Pleural effusion

Question 1

An 82 year old woman presents with shortness of breath and is found to have a moderate sized left pleural effusion. How would you assess and manage her?

Imp/DDx/Goals

Answer 1

Impression
Pleural effusion. Concerns are pertaining to reduced respiratory function and subsequent decompensation. Would need to consider underlying cause including exudative (infection, malignancy), and transudative (CCF, CKD) and whether any degree of chronicity/recurrence. Particularly concerned about malignancy given patient age.

Goals

• Take thorough assessment using H/E/I, identify risk factors for complications
• treat appropriately to prevent complications in acute setting
• identify underlying cause and institute appropriate management

Question 2

Pleural effusion - Assessment

Answer 2

Assessment
Would want to initially ensure haemodynamic stability and appropriate sats, so would take an A to E approach to initial assessment:
A
B
C
D
E

Question 3

Pleural effusion - History

Answer 3

History

• sx: SOBOE, reduced exercise tolerance, semi-acute onset, dry cough, chest pain (pleuritic),
• REDF: weight loss, night sweats, fevers, masses, bone pain
• HxPC: infective sx, previous effusions
• PMHx: cardiac disease, renal disease
• family history
• medications
• SNAP

Question 4

Pleural effusion - Examination

Answer 4

Examination

• General observation (WOB), vitals
• Cardiorespiratory (stony dull percussion, reduced breath sounds, increased vocal resonance)
• Fluid assessment (fluid overload)
• systems review (for other systemic cause)

Question 5

Pleural effusion - Investigations

Answer 5

Investigations
- Key/diagnostic: CXR (HF, effusion, etc), lung ultrasound, thoracocentesis (MCS, biochem, flow cytometry, lights criteria: effusion protein, LDH).

• Bedside: VBG, vitals (sats)
• Bloods: UEC, Lights criteria (serum LDH, serum protein), BNP, FBC, CMP (paraneoplastic syndrome), markers of malignancy
• Imaging: CXR, ultrasound, CT chest + staging investigations (if malignancy)

Question 6

Pleural effusion - Management

Answer 6

Management:
Supportive
- supplemental 02 as required
- analgesia
- chest physiology

Definitive

• thoracocentesis +/- chest drain
• transudative: CCF/CKD
• exudative: MDT and specific management for malignant cause, consider talc pleurodesis for recurrent effusions.