Pleural Effusion

Question 1

What is a Pleural Effusion?

Answer 1

A collection of fluid in the pleural cavity.

Question 2

Types of Pleural Effusion (2).

Answer 2

1. Exudative - High Protein Content (>3g/dL).
2. Transudative - Low Protein Content (<3g/dL).

Question 3

Exudative Causes of Pleural Effusion (4).

Answer 3

INFLAMMATORY - causes protein leakage :
1. Lung Cancer.
2. Pneumonia.
3. Rheumatoid Arthritis.
4. Tuberculosis.
(PACT - P, Arthritis, Cancer, T).

Question 4

Transudative Causes of Pleural Effusion (4).

Answer 4

Fluid moves into pleural space :
1. Congestive Cardiac Failure.
2. Hypoalbuminaemia.
3. Hypothyroidism.
4. Meig’s Syndrome.
(M 3H - M, H, H, Heart Failure).

Question 5

What is Meig’s Syndrome?

Answer 5

Triad of Ascites, Right-Sided Pleural Effusion and Benign Ovarian Tumour.

Question 6

Give 3 causes of Hypoalbuminaemia.

Answer 6

1. Liver Disease.
2. Nephrotic Syndrome.
3. Malabsorption.

Question 7

What criteria can be used to distinguish in borderline cases?

Answer 7

Light’s Criteria - if between 25-35g/L : exudative if any of :
1. Pleural Fluid Protein divided by Serum Protein > 0.5.
2. Pleural Fluid LDH divided by Serum LDH > 0.6.
3. Pleural Fluid LDH < 2/3 Upper Limits of Normal Serum LDH.

Question 8

Clinical Features of Pleural Effusion (4).

Answer 8

1. SOB.
2. Dullness to Percussion.
3. Reduced Breath Sounds.
4. Tracheal Deviation (if massive effusion).

Question 9

Investigations of Pleural Effusion (3).

Answer 9

1. CXR.
2. Aspiration/Chest Drain Sample of Pleural Fluid (protein count, cell count, pH glucose, LDH and microbiology).
3. US + Contrast CT - underlying cause.

Question 10

CXR Findings of Pleural Effusion (3).

Answer 10

1. Blunting of Costophrenic Angle.
2. Fluid in Lung Fissures.
3. Large Effusion - Meniscus (Curving Upwards) and Tracheal/Mediastinal Deviation.

Question 11

Management of Recurrent Pleural Effusion (4).

Answer 11

1. Recurrent Aspiration.
2. Pleurodesis (Obliteration of Pleural Space).
3. Indwelling Pleural Catheter.
4. Opioids to relieve Dyspnoea.

Question 12

Management of Pleural Effusion (2).

Answer 12

1. Conservative - Small.
2. Aspiration/Chest Drain - Large.

Question 13

Pleural Aspiration.

Answer 13

21G needle and 50ml Syringe.

Question 14

Causes of Low Glucose in Pleural Fluid (2).

Answer 14

1. Rheumatoid Arthritis.
2. TB.

Question 15

Causes of Raised Amylase in Pleural Fluid (2).

Answer 15

1. Pancreatitis.
2. Oesophageal Perforation.

Question 16

Causes of Heavy Blood Staining (3).

Answer 16

1. Mesothelioma.
2. PE.
3. TB.

Question 17

What is an Empyema?

Answer 17

An infected pleural effusion, likely in a patient with improving pneumonia but new/ongoing fever.

Question 18

Investigation of Empyema.

Answer 18

Pleural Aspiration - Pus, Acidic pH (<7.2), Low Glucose and High LDH (bacterial survival).