Pleural Effusion

Question 1

What are the causes of a pleural effusion?

Answer 1

Transudate

• CCF
• CKD
• Hypoalbuminaemia
• Liver failure
• Hypothyroidism
• Meig syndrome

Can also cause pulmonary oedema.

Exudate:
Infections- Pneumonia 
Lung Ca
Rheumatoid arthiritis
Asbestosis
TB
Pancreatitis

Question 2

What are the symptoms of pleural effusions?

Answer 2

SoB
Non productive cough
Pleuritic chest pain

Question 3

What is an empyema, what are the clinical features?

Answer 3

An empyema is the presence of pus in the pleura space.
It may be a complication of bacterial LRTI or Tb.

An empyema should be suspected in the same way as an abscess – if a patient stays pyrexial despite treatment.

Symptoms include: fever, rigors, malaise + pleural effusion symptoms (dysopnea, pleuritic pain, cough).

Question 4

What investigations are needed for a pleural effusion?

Answer 4

Bloods

• FBC
• CRP- infection
• U&Es
• LFTs
• BNP
• Clotting

CXR

• blunting of costophrenic angle
• fluid in lung fissures
• trachea deviating away from effusion

Fluid sample

• via aspiration or chest drain
• USS guidance

Question 5

What are the criteria used to differentiate a transudate and an exudate?

Answer 5

Protein content greater than 30g/l

OR

Lights Criteria: one of the following

• Pleural fluid protein divided by serum protein >0.5.
• Pleural fluid LDH divided by serum LDH >0.6.
• Pleural fluid LDH more than two thirds the upper limits of normal serum LDH.

Question 6

How should pleural effusions be managed?

Answer 6

Conservative

• if small effusion
• should resolve once underlying cause resolved

Aspiration should be avoided in transudate

If aspiration- recurrence likely to occur
Chest drain favoured

If malignancy is cause then recurrence is likely so should use pleurodesis to prevent

Question 7

How are empyemas managed?

Answer 7

Infection will not clear unless there is drainage therefore it needs drainage either with:

• percutaneous thoracentesis
• chest drain

Followed with antibiotic treatment

Question 8

What are the signs of pleural effusion?

Answer 8

Dullness to percussion over effusion
Decreased breath sounds
Tracheal deviation away from effusion if large
Bronchial breathing in lower aspect of lung