Pleural Effusion

Question 1

What are the symptoms of a pleural effusion?

Answer 1

SOB, chest pain, haemoptysis, cough, weight loss, fever and lethargy

Question 2

What are parts of the history and examination of a pleural effusion?

Answer 2

History – Onset (did they have a fall, change in medication or recent travel), any red flag symptoms, PMH (cancer or TB), occupational exposure?
Examination - on systemic examination, look for clubbing, ascites and lymphadenopathy. Then preform cardiovascular and resp exam.

Question 3

Explain the lights criteria

Answer 3

It is the criteria which determines whether fluid is exudate. It is classed as exudate if it has one of the following: fluid protein to serum protein ration over 0.5. Fluid LDH to serum LDH ratio of over 0.6. and if the fluid LDH is over 2/3rds of maximum serum normal. Therefore always need to send paired samples.

Question 4

What are the typical causes of an exudate fluid?

Answer 4

Exudate – think extra substance. Examples include: Malignancy, infection, empyema (pus), TB, haemothorax, PE.

Question 5

What are the typical causes of transudate fluid?

Answer 5

Transudate – think high pressure system. Examples include: Heart failure, cirrhosis, and renal failure (the 3 failures) or hypothyroidism or hypoalbuminaemia.

Question 6

What are the investigations for a pleural effusion?

Answer 6

• Imaging,
• Bloods
• Sampling: Never drain an undiagnosed effusion as it can limit further diagnostic tests eg, local anaesthetic thoracoscopy.

Question 7

What is the D sign?

Answer 7

It is a radiological sign where a pleural effusion is held in place by a thickened wall. Indicated infection

Question 8

What is a thoracoscopy and when is it indicated?

Answer 8

It is an investigation where there is direct visual examination of the pleura with a thoracoscopy. It is preformed under local anaesthesia and mild sedation. Allows for direct visualisation of pleural space, biopsies to be taken and definitive management. It is indicated in undiagnosed cytology negative pleural effusions.

Question 9

What is the treatment for a pleural effusion?

Answer 9

It depends on the cause and fitness of patient. It also depends whether it is a parapneumonic effusion, empyema or malignant pleural effusion.

Question 10

What are the potential causes of a malignant pleural effusion?

Answer 10

Primary pleural malignancy (mesothelioma) which is incurable and managed with supportive treatment only. Metastatic spread which commonly spreads from lung but can spread from breast or ovary.

Question 11

What is the diagnosis and management of malignant pleural effusions?

Answer 11

Diagnosis – aspiration and may need tissue biopsy for genetics.
Management – Chest drain +/- talk pleurodesis (talc between pleura). Or patient can have an indwelling pleural catheter.

Question 12

What is a complex parapneumonic effusion?

Answer 12

Occurs in pneumonia. Pleural fluid has a pH less than 7.2, LDH over 1000 and glucose less than 2.2. (if fluid is acidotic or low in glucose then think infection!) It appears with lots of septae on ultrasound and always requires a drain.

Question 13

What is empyema and the management?

Answer 13

Pleural effusion with presence of pus/bacteria. 15% mortality. Management includes drainage, IV antibiotics, fibrinolytics (if fluid is too thick to drain via chest drain) and surgery (again if fluid is too thick)

Question 14

What should the normal protein levels of pleural fluid be?

Answer 14

1-2g/dL

Question 15

What are the protein levels of a transudate fluid and an exudative fluid?

Answer 15

Transudate <30g/dL.
Exudate >30g/dL