pleural effusion Flashcards
percussion presents like
Stony dull to percussion of the right side of the chest
list some sign of pleural effusion
General inspection: the patient may be in respiratory distress and tachypnoeic.
On examination of the chest:
The trachea is central or deviated away from the affected side (if large).
Chest expansion is reduced on the affected side.
The percussion note is stony dull on the affected side.
On auscultation there are reduced/absent breath sounds over the effusion. There may be bronchial breathing at the upper border of the pleural effusion.
Vocal resonance/tactile vocal fremitus is reduced over the effusion.
Whilst examining the patient it is also important to look for underlying clues as to the aetiology of the effusion, such as: pyrexia (suggestive of infection), cachexia and clubbing (suggestive of malignancy), raised JVP and ankle oedema (suggestive of heart failure).
pH under 7.2 indicates if drained from a pleural effsuion
empyema
Glucose: low in rheumatoid arthritis, TB, or malignancy
pH: <7.2 in empyema
Amylase: raised in pancreatitis
Immunology: rheumatoid factor is useful if rheumatoid arthritis is suspected; anti-nuclear antibody (ANA) is useful if systemic lupus erythematosus (SLE) is suspected; complement is typically low in pleural effusions caused by rheumatoid arthritis or SLE.
A 60 year old male patient is brought to the emergency department by his wife with confusion. His wife also reports that he has lost approximately 5 kg in the last 2 months and has been complaining of a cough. He has no past medical history of note. He smokes 15 cigarettes per day.
The patient is tachypnoeic but apyrexial. Physical examination reveals dullness to percussion and quiet breath sounds over the right lung base.
Given the most likely diagnosis, which of the following pleural fluid investigations is likely to be abnormal?
lung cancer so cytology of pleural fluid
what is a para=pneumonic effusion
A parapneumonic effusion is a pleural effusion that forms in the pleural space adjacent to a pneumonia.
Pleural fluid LDH : serum LDH ratio
A pleural fluid/serum LDH ratio greater than 0.6 suggests an exudate, whereas the ratio is usually less than 0.6 in a transudate. Similarly, a pleural fluid LDH level greater than 67% of the upper limit of the normal level for serum LDH suggests an exudate.
indicative of lung or pleural tissue damage and endothelial injury
A pH of 7.60-7.64. Protein content of less than 2% (1-2 g/dL)15 Oct 2021
what cause tends to be bilateral
liver cirrhosis
if clear evidence that pleural effusion caused by heart failure what is the best test
echo
is heart failure worse when lying down
yes
what is required in most cases to determine the cause of a pleural effusion
Pleural fluid aspirate via thoracocentesis is required in most patients to determine the cause of the pleural effusion, except when there is clear evidence of heart failure.
A 20 year old female of Asian ethnicity is referred to the respiratory clinic with a 2 week history of shortness of breath. She has also noticed fatigue, musculoskeletal pain, and a facial rash over the last 2 months.
On physical examination there is an erythematous rash over the bridge of the nose, sparing the nasolabial folds, and multiple oral ulcers. On examination of the chest there is a dull percussion note and reduced breath sounds at the left lung base.
Given the most likely underlying diagnosis, which of the following is most likely to be present in the pleural fluid?
low complement SLE
A 42-year-old woman presents to A&E with a one-week history of worsening shortness of breath. In addition, over the last two months, she has noticed unintentional weight gain and feeling excessively tired.
Her vital signs reveal a heart rate of 50 and respiratory rate of 22. On examination, there is mild use of accessory muscles of respiration and on the left-hand side there is reduced chest expansion, stony dullness to percussion and reduced breath sounds.
An ultrasound-guided pleural aspirate is taken and reveals a pleural protein level of 24 g/L.
Which of the following is the most likely diagnosis?
hypothyroidism
A 73 year old female patient presents to the Emergency Department with decreased exercise tolerance and shortness of breath over the past week. On examination of the chest she has dullness to percussion over the right base.
Given the most likely diagnosis, which investigation would be most useful to identify it’s underlying aetiology?
Aspiration with testing of the sample for protein and lactate dehydrogenase (LDH) + culture
The best test to understand the origins of a pleural effusion is to perform an aspiration and to test the fluid, primarily for protein levels. With this information you can then categorise the effusion as either transudative (protein <25g/L) or exudative (protein >35g/L). If the protein level is between 25-35g/L you use Light’s criteria to establish the type of effusion.
Exudative if >=1 of the following criteria are met:
Pleural fluid protein/ serum protein >0.5
Pleural fluid/serum LDH >0.6
Pleural fluid LDH >2/3 upper limit of normal serum LDH
Transudative if none of the above levels are met.
Exudative effusions are primarily caused by infection or malignancy, they can more rarely be associated with rheumatoid arthritis and pancreatitis.
Transudative effusions are primarily associated with heart, liver or kidney failure, or as a result of malnutrition or nephrotic syndromes (due to low albumin levels)
