Pleural Effusion

Question 1

Describe Light’s criteria for determining transudate vs exudate

Answer 1

1. Fluid protein (serum) >0.5
2. Fluid LDH (serum) >0.6
3. Fluid LDH > 2/3 maximum serum total

• any 1 of 3 = exudate (meaning there is something causing increased pressure in the lung pushing fluid into the pleural space)

Question 2

Describe conditions that cause transudate pleural effusion

Answer 2

(Fluid overload)
- heart failure
- cirrhosis
- renal failure
- hypothyroidism
- hypoalbuminaemia

Question 3

What conditions cause exudate pleural effusion?

Answer 3

(Things that increase pressure)
- malignancy
- infection
- empyema (presence of pus/bacteria)
- TB
- haemothorax
- autoimmune causes
- PE
- post CABG/MI
- drug induced
- pancreatitis
- chylothorax

Question 4

What investigations would you do for pleural effusion?

Answer 4

• imaging
• bloods
• sampling (don’t drain until diagnosed)
• local anaesthetic thorascopy (looking at pleural space with camera)

Question 5

What do bilateral effusions usually suggest?

Answer 5

Transudate fluid

Question 6

Describe thorascopy

Answer 6

• direct visual examination of the pleura with a thorascope
• indicated in undiagnosed cytology negative pleural effusions
• performed under LA and mild sedation (direct visualisation of pleural space, biopsy of abnormal regions, definitive effusion management)
• highly diagnostic for malignant pleural disease

Question 7

What is the management of malignant pleural effusion?

Answer 7

• symptom driven and patient centred (no need to drain if patient is stable)
• chest drain with/without talc pleurodesis
• indwelling pleural catheter

Question 8

What are the signs of complex parapneumonia?

Answer 8

• pH <7.2 (indication for draining because bacteria is present)
• LDH >1000
• glucose <2.2
• loculated on US

Question 9

What is the management of empyema?

Answer 9

• drainage
• IV antibiotics
• fibrinolytics (to break up thick fluid that is not draining)
• surgery