Pleural Effusion

Question 1

Pleural Effusion

What can cause it?

5

Answer 1

• congestive heart failure
• pneumonia
• cancer
• cirrhosis
• kidney disease

Question 2

Pleural Effusion

What is a trasudate? Why does it occur?

Answer 2

when water leaves the capillaries
- high hydrostatic pressure
- low oncotic pressure

Question 3

Pleural Effusion

What is an exudate? Why does it occur?

Answer 3

when capillary walls become leaky and immune cells / protein leakes out
- inflammation

Question 4

Pleural Effusion

How can we divide exudate effusions?

Answer 4

• parapneumonic effusions
• malignant effusions
• inflammatory effusions
• chylous effusions.

Question 5

Pleural Effusion

How do we manage a pleural effusion in an emergency?

Answer 5

ABCDE to stabilise

If unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access and provide supplemental oxygen, if needed. Finally, put your patient on continuous vital sign monitoring, including heart rate, blood pressure, and pulse oximetry.

Question 6

Pleural Effusion

How do we manage pleural effusion when a pt is stable?

Answer 6

acute management:
- obtaining IV access
- providing supplemental oxygen
- initiating continuous vital sign monitoring

Next, you should perform a focused history and physical, and order labs, including a CBC.

Question 7

Pleural Effusion

What is the typical presentation?

Answer 7

• cough
• SOB
• pleuritic chest pain
• ± fever

Question 8

Pleural Effusion

What are some physical exam findings?

Answer 8

• dullness to chest percussion
• decreased tactile fremitus
• absent basilar breath sounds on the affected side.

Question 9

Pleural Effusion

What might CBC show?

Answer 9

leukocytosis

Question 10

Pleural Effusion

What are some imaging studies we can order?

Answer 10

• CXR
• POCUS
• CT

Question 11

Pleural Effusion

What might a CXR show?

Answer 11

• blunting of the cardiophrenic and costophrenic angles
• meniscus sign

A chest X-ray might not show a pleural effusion until at least 250 ml of fluid has accumulated.

Question 12

Pleural Effusion

What position of x-ray might better show a small effusion on a CXR?

Answer 12

lateral decubitus
might also help you determine if the fluid is loculated

Question 13

Pleural Effusion

What might you see on POCUS?

Answer 13

• a fluid-filled, or anechoic, collection just above the diaphragm
• a spine sign

can detect as little as 5 mL

a spine sign, which refers to the visualization of the part of the thoracic spine due to the presence of fluid that is typically obscured by air in the lungs.

Question 14

Pleural Effusion

What might we use a CT for?

Answer 14

find the underlying cause, and aid in potential treatment such as thoracentesis or chest drains

Question 15

Pleural Effusion

What are some physical exam findings of CHF?

Answer 15

tachypnea, jugular venous distension, peripheral edema, rales, or an S3 heart sound

Question 16

Pleural Effusion

How do we manage CHF?

Answer 16

diuretics

Question 17

Pleural Effusion

If a pt with CHF does not response to diuretics, what is the next step?

Answer 17

if your patient has an inadequate response, with no reduction of pleural fluid, proceed with a therapeutic thoracentesis.

Question 18

Pleural Effusions

Large effusions may reaccumulate despite therapeutic thoracentesis. If this is the case, what might the next step be for your pt?

Answer 18

your patient may need to be evaluated by the surgery team for a chest tube or video-assisted thoracoscopic surgery, or VATs for short.

Question 19

Pleural Effusion

If a pt does not have CHF, what do we do?

Answer 19

proceed with diagnostic and therapeutic thoracentesis

This includes removing accumulated fluid from the pleural cavity, and sending it for lab analysis.

Question 20

Pleural Effusion

What do we investigate for in the pleural fluid and why?

Answer 20

a cell count with differential, total protein, LDH, glucose, and cholesterol and triglycerides. At the same time, order serum total protein and LDH.

Question 21

Pleural Effusion

What criteria do we use to determine if the fluid is an exudate or a transudate?
What are the specific criteria?

Answer 21

Light’s criteria

Question 22

Pleural Effusion

What are the values that differentiate a transudate or exudate?

Answer 22

Question 23

Pleural Effusion

What conditions might cause a transdute?

Answer 23

CHF, cirrhosis, or nephrotic syndrome

Question 24

Pleural Effusion

If a pt has a transudate, but its not clear if they have CHF, what do you do?

Answer 24

order a test called the pleural NT-proBNP.

If the value is greater than 1300 to 4000 pg/mL, it confirms a CHF diagnosis.

Question 25

# Pleural Effusion If a pt has a transudate, and they dont have CHF, what might be the cause?

Answer 25

* hypoalbuminemia * hepatic hydrothorax * peritoneal dialysis.

Question 26

# Pleural Effusion When does an exudate occur?

Answer 26

increased capillary permeability and compromised lymphatic drainage.

Question 27

# Pleural Effusion What might cause an exudative effusion?

Answer 27

* malignancy * pneumonia * tuberculosis * ARDS * pancreatitis * trauma

Question 28

# Pleural Effusion What investigations do we use to determine the type of exudate?

Answer 28

additional pleural fluid studies like **cytology** and **gram stain**. You may also need to order pleural fluid **amylase** and **rheumatoid factor**.

Question 29

# Pleural Effusion What would the lab findings of a parapneumonic effusion be like?

Answer 29

Cytology: -ve malignant cells Gram stain: +ve Cell count: elevated WBCs with a neutrophil predominance. Glucose is usually low pleural fluid LDH is high, often above 1000 IU/L pleural protein is elevated.

Question 30

# Pleural Effusion What does the pH of a parapneumonic effusion mean?

Answer 30

* a pH higher than 7.2 means **uncomplicated parapneumonic effusion** * a pH lower than 7.2 indicates **complicated parapneumonic effusion.**

Question 31

# Pleural Effusion When might you suspect TB for the cause of an effusion and what might you then go on to test for it?

Answer 31

if the **pleural protein** is extremely high -> think TB test adenosine deaminase (**ADA**) levels in the pleural fluid.

Question 32

# Pleural Effusion What would the lab findings of a malignant effusion be like?

Answer 32

* Cytology: +ve malignant cells * Gram stain: -ve * Cell count: increased WBCs with a lymphocyte predominance. * The glucose might be decreased * pleural LDH is typically elevated, often over 1000 IU/L.

Question 33

# Pleural Effusion What would the lab findings of an inflammatory effusion be like?

Answer 33

Cytology: no malignant cells Gram stain: -ve The cell count: elevated WBCs

Question 34

# Pleural Effusion What might cause an inflammatory exudative effusion? What other markers might differentiate each cause?

Answer 34

- pancreatitis + ARDS *the pleural fluid amylase might be elevated.* - autoimmune diseases: SLE / RA *rheumatoid factor could be positive*

Question 35

# Pleural Effusion What would the lab findings of a chylous effusion be like?

Answer 35

Cytology: no malignant cells Gram stain: -ve - raised cholesterol + triglycerides are often elevated - milky-white pleural fluid,

Question 36

# Pleural Effusion What causes a chylous effusion?

Answer 36

chylothorax *(leakage of lymphatic fluid into the thoracic cavity)*

Question 37

# Pleural Effusion What is the presence of amylase in the pleural fluid diagnostic of?

Answer 37

esophageal rupture

Question 38

# Pleural Effusion How can we use the haemocrit to diagnise haemothorax?

Answer 38

pleural fluid hematocrit >0.5x serum hematocrit