permeability of the pleural surface and/or capillaries, usually as a result of inflammation
What is the light criteria
Consists of measurement of the lactate dehydrogenase(LDH) and protein concentration in the pleural fluid and serum
When is a pleural effusion considered exudative
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
Most common causes of transudates
Heart failure
Cirrhosis
Hypoalbuminaemia
Peritoneal dialysis
Less common causes of transudates
Hypothyroidism
Nephrotic syndrome
Mitral stenosis
Pulmonary embolism(more likely to be exudate)
Common causes of exudates
Pneumonia
Malignancy
Less common causes of exudates
Pulmonary infarction(from PE) Autoimmune disease(RA) Asbestos exposure Pancreatitis Dressler's syndrome TB
Causes of chylothorax
Neoplasm(lymphoma, metastatic carcinoma) Trauma(operative and penetrating injuries) TB Sarcoidosis Cirrhosis Amyloidosis
What is pseudochylothorax
Accumulation of cholesterol crystals in a long-standing pleural effusion
Causes of pseudochylothorax
TB
Rheumatoid arthritis
Poorly treated empyema
Tracheal deviation in pleural effusions
With a large unilateral effusion, it is displaced away from the lesion
If there is associated collapse, trachea is deviated towards the lesion
What does mediastinal shift in the presence of an effusion suggest
A large effusion that is in excess of a litre
What type of pleural aspiration may be carried out if the pleural effusion is small or loculated
Ultrasound-guided pleural aspiration
Which additional test can be carried out for a suspected empyema
Centrifuge to differentiate from chylothorax
Which additional test can be carried out if a chylothorax is suspected
Cholesterol and triglyceride levels
Centrifuge; presence of cholesterol crystals and chylomicrons
Which additional test can be carried out if a haemothorax is suspected
Haematocrit
Use of pleural aspiration in bilateral pleural effusions
Aspiration should not be performed for bilateral effusions in a clinical setting strongly suggestive of transudate unless atypical features present
Causes of bloody pleural fluid
Malignancy Pulmonary embolus with infarction Trauma Benign asbestos pleural effusions Post-cardiac injury syndrome
Purpose of pleural fluid haematocrit
If haematocrit of fluid is more than half of patient’s peripheral blood haematocrit, this confirms haemothorax
< 1% haematocrit of pleural fluid is insignificant
Normal pleural pH
7.6
Causes of pleural pH < 7.2 with a normal blood pH
Pleural infection and empyema
Rheumatoid disease and SLE
TB
Malignancy
Oesophageal rupture
Why should pleural cytology specimen be repeated if negative
Malignant effusions are diagnosed by pleural fluid cytology alone in only 60% of cases
Causes of low pleural glucose levels
Empyema Rheumatoid disease SLE TB Malignancy Oesophageal rupture
Management options for pleural effusions where aspiration has failed
Pleurodesis
Pleurectomy
Surgically implanted pleuroperitoneal shunts
Management options for pleural effusions where aspiration has failed
Pleurectomy
Surgically implanted pleuroperitoneal shunts
What is pleurodesis
Injection of a sclerosant to cause adhesion of the visceral and parietal pleura and to prevent reaccumulation of effusion
Commonly used sclerosing agents
Tetracycline
Sterile talc
Bleomycin
When is pleurodesis commonly used
Management of recurrent malignant effusions
What might pleural fluid with low glucose indicate
Rheumatoid arthritis
TB
What might pleural fluid with raised amylase indicate
Pancreatitis
Oesophageal perforation
