Pleural Effusion Flashcards
What are the symptoms and signs of a pleural effusion?
Symptoms - SOB, chest pain, haemoptysis, cough, weight loss, fever and lethargy.
Signs - Pyrexia, cachexia, raised JVP, stoney dull percussion, absent breath sounds, reduced vocal resonance.
What are the causes of a transudative pleural effusion
Heart failure - most common,
Hypoalbuminaemia - liver disease, nephrotic syndrome, malabsorption,
Hypothyroidism
Meig’s syndrome
The 3 failures - heart, liver and kidney.
What are the protein levels seen in a transudative/exudative fluid?
Transudate < 30g/L - more likely to be bilateral
Exudate >30g/L - More likely to be unilateral
What are the causes of an exudative pleural effusion?
E for extra!
Infection - pneumonia, tuberculosis, subphrenic abscess.
Malignancy - Lung cancer or mets.
Connective tissue disease - RA or SLE.
Pulmonary infarction - due to PE.
Chylothorax - usually secondary to trauma to lymphatic system.
Pancreatitis.
Dressler’s syndrome.
Oesophageal perforation
What are the investigations for a pleural effusion?
Imaging - CXR is first line. Can do thoracic US or CT
Bloods
Sampling: Never drain an undiagnosed effusion as it can limit further diagnostic tests eg, local anaesthetic thoracoscopy.
Explain the lights criteria
Determines whether fluid is exudate. It is classed as exudate if it has one of the following:
1. Fluid protein to serum protein ration over 0.5.
2. Fluid LDH to serum LDH ratio of over 0.6.
3. Fluid LDH is over 2/3rds of maximum serum normal. Therefore always need to send paired samples.
Prove please, please, please…this fluid is exudative. PRO-Protein. Prove has 5 letters so 0.5
Please has 6 letters so 0.6
What is the D sign?
It is a radiological sign where a pleural effusion is held in place by a thickened wall. Indicated infection
What are some other characteristic pleural fluid findings?
Low glucose - RA, tuberculosis
Raised amylase - Pancreatitis, oesophageal perforation.
Heavy blood staining - Mesothelioma, PE, TB
When should a chest drain be placed for a pleural effusions?
If fluid is purulent/turbid or if fluid is clear by pH is less than 7.2
What is the management for recurrent pleural effusions?
Recurrent aspiration, pleurodesis, indwelling pleural catheter and drug management to alleviate symptoms (opioids to relieve dyspnoea).
What is a thoracoscopy and when is it indicated?
t is an investigation where there is direct visual examination of the pleura with a thoracoscopy. It is preformed under local anaesthesia and mild sedation. Allows for direct visualisation of pleural space, biopsies to be taken and definitive management. It is indicated in undiagnosed cytology negative pleural effusions.
What are the potential causes of a malignant pleural effusion?
Primary pleural malignancy (mesothelioma) which is incurable and managed with supportive treatment only. Metastatic spread which commonly spreads from lung but can spread from breast or ovary.
What is the diagnosis and management of malignant pleural effusions?
Diagnosis – aspiration and may need tissue biopsy for genetics.
Management – Chest drain +/- talk pleurodesis (talc between pleura). Or patient can have an indwelling pleural catheter.
What is a complex parapneumonic effusion?
Occurs in pneumonia.
Pleural fluid has a pH less than 7.2, LDH over 1000 and glucose less than 2.2. (if fluid is acidotic or low in glucose then think infection!) It appears with lots of septae on ultrasound and always requires a drain.
What is empyema and the management?
Pleural effusion with presence of pus/bacteria. 15% mortality. Management includes drainage, IV antibiotics, fibrinolytics (if fluid is too thick to drain via chest drain) and surgery (again if fluid is too thick)
