Pleural Effusion

Question 1

What are the symptoms of pleural effusion?

Answer 1

Dependent on the cause of the pleural effusion 
•Shortness of breath 
•Weight loss 
•Haemoptysis 
•Chest pain 
•Lethargy 
•Fever

Question 2

What should you ask about when taking a history from someone with a suspected pleural effusion?

Answer 2

• Associated symptoms
• Red flag symptoms
• Onset - fall? change in medication? Travel?
• Past medical history
• Smoking history
• Occupational history

Question 3

What can you use to tell if the effusion is transudate or exudate?

Answer 3

Light’s criteria

Question 4

What is light’s criteria?

Answer 4

•Positive (i.e. is exudate) if any one of these is true:

• Fluid protein: serum protein >0.5
• fluid LDH: serum LDH >0.6
• fluid LDH >2/3 maximum serum normal

Question 5

What are the causes of a transudate pleural effusion?

Answer 5

• Heart failure
• cirrhosis
• Renal failure
• Hypothyroidism
• Hypoalbuminaemia

Question 6

What are the causes of an exudate pleural effusion?

Answer 6

• Malignancy
• Infection
• Empyema
• TB
• Haemothorax
• Autoimmune
• Pulmonary embolism
• MI
• Drug induced
• Pancreatitis
• Chylothorax

Question 7

What investigations should you carry out in someone with a pleural effusion?

Answer 7

•Imaging 
•Bloods 
•Sampling 
 - never drain an undiagnosed effusion 
 - local anaesthetic thorascopy

Question 8

What is d sign?

Answer 8

• Pleural effusion doesn’t follow gravity, it is held up

* Suggests pleural infection or empyena

Question 9

If a pleural effusion is bilateral is it more likely to be transudate or exudate?

Answer 9

Most likely transudate

Question 10

What is thorascopy?

Answer 10

•direct visual examination of the pleura with a thorascope
•Indicated in undiagnosed cytology negative pleural effusions
•Performed under local anaesthesia and mild sedation
- biopsy abnormal areas
- definitive effusion management

Question 11

What is the treatment of pleural effusion?

Answer 11

• Depends on the cause

* Take the fitness and symptoms of the patient into account

Question 12

Describe the management of malignant pleural effusion

Answer 12

• Symptom driven, patient centred
• Chest drain with or without talc pleurodesis
• Indwelling pleural catheter
• Patient choice unless talc failed or lung trapped

Question 13

What is the definition of a complex parapneumonic effusion

Answer 13

• pH <7.2
• LDH>1000
• Glucose <2.2
• Loculated on ultrasound

Question 14

What is the management of empyema

Answer 14

• Drainage
• IV antibiotics
• Fibrinolytics
• Surgery (to wash out the space)