Pleural effusion

Question 1

What is it?

Answer 1

A pleural effusion is a collection of fluid in thepleural cavity

Question 2

What are the 2 diff types ?

Answer 2

Exudative and transudative

Question 3

Causes of transudate effusions?

Answer 3

• 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)

Question 4

Exudative effusion causes?

Answer 4

• 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

Question 5

Differentials for SOB

Answer 5

• cardiac- CCF, ACS, stable angina
• lung- PE, Pneumonia

Question 6

Symptoms of effusion?

Answer 6

Shortness of breath
Pleuritic chest pain

Question 7

Signs on examination?

Answer 7

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

Question 8

Investigations?

Answer 8

-CXR
-ECG
- Bloods
- Echo
- Staging CT
- USS Pleural aspiration
- Thoracoscopy
- CT pleural biopsy

Question 9

How do we diagnose the cause and when do we use Lights criteria ?

Answer 9

Ultrasound guided pleural aspiration
- Biochemistry
- Cytology
- Microbiology
Light’s criteria is used when the pleural protein level is between 25-35 g/l (borderline)

Question 10

A pleural protein <30g/L means the effusion is

Answer 10

Transudate: pleural protein <30g/l

Question 11

A pleural protein <30g/L means the effusion is

Answer 11

Exudate: pleural protein >30g/l

Question 12

In light’s criteria exudate is one or more of the following - 3 things

Answer 12

• 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

Question 13

What is Empyema ? what does aspiration show?

Answer 13

infected pleural effusion
Pleural aspiration have visible pus,acidic pH
(pH < 7.2), low glucose and high LDH

Question 14

If empyema is causing acute pleural effusion what management should be done urgently

Answer 14

chest drain

Question 15

What is the conservative management of pleural effusion?

Answer 15

small effusions will resolve with treatment of the underlying cause

Question 16

How to manage transudative effusions?

Answer 16

Treat the underlying cause
* If effusion resolves, stop or reduce treatment
* If effusion persists, then therapeutic aspiration/drainage is required

Question 17

When to use pleural aspiration as treatment

Answer 17

temporarily relieve the pressure but the effusion may recur and repeated aspiration may be required

Question 18

When to use a chest drain?

Answer 18

• 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

Question 19

What can you see on CXR that suggest pleural effusion?

Answer 19

• 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