Pleural Effusion Flashcards
What is the pleurisy?
inflammation of the pleura that causes sharp pain with breathing.
What is the pleural effusion?
excess fluid in the pleural space
What is empyema?
collection of pus in the pleural space. ‘
What is he hemothorax?
buildup of blood in the pleural space.
What is the pneumothorax?
buildup of air or gas in the pleural space.
What is pleural space (cavity), the parietal pleura and visceral pleura?
Pleural space (cavity) in a healthy
patient is a potential space sandwiched between the parietal and visceral pleurae.
• The parietal pleura completely
lines the inner chest wall surface of the thoracic cavity.
• The visceral pleura tightly
envelopes both lungs completely, meeting the parietal pleura at the hilar root of the lungs.
How does pleural effusion occur?
1-Usually result from excess
fluid production
2-decreased lymphatic absorption.
What are the two factors that responsible for increasing the production fluid in patients with pleural effusion?
1.Increased hydrostatic pressure.( increased heart pressure)
2.Decreased osmotic pressure.( hypoalbuminemai)
3.Increased microvascular permeability/pressure any inflammatory disease can cause this )
What is the normal amount fluid that pleural space contain?
10 to 20 mL
What is the transudative effusion?
1- trnasudative effusion:
Result from an imbalance in oncotic and hydrostatic pressures.
Causes:
1.Congestive heart failure ( bilateral effusion)
2.Cirrhosis (hepatic hydrothorax) 3.Atelectasis
4.Hypoalbuminemia ( bilateral)
5.Nephrotic syndrome 6.Peritoneal dialysis 7.Urinothorax
8.Cerebrospinal fluid (CSF) leaks to the pleura (in the setting of ventriculopleural shunting or of trauma/surgery to the thoracic spine)
Pleural effusion can be either, mention the two types?
1- Transudative effusion
2- Exudative effusion
What is the exudative effusion?
Result mainly from inflammation and malignancies and
increased microvascular permeability.
- Tuberculosis (Lymphocytes).
- Pneumonia (parapneumonic effusion).
- Malignant disease (malignant effusion)
- Asbestos-related pleural effusion
- Pulmonary infarction (Red blood cells).
- Rheumatoid disease (Lymphocytes)
- Systemic lupus erythematosus (Lymphocytes)
- Acute pancreatitis (Higher amylase in pleural fluid than in serum)
What is parapneumonic effusion?
If the patient has Pneumonia and then develops pleural effusion
What are symptoms or presentation of pleural effusion?
- Dyspnea:
• Most common symptom associated with pleural effusion
• In many patients, drainage of pleural fluid alleviates dyspnea despite
• Note that dyspnea may be caused by the condition producing the pleural effusion, such as underlying
intrinsic lung or heart disease or obstructing endobronchial lesions rather than by the effusion itself. - Cough:
• Often mild and nonproductive. • More severe cough or the production of purulent or bloody sputum suggests an underlying pneumonia or
endobronchial lesion. - Chest pain:
• Raises the likelihood of an exudative etiology, such as pleural infection, mesothelioma(any malignant disease), or pulmonary infarction.
• Pain may be mild or severe. It is typically described as sharp or stabbing and is exacerbated with deep
inspiration.
If a patient comes with pleural effusion symptoms + lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea, what is the mots likely diagnosis?
may all occur with congestive heart failure.
If a patient comes with pleural effusion symptoms + night sweats, fever, hemoptysis and weight loss, what is the diagnosis?
TB
What is the physical examination in pleural effusion patients ?
1-Typically, there are no clinical findings for effusions less than 300 mL.
2-Dullness to percussion.
3-Decreased tactile fremitus( in palpation).
4- Asymmetrical chest expansion, with diminished or delayed expansion on the side of the effusion.
5- Egophony ( on auscultation) (known as “E-to-A” changes). Decrease breath sound
What do we find in chest x ray in pleural effusion pateints?
Right side pleural effusion
(blunting of the costophrenic angle)
What is the investigation other than chest x ray of pleural effusion?
Point of care ultrasound ( PoCUS)
What is the diagnostic investigation of pleural effusion?
Thoracentesis ( for light criteria)
Helps to distinguish pleural fluid transudates
from exudates.
Do we need to do thoracentesis to every patients who has pleural effusion?
No.
• Should be performed for new and unexplained
pleural effusions or effusion that does not respond to therapy as expected when sufficient fluid is present.
Pleural effusions do not require thoracentesis if
they are too small to safely aspirate.
What are the gross
characteristics of the fluid obtained during thoracentesis exudative pleural effusions ?
- Frankly purulent fluid indicates an empyema.
- A putrid odor suggests an anaerobic empyema.
- A milky, opalescent fluid suggests a chylothorax, resulting most often from lymphatic obstruction by malignancy or thoracic duct injury by trauma or surgical procedure
- Grossly bloody fluid may result from trauma, malignancy, traumatic tap, pulmonary
infarction or asbestos-related effusion. - Black pleural fluid suggests a limited number of diseases, including infection ( fungal infection) with Aspergillus
niger or Rizopus oryzae, malignant melanoma, non-small cell lung cancer
What are the normal pleural fluid ?
Normal pleural fluid has the following characteristics:
• Clear ultrafiltrate of plasma that originates from the
parietal pleura
• PH of 7.60-7.64
• Protein content of less than 2% (1-2 g/dL)
• Fewer than 1000 white blood cells (WBCs) per cubic
millimeter
• Glucose content similar to that of plasma
• Lactate dehydrogenase (LDH) less than 50% of plasma
What are the light’s criteria of pleural effusion types ?
Light’s Criteria are used to determine whether a pleural effusion is exudative or transudative.
Satisfying any ONE criterium means it is exudative:
1- Pleural Total Protein/Serum Total Protein ratio > 0.5.
2- Pleural lactate dehydrogenase/Serum lactate dehydrogenase ratio > 0.6.
Always send pleural fluid for protein, LDH, glucose, pH, gram stain and culture and cytoloy ( if suspected malignancy). Also serum LDH and protein
What are the complication of thpracentesis?
.1- Puncture site, cutaneous or internal bleeding from laceration of an
intercostal artery or spleen/liver puncture.
2- Pneumothorax.
3- Infection.
4-Reexpansion pulmonary edema (when removing more than 1.5 L at a time)
What are contraindications to diagnostic thoracentesis include?
• Bleeding diathesis or systemic anticoagulation.
• cutaneous disease over the proposed puncture site.
How to manage pleural effusion?
- Treat the underline condition (e.g. heart failure, pneumonia, PE or subphrenic
abscess). - Therapeutic thoracentesis to palliate breathlessness.
- Chest tube (indication: large effusion >50% of hemithorax, loculated effusion,
complicated Parapneumonic effusion, empyema or sepsis from pleural source). - Pleurodesis (for recurrent effusion).
- Indwelling tunneled pleural catheters (for recurrent effusion)
Where is the site for chest tube?
4th - 5th intercostal space
What is the Parapneumonic effusion
and types?
Exudative plural effusion secondary to pneumonia.
- Uncomplicated:
• Effusion is clear. pH >7.2, LDH <1000, glucose <60 mg/dl. Gram stain and culture are negative.
• Treatment with antibiotics.
- Complicated:
• Effusion is cloudy. pH <7.2, LDH >1000, glucose <60 mg/dl. Gram stain and culture are positive. • Effusion can be loculated.
• Treatment with antibiotics (intravenous ceftriaxone + metronidazole) and chest tube drainage.
What are the symtoms of empyema?
Symptoms include
1-severe pleuritic chest pain,
2-persisting or recurrent fever.
,3-dyspnea,
4- rigors and
sweating, despite appropriate antibiotic treatment
Empyema caused by?
always secondary to infection in a neighboring structure, usually the lung.
Most commonly
due to the bacterial pneumonias and tuberculosis.
How to investigate a patient with empyema?
Chest X-ray, Ultrasound and CT chest.
- Thoracentesis»_space; Fluid is thick and turbid pus. Pleural fluid glucose <60 mg/dL (or < 30 mg/dl), LDH
>1000 IU/L, or a fluid pH <7.0 - 7.1. Gram stain and culture are positive.
How to treat empyema?
Treatment should include:
1. Removal of all the pus from the pleural space by chest tube. 2. Antibiotics:
- If the organism is identified, the appropriate antibiotic should be given for 2–4 weeks. - If not Identified, intravenous ceftriaxone + metronidazole for 2–4 weeks
What distinguish hemothorax?
Hematocrit distinguish hemothorax from bloody exudate:
- Hemothorax: Hematocrit in pleural fluid ≥ 50% of peripheral blood hematocrit.
- Bloody exudative pleural effusion : Hematocrit in pleural fluid < 50% of peripheral blood
hematocrit (caused by malignancy or pulmonary infarction)
What is the treatment of hemothorax?
Chest tube to drain blood
Pneumothorax can be ?
- Primary spontaneous (risk factors): - Smoking. - Tall and thin stature. - presence of apical subpleural blebs.
- Secondary spontaneous pneumothorax affects patients with pre-existing lung disease and is associated with higher mortality rates
- Result from iatrogenic injury or trauma to the lung or chest wall. ( thoracocentisi) an example
What type of pnemothorax is medical emergency?
Tension type ( likd a valve )
What is the closed type pneumothorax?
communication between the airway and the pleural space seals off as the lung deflates and does not re-open
What is the open type of pneumothorax?
communication fails to seal and air continues to pass freely between the bronchial tree and pleural space
What is the tension type of pneumothorax?
communication between the airway and the pleural space acts as a one-way valve, allowing air to enter the pleural space during inspiration but not to escape on expiration (tension pneumothorax)
Clincal features of pneumothorax?
• Sudden-onset unilateral pleuritic chest pain or breathlessness.
• Decreased or absent breath sounds.
• The combination of absent breath sounds and a resonant percussion note is diagnostic of
pneumothorax.
• In tension pneumothorax there is rapidly progressive breathlessness associated with a marked
tachycardia, hypotension, cyanosis and tracheal displacement away from the side of the silent hemithorax
Sudden onset chest pain or sudden onset dyspnea and and no breath sound on auscultation, what is the diagnosis?
Always pneumothrax until proven otherwise
What do we see in chest x ray of pneumothrax?
Collapsed lung
What are the signs and symptoms of tension pneumothorax?
In tension pneumothorax there is rapidly progressive breathlessness associated with a marked
tachycardia, hypotension, cyanosis and tracheal displacement away from the side of the silent hemithorax
How to mange pneumothorax?
Management:
Chest tube +/- percutaneous needle aspiration.
In tension pneumothorax, immediate percutaneous needle decompression prior to insertion of the chest tube
Recurrent spomtaneuos pneumothorax is treated with?
Pleurodesis is recommended in all patients following a second pneumothorax
Should prompt definitive treatment.
