PLEURAL EFFUSION

Question 1

Considerations for the Critially Ill Pleural Effusion

Answer 1

A - generally do not affect airway patency. May require a ramped or upright approach.

B - Emergent thoracentesis if in extremis or respiratory distress

Urgent tube thoracostomy for complex parapneumonic effusion / empyema, chylothorax, or hemothorax

Question 2

DDx Pleural Effusion

Answer 2

Hemothorax

Parapneumonic effusion or empyema

CHF
Malignancy
Urinothorax
Chylothorax
Pulmonary Embolism

Question 3

Clinical Features

Answer 3

Dyspnea
Cough
Pleuritic Chest pain most likely assiciated with exudative pleural effusion

Asymmetric chest expansion (LR 8.3)

Diminished vocal resonance (LR 6.5)

Reduced tactile fremitus (LR 5.7)

Diminished or absent breath sounds (LR 5.2)

Dullness to percussion (LR 4.8)

Question 4

History

Answer 4

Screen for:
Trauma

Acute onset symptoms, fever, cough, sick contacts

Bilateral leg swelling, orthopnea, PND, h/o chf

Weight loss, night sweats, history of malignancy or immunocompromise

U/L leg swelling, recent hospitalizations, surgeries, sudden onset pleuritic chest pain

Recent thoracic surgical procedures, TPN

Question 5

Investigations

Answer 5

CBC
Coags
Creatinine, K
Trops
ECG
Pro BNP
Lipase

Thoracentesis

CXR

POCUS

Chest CT

Question 6

CXR Features and sensitivities

Answer 6

Left Lateral Decubitus Position: highest sensitivity. Detects as little as 5-10 mL

Lateral Upright: Detects up to 50-75 mL

Standard Upright: Detects up to 175-200 mL

Supine: only 67% Sn. Requires minimum 500-525 mL

Question 7

Pleural Ultrasound Features

Answer 7

92-94% Sensitive

Can detect as little as 5-20 mL of fluid

Question 8

Thoracentesis: Investigations

Answer 8

Serum:
Protein
LDH

Pleural:
Protein
LDH
Cell Count
Gram Stain
Culture
pH

Send to lab immediated in an arterial blood gas syringe, on ice

Other investigations:
Pleural
cholesterol
triglycerides
glucose
adenosine deaminase
creatinine
cytology
amylase

Question 9

Management: Community Acquired Empyema, Hospital / Postprocedural

Answer 9

Community Acquired:
Option 1:
Ceftriaxone 1-2 g IV q24h PLUS
Clindamycin 600 mg IV q8h or
Metronidazole 15 mg/kg IV once, then 7.5 mg/kg IV q6h (MAX 4 g/d)

Option 2:
Ampicillin-sulbactam 1.5-3 g IV q6h

Hospital / Postprocedural:
Vancomycin loading dose 25-30 mg/kg IV followed by 15-20 mg/kg IV q8h (adjust based on vancomycin levels)
PLUS piperacillin-tazobactam 4.5 g IV q6h (note dosage adjustment needed in renal insufficiency).

Question 10

Management: Malignant Pleural Effusion

Answer 10

Therapeutic Thoracentesis

Question 11

Disposition: Discharge Criteria

Answer 11

clinically stable without obvious infection, discharge home may be appropriate if follow-up is available

Question 12

Disposition: Admission Criteria

Answer 12

parapneumonic pleural effusion or empyema should be admitted for further evaluation and treatment