Pleural Effusion

Question 1

How do you classify pleural effusion?

Answer 1

transudate or exudate according to the protein concentration

Question 2

What is Transudate pleural effusion?

Answer 2

< 30g/L protein

Question 3

What is the most common transudate pleural effusion cause?

Answer 3

heart failure

Question 4

What are the causes of transudate pleural effusion?

Answer 4

heart failure (most common transudate cause)
hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
hypothyroidism
Meigs’ syndrome

Question 5

What is exudate pleural effusion?

Answer 5

> 30g/L protein

Question 6

What is the most common exudate pleural effusion cause?

Answer 6

pneumonia

Question 7

What are the causes of exudate pleural effusion?

Answer 7

infection: pneumonia (most common exudate cause), TB, subphrenic abscess
connective tissue disease: RA, SLE
neoplasia: lung cancer, mesothelioma, metastases
pancreatitis
pulmonary embolism
Dressler’s syndrome
yellow nail syndrome

Question 8

What are the features of pleural effusion?

Answer 8

dyspnoea, non-productive cough or chest pain are possible presenting symptoms
classic examination findings include dullness to percussion, reduced breath sounds and reduced chest expansion

Question 9

AP CXR should be performed in all patients with suspected pleural effusiion

Answer 9

false!

posterioranterior (PA) chest x-rays should be performed in all patients

Question 10

What investigation increases the likelihood of successful pleural aspiration?

Answer 10

US is reccomended

sensitive for detecting pleural fluid septations

Question 11

Which investigation is useful for investigate the underlying cause?

Answer 11

CT contrast

particularly for exudative effusions

Question 12

What needle is used for pleural aspiration?

Answer 12

a 21G needle and 50ml syringe

Question 13

What should fluid from pleural aspirate be sent for?

Answer 13

pH, protein, lactate dehydrogenase (LDH), cytology and microbiology

Question 14

In pleural fluid low glucose is a common finding in?

Answer 14

rheumatoid arthritis, tuberculosis

Question 15

In pleural fluid raised amylase is a common finding in?

Answer 15

pancreatitis, oesophageal perforation

Question 16

In pleural fluid heavy blood staining is a common finding in?

Answer 16

mesothelioma, pulmonary embolism, tuberculosis

Question 17

All patients with a pleural effusion in association with sepsis or a pneumonic illness require what?

Answer 17

diagnostic pleural fluid sampling

Question 18

When should you be place a chest tube for drainage?

Answer 18

if the fluid is purulent or turbid/cloudy

if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection

Question 19

What are the options for managing recurrent pleural effusion?

Answer 19

recurrent aspiration
pleurodesis
indwelling pleural catheter
drug management to alleviate symptoms e.g. opioids to relieve dyspnoea

Question 20

Which criteria is used for borderline cases?

Answer 20

Light’s criteria

if the protein level is between 25-35 g/L, Light’s criteria should be applied

Question 21

An exudate is likely if at least one of the following criteria are met:

Answer 21

pleural fluid protein divided by serum protein >0.5
pleural fluid LDH divided by serum LDH >0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH