Pleural Effusion Flashcards
What is a pleural effusion?
It is defined as a collection of fluid within the pleural cavity, which is associated with either increased fluid production or decreased fluid absorption
What are the two classifications of pleural effusion?
Transudate Pleural Effusion
Exudate Pleural Effusion
What is a transudate pleural effusion?
It is defined as a collection of fluid within the pleural cavity, with a relatively low protein count < 25g/L
Fluid protein/serum protein ratio is < 0.5
What is the general cause of transudate pleural effusions?
They are related to fluid movement into the pleural space, resulting in disruption of the hydrostatic and oncotic pressures
How can we remember the general cause of transudate pleural effusions?
‘Trans’ = movement
What are the five conditions associated with transudate pleural effusions?
Congestive Heart Failure
Liver Failure
Hypoalbuminaemia
Hypothyroidism
Meigs’ Syndrome
What is the most commonly associated condition with transudate pleural effusions?
Congestive heart failure
What are the three causes of hypoalbuminaemia?
Liver disease
Nephrotic syndrome
Malabsorption
What is Meigs’ syndrome?
It is defined as a right sided pleural effusion with ovarian malignancy
Are transudate pleural effusions - unilateral or bilateral?
Bilateral
What is an exudate pleural effusion?
It is defined as a collection of fluid within the pleural cavity, with a relatively high protein count > 35g/L
Fluid protein/serum protein ratio is > 0.5
What is the general cause of exudate pleural effusions?
Inflammation, which results in increased pleural and capillary permeability
This means that protein can leak out of the tissue into the pleural space
What are the seven conditions associated with exudate pleural effusions?
Lung Infection
Connective Tissue Disease
Malignancy
Pulmonary Embolism
Pancreatitis
Dressler’s Syndrome
Yellow Nail Syndrome
What two lung infections are associated with exudate pleural effusions?
Pneumonia
TB
What is the most commonly associated condition with exudate pleural effusions?
Pneumonia
What two connective tissue diseases are associated with exudate pleural effusions?
Rheumatoid arthritis
Systemic lupus erythematous
What two malignancies are associated with exudate pleural effusions?
Lung cancer
Mesothelioma
Are exudate pleural effusions - unilateral or bilateral?
Unilateral
What are the seven clinical features of pleural effusions?
Dyspnoea
Dry Cough
Pleuritic Chest Pain
Percussion Stony Dullness
Tracheal Deviation
Reduced Breath Sounds
Reduced Chest Expansion
What side does the trachea deviate to in pleural effusions?
It deviates away from the effusion
What clinical feature indicates a severe pleural effusion?
Trachea deviation
What are the three investigations used to diagnose pleural effusions?
Chest X-Ray (CXR)
Ultrasound Scan
Fluid Aspiration
What are the four signs of pleural effusion on a CXR?
Costophrenic Angle Blunting
Fluid In Lung Fissures
Meniscus Sign
Tracheal & Mediastinal Deviation
What are the costophrenic angles?
They are the places where the diaphragm meets the ribs
How do costophrenic angles usually appear on CXR?
A sharply-pointed, downward indentation between each hemi-diaphragm
What is a lung fissure?
A double fold of visceral pleura that either completely or incompletely invaginate lung parenchyma to form the lung lobes
What is the meniscus sign?
It is as an upward curving concave line that obscures the costophrenic angle and part/all of the hemidiaphgram
What two CXR signs indicate a severe pleural effusion?
Meniscus sign
Trachea deviation
What are the three signs of pleural effusion on US?
Pleural Cavity Granulation
Pleural Cavity Loculations
Unclear Pleural Cavity Border
How does the pleural cavity usually appear on US?
Black
How do pleural cavity granulations appear on US?
The pleural cavity is grey/white instead of black
What are pleural cavity loculations?
It is defined as the presence of fibrotic scar tissue in the pleural cavity
What is fluid aspiration?
It involves collecting a sample of pleural fluid via the insertion of a needle
It is usually conducted under ultrasound guidance
Which two pieces of equipment are used to conduct fluid aspiration in pleural effusion?
Green 21G needle
50ml syringe
What information does fluid aspirate inspection give us about the pleural effusion?
The underlying cause
What does straw coloured pleural fluid aspirate indicate?
No pleural effusion
What cause of pleural effusion is indicated with cloudly coloured aspirate?
Infection
What three causes of pleural effusion are indicated with blood stained aspirate?
Malignancy
Pulmonary Embolism
Trauma
What cause of pleural effusion is indicated with pus stained aspirate?
Empyema
What information does fluid aspirate biochemistry give us about the pleural effusion?
It enables us to distinguish between the pleural effusion classifications
What protein level indicates transudate pleural effusions?
< 25g/L
What LDH level indicates transudate pleural effusions?
Normal levels
What protein level indicates exudate pleural effusions?
> 35g/L
What LDH level indicates exudate pleural effusions?
Increased levels
What is Light’s criteria?
It is defined as a list of criteria to determine exudate pleural effusion diagnosis
It states that if one or more of the following criteria are met then the fluid is an exudate
What are the three Light’s criteria?
Fluid Protein/Serum Protein > 0.5
Fluid LDH/Serum LDH > 0.6
Fluid LDH 2/3 Upper Limit of Normal Serum LDH
In which pleural effusions patients do we recommend no treatment in?
In individuals who have smaller pleural effusions, with the absence of clinical features
What are the two pharmacological management options for pleural effusion? When do we administer them?
Diuretics (Heart Failure)
Antibiotics (Infection)
How is fluid aspiration used to manage pleural effusions?
It can temporarily relieve the pressure in the pleural space
What is the disadvantage of fluid aspiration to manage pleural effusion?
The effusion may reoccur, and repeated aspiration may be required
What is a chest drain?
It involves collecting a sample of pleural fluid via the insertion of a drain
It is usually conducted under ultrasound guidance
How much fluid do we remove from a chest drain to treat pleural effusions? Why?
One and a half litres
If more fluid is removed, hypotension and pulmonary oedema can occur
Where are chest drains inserted?
‘Triangle of safety’
What are the three borders that form the triangle of safety?
5th Intercostal Space
Mid-Axillary Line
Anterior Axillary Line
What anatomical landmark is used to locate the 5th intercostal space?
Inferior nipple border
Which border of the ‘triangle of safety’ does the 5th intercostal space form?
Inferior
What anatomical landmark is used to locate the mid-axillary line?
Lateral edge of the latissimus dorsi
What anatomical landmark is used to locate the anterior axillary line?
Lateral edge of the pectoris major
Which border of the ‘triangle of safety’ does the mid-axillary line form?
Lateral border
Which border of the ‘triangle of safety’ does the anterior axillary line form?
Anterior border
What investigation should be conduced after insertion of a chest drain? Why?
CXR
To confirm correct positioning
Do we insert the chest drain needle above or below the rib? Why?
Above the rib
To avoid the neurovascular bundle that runs just below the rib, containing the long thoracic nerve
What occurs when there is damage to the long thoracic nerve?
Winging of the scapula
What is pleurodesis?
It involves insertion of a mildly irritant drug into the pleural space, in the aim to cause inflammation of the visceral and parietal pleura
This will cause bonding of these two surfaces, in the aim to seal the pleural space between them and prevent further collection of fluid
In what two ways can we conduct pleurodesis?
Chest drain
Medical thoracoscopy
What surgery is used to treat pleural effusion?
Video-Assisted Thoracic Surgery (VATS)
What is VATS?
It is defined as a minimally invasive surgical technique used to diagnose and treat respiratory problems
How can VATS be used to treat pleural effusions?
This surgery can be used to seal the pleural space
What is empyema a classification of?
Parapneumonic effusion
What is empyema?
It is defined as pleural effusion development in relation to pneumonia infection
This results in a collection of pus within the pleural cavity
What are the five features that distinguish empyema from other pleural effusions?
Improving Pneumonia, New/Ongoing Fever
Pus In Pleural Fluid Aspirate
Pleural Fluid Aspirate < 7.2
Reduced Glucose Levels
Increased LDH Levels
What are the two management options for empyema?
Chest Drain
IV Antibiotics
