Pleural effusion Flashcards
What is it?
A pleural effusion is a collection of fluid in thepleural cavity
What are the 2 diff types ?
Exudative and transudative
Causes of transudate effusions?
- Common:- bilateral
- Congestive Heart failure
- Cirrhosis- Liver failure (low albumin)
- Hypoalbuminaemia (nephrotic syndrome or peritoneal dialysis)- Renal failure
- Less common:
- Hypothyroidism, mitral stenosis, pulmonary embolism
- Rare:
- Constrictive pericarditis, superior vena cava obstruction, Meig’s syndrome (right sided pleural effusion with ovarian malignancy)
Exudative effusion causes?
- Common:- unilateral
- Malignancy
- Infections – parapneumonic, TB, HIV (kaposi’s)
- Less common:
- Inflammatory (rheumatoid arthritis), pancreatitis, benign asbestos effusion, Dressler’s, pulmonary infarction/pulmonary embolus), Lymphatic disorders, Connective tissue disease
- Rare:
- Yellow nail syndrome, fungal infections, drugs
Differentials for SOB
- cardiac- CCF, ACS, stable angina
- lung- PE, Pneumonia
Symptoms of effusion?
Shortness of breath
Pleuritic chest pain
Signs on examination?
Tracheal deviation- away from affected side - only if large
Chest movement - reduced on affected side
Percussion- Stony dullness
Auscultation- Decreased/absent breath sounds and Vocal resonance reduced over the affected side
Investigations?
-CXR
-ECG
- Bloods
- Echo
- Staging CT
- USS Pleural aspiration
- Thoracoscopy
- CT pleural biopsy
How do we diagnose the cause and when do we use Lights criteria ?
Ultrasound guided pleural aspiration
- Biochemistry
- Cytology
- Microbiology
Light’s criteria is used when the pleural protein level is between 25-35 g/l (borderline)
A pleural protein <30g/L means the effusion is
Transudate: pleural protein <30g/l
A pleural protein <30g/L means the effusion is
Exudate: pleural protein >30g/l
In light’s criteria exudate is one or more of the following - 3 things
- pleural fluid protein/serum protein >0.5
- pleural fluid LDH / serum LDH >0.6
- pleural fluid LDH >2/3 of the upper limit of normal
What is Empyema ? what does aspiration show?
infected pleural effusion
Pleural aspiration have visible pus,acidic pH
(pH < 7.2), low glucose and high LDH
If empyema is causing acute pleural effusion what management should be done urgently
chest drain
What is the conservative management of pleural effusion?
small effusions will resolve with treatment of the underlying cause
How to manage transudative effusions?
Treat the underlying cause
* If effusion resolves, stop or reduce treatment
* If effusion persists, then therapeutic aspiration/drainage is required
When to use pleural aspiration as treatment
temporarily relieve the pressure but the effusion may recur and repeated aspiration may be required
When to use a chest drain?
- only inserted when diagnosis is well established as draining all fluid may prevent pleural biopsies being taken
- drain the effusion and prevent it recurring
- URGENT chest drain and antibiotics used when empyema causing new pleural effusion- pH of pleural fluid <7.2 or visible pus on aspirate
What can you see on CXR that suggest pleural effusion?
- Larger effusion- Meniscus sign
- Loss of costophrenic angle/ blunting of costophrenic angle
- loss of Cardiophrenic angle
- hemidiaphragm obscured
- Opacification in lower lung zone
- Fluid in the lungfissures
- Tracheal and mediastinaldeviationif it is a massive effusion