Pleural effusion Flashcards

1
Q

What is pleural effusion?

A

Fluid collecting between parietal + visceral pleura

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2
Q

What are the 2 types of fluid pleural effusions can be classified upon?

A

Transudate: <30g/L protein

Exudate: >30g/L protein

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3
Q

What mechanism causes an exudate?

A

Inflammation causes increased permeability of pleural capillaries- leaking intravascular fluid (cells, their contents + proteins)

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4
Q

What mechanism causes a transudate?

A

Hydrostatic forces cause extravasation of fluid through a normal membrane

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5
Q

Give 4 causes of transudative pleural effusion

A

HF (most common)
Hypoalbuminaemia
Hypothyroidism
Meig’s syndrome

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6
Q

Give 3 causes of hypoalbuminaemia

A

Liver disease
Nephrotic syndrome
Malabsorption

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7
Q

Give 7 causes of exudative pleural effusion

A

Infection
Malignancy
CTDs: RhA + SLE
PE
Pancreatitis
Dressler’s syndrome
Yellow nail syndrome

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8
Q

Give 3 infectious causes of pleural effusion

A

Pneumonia (most common exudative cause)
TB
Subphrenic abscess

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9
Q

List 3 types of malignancy that can cause exudative pleural effusion

A

Lung cancer
Mesothelioma
Mets

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10
Q

What criteria is used to determine if the fluid is an exudate?

A

Light’s criteria
Ratio of pleural fluid to serum protein >0.5
Ratio of pleural fluid to serum LDH >0.6
Pleural fluid LDH >2/3 the upper limit of normal serum value

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11
Q

What is indicated by frankly purulent fluid?

A

Empyema

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12
Q

What is indicated by milky fluid? What is this likely caused by?

A

Chylothorax or pseudochylothorax
Lymphatic obstruction secondary to malignancy, chronic inflammation or thoracic duct injury

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13
Q

What is indicated by bloody fluid?

A

Trauma
(Less commonly TB, PE, aortic dissection, ruptured aortic aneurysm, malignancy)

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14
Q

What does the presence of food particles indicate?

A

Oesophageal rupture

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15
Q

What is black pleural fluid indicative of?

A

Extremely rare!
Aspergillus niger infection
Malignant melanoma
Haemorrhage + haemolytic a/w non-small cell lung cancer

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16
Q

What does pleural fluid LDH level >1000 IU/L indicate?

A

Empyema
Malignancy
Rheumatoid effusion

17
Q

Give 3 symptoms of pleural effusion

A

Dyspnoea
Non-productive cough
Chest pain

18
Q

Give 3 signs of pleural effusion

A

Dullness to percussion
Reduced breath sounds
Reduced chest expansion

19
Q

What investigations should be performed in pleural effusion?

A

PA CXR
+/- US
+/- Contrast CT

20
Q

Why is US recommended in pleural effusions?

A

Increases likelihood of successful pleural aspiration + is sensitive for detecting pleural fluid septations

21
Q

Why is CT increasingly performed in pleural effusion?

A

Ix underlying cause, esp if exudative

22
Q

When should Light’s criteria be used?

A

Protein level 25-35g/L

23
Q

How should pleural aspiration be performed?

A

US guided
21G needle + 50ml syringe
Fluid sent for pH, protein, LDH, cytology + microbiology

24
Q

What does low glucose in pleural fluid indicate?

A

Empyema
RhA
TB

25
Q

What does raised amylase in pleural fluid indicate?

A

Pancreatitis
Oesophageal perforation

26
Q

What is first line management for pleural effusion caused by congestive HF?
What should be considered if symptomatic, large effusion?

A

Furosemide PO/ IV

Consider therapeutic thoracentesis

27
Q

What is first line management for pleural effusion caused by infection?

A

IV Abx: Co-amoxiclav + Metronidazole IV

Therapeutic thoracentesis if clinical deterioration/ increasing fluid

28
Q

What do all patients with a pleural effusion in a/w sepsis or pneumonic illness require?

A

Diagnostic pleural fluid sampling
Purulent or turbid/ cloudy: insert chest drain
Clear but pH <7.2: insert chest drain

29
Q

Give 4 options for managing patients with recurrent pleural effusions

A

Recurrent aspiration
Pleurodesis
Indwelling pleural catheter
Drug Mx to alleviate Sx e.g. opioids to relieve dyspnoea

30
Q

What is first line management for pleural effusion caused by malignancy in a patient with poor performance status?

A

Therapeutic thoracentesis

31
Q

What is first line management for pleural effusion caused by malignancy in a patient with good performance status?

A

Insertion of temporary chest tube + when drained, talc pleurodesis

32
Q

What is pleurodesis?

A

Procedure to obliterate the pleural space

33
Q

Name a complication of rapid drainage via chest drain insertion in pleural effusion

A

Re-expansion pulmonary oedema
due to lung interstitial damage plus hydrostatic imbalance that occur following rapid expansion of the underlying collapsed lung

34
Q

When should re-expansion pulmonary oedema be suspected?

A

Onset of cough +/- SOB

35
Q

Describe management of suspected re-expansion pulmonary oedema

A

Clamp chest drain
Urgent CXR

36
Q

How can re-expansion pulmonary oedema be avoided?

A

Drain tubing should be clamped regularly in the event of rapid fluid output
i.e. drain output should not exceed 1L of fluid over a short period of time (<6h).