Pleural Effusion Flashcards
What is pleural effusion?
The abnormal accumulation of fluid in the pleural cavity between the lining of the lungs and the thoracic cavity
It involves the visceral and parietal pleurae.
What is the normal function of pleural fluid?
Helps lubricate the pleural cavity and facilitates lung movement within the thoracic space
A small amount of pleural fluid is normally present.
What causes excessive fluid accumulation in the pleural cavity?
An imbalance between the oncotic and hydrostatic forces that govern pleural fluid formation and lymphatic drainage
This imbalance can lead to either transudate or exudate formation.
What is a transudate?
Fluid that permeates into the pleural cavity through intact pulmonary vessels
Commonly seen in conditions like congestive heart failure (CHF).
What is an exudate?
Fluid that escapes into the pleural cavity through lesions in blood and lymph vessels
Often associated with inflammation or tumors.
Which imaging techniques are used to diagnose pleural effusion?
Chest x-ray, ultrasound, and chest CT
Chest CT may be used for very small effusions.
What is thoracentesis?
A procedure that serves as both a diagnostic and therapeutic intervention for pleural effusion
It allows for pleural fluid analysis and evacuation.
What are the two main purposes of thoracentesis?
Identify the underlying cause and provide symptomatic relief by evacuating excess pleural fluid
Analysis of pleural fluid can help in diagnosis.
What is the primary focus of treatment for pleural effusion?
Treating the underlying condition causing the pleural effusion
Management may vary based on the specific cause.
What is pleural effusion?
An excessive amount of fluid between pleural layers that impairs the expansion of the lungs
Pleural effusion can result from various underlying conditions.
What are the two main types of pleural effusion?
Transudative and exudative pleural effusion
These classifications are based on the underlying pathology and characteristics of the pleural fluid.
What is a common cause of transudative pleural effusion?
Congestive heart failure
Other causes include low protein states and chronic kidney or liver disease.
What is a common cause of exudative pleural effusion?
Pulmonary infections
Malignancy of pulmonary or metastatic origin is also a significant cause.
What does increased capillary hydrostatic pressure lead to?
Transudative pleural effusion
This condition can occur due to factors like congestive heart failure.
Fill in the blank: A pleural fluid protein/serum protein ratio of _____ indicates exudative pleural effusion.
> 0.5
This criterion helps differentiate between transudative and exudative effusions.
What pleural fluid LDH/serum LDH ratio indicates exudative pleural effusion?
> 0.6
LDH levels in pleural fluid can indicate the nature of the effusion.
What is the pleural fluid LDH threshold for exudative pleural effusion?
> ⅔ the upper limit of normal serum LDH
This criterion is part of Light’s criteria for classifying pleural effusions.
True or False: Low protein states can lead to exudative pleural effusion.
False
Low protein states are associated with transudative pleural effusions.
What role does capillary permeability play in exudative pleural effusion?
Increased capillary permeability due to inflammation
This can occur in conditions like infections or malignancies.
What injury can lead to a type of pleural effusion known as hemothorax?
Injury
Hemothorax is a specific type of pleural effusion that involves blood.
What is pleural effusion?
Accumulation of fluid in the pleural space
Pleural effusion can be classified into transudative and exudative types based on the underlying causes.
Name one etiology of transudative effusions.
Congestive heart failure
Other causes include hepatic cirrhosis, nephrotic syndrome, and chronic kidney disease.
What are some rare causes of transudative pleural effusions?
Superior vena cava obstruction, myxedema
These conditions can lead to abnormal fluid accumulation in the pleural space.
What type of effusion is pneumonia associated with?
Exudative effusion
This is known as parapneumonic effusion.
List four infections that can cause exudative effusions.
- Tuberculosis
- Pleural empyema
- Parasitic illness
- Pneumonia
Parasitic illnesses include amebiasis and echinococcal disease.
What malignancies are associated with exudative effusions?
- Lung cancer
- Metastatic breast cancer
- Lymphoma
- Mesothelioma
- Ovarian cancer
These cancers can lead to fluid accumulation in the pleural space.
True or False: Pulmonary embolism can cause exudative pleural effusion.
True
Pulmonary embolism is one of the causes that can lead to exudative effusions.
Name two autoimmune diseases that can lead to exudative effusions.
- Systemic lupus erythematosus (SLE)
- Rheumatoid arthritis
These collagen vascular diseases can result in pleural effusion.
Fill in the blank: Trauma can lead to pleural effusion due to _______.
high vascular permeability
Trauma can increase the permeability of blood vessels, allowing fluid to enter the pleural space.
What is hemothorax?
Accumulation of blood in the pleural space
Hemothorax is a type of pleural effusion that occurs due to bleeding.
List two rare causes of pleural effusion.
- Postcardiac surgery
- Esophageal perforation
These rare events can lead to fluid accumulation in the pleural cavity.
What gynecological conditions can cause pleural effusion?
- Endometriosis
- Ruptured ectopic pregnancy
- Meigs syndrome
These conditions can lead to fluid buildup in the pleural space.
Whats the normal pleural fluid ?
10 ml
When does symptoms typically appear in case of pleural effusion ?
> 300 ml the patient will be symptomatic
Small pleural effusion can be detected through ?
CT scan
effusions < 200 mL may not be visible on frontal upright CXR.
What is pleural empyema ?
It is the accumulation of pus within a pleural cavity.
What is a common characteristic of patients with a small pleural effusion (< 300 mL)?
Often asymptomatic
Patients may not exhibit noticeable symptoms with a small pleural effusion.
What are some characteristic symptoms of pleural effusion?
- Dyspnea
- Symptoms of hypoxia
- Pleuritic chest pain
- Dry, nonproductive cough
- Symptoms of underlying disease
Symptoms may vary depending on the underlying condition, such as fever in empyema.
What physical exam finding indicates asymmetric expansion in pleural effusion?
Unilateral lagging on the affected side
This finding is noted during inspection and palpation.
What is reduced tactile fremitus associated with in pleural effusion?
Fluid in the pleural space
Tactile fremitus is decreased due to the presence of fluid.
What breath sound finding may be observed over the area of pleural effusion?
Faint or absent breath sounds
This is a typical auscultation finding in pleural effusion.
What sound may indicate inflamed pleural layers during auscultation?
Pleural friction rub
This sound occurs during inspiration and expiration.
What percussion finding is associated with pleural effusion?
Dullness over the area of effusion
Dullness is a common percussion finding in the presence of fluid.
What signs you would find of physical examination?
What is the primary imaging modality for detecting pleural effusion?
Chest x-ray
It is the standard initial imaging modality.
What is the most sensitive view for detecting fluid collections in pleural effusion?
Lateral decubitus view
This view allows for detection of fluid collections as small as 5 mL.
What are typical supportive findings on a chest x-ray for pleural effusion?
- Unilateral blunting of the costophrenic angle
- Homogeneous density with a meniscus-shaped margin (meniscus sign)
These findings are indicative of pleural effusion.
What indicates a large pleural effusion on imaging?
- Complete pacification of the lung
- Mediastinal shift
- Tracheal deviation away from the effusion
These signs suggest a significant volume of pleural fluid.
What additional diagnostic procedures may be considered if the diagnosis of pleural effusion remains unclear?
- Diagnostic thoracentesis
- Bronchoscopy
- Video-assisted thoracoscopic surgery (VATS)
These procedures can provide further information when initial imaging is inconclusive.
True or False: Supine chest x-rays have high sensitivity for detecting pleural effusions.
False
Supine CXR has poor sensitivity, and effusions < 200 mL may not be visible.
Fill in the blank: False positives for pleural effusions on CXR include _______.
- Elevated hemidiaphragm
- Atelectasis
- Consolidation
- Mass lesions
These conditions can mimic pleural effusion on imaging.
Massive pleural effusion with mediastinal shift
Pleural effusion with meniscus sign
What is a primary indication for thoracic ultrasound?
Quick bedside assessment
Additional indications include thoracentesis planning.
What ultrasound findings are suggestive of pleural effusion?
Hypoechoic or anechoic collection in the lower margins of the pleural cavity
Specifically observed in the costodiaphragmatic recess.
What is the sensitivity of thoracic ultrasound in detecting pleural effusion?
Can detect fluid amounts as low as 20 mL
True or False: Hemothorax and empyema appear homogeneous on ultrasound.
False
They may appear heterogeneous.
What additional features can thoracic ultrasound detect?
Pleural thickening and pleural nodules
How does thoracic ultrasound compare to chest x-ray for diagnosing effusions?
More sensitive for diagnosing effusions and estimating effusion size
Fill in the blank: False positives on ultrasound can occur if _______ is mistaken for pleural fluid.
subdiaphragmatic fluid (e.g., ascites), pericardial fluid, contained fluid (e.g., hypoechoic masses, abscesses), or pleural thickening
What may cause false negatives in thoracic ultrasound findings?
Clotted blood or empyema fluid mistaken for normal lung or liver tissue
What is the gold standard imaging technique for small effusions?
Chest CT
Use is limited due to radiation and contrast exposure.
What are some indications for using chest CT?
- Guiding placement of indwelling pleural catheters
- Directed thoracentesis of a loculated effusion
- Suspected parenchyma or pleural pathology
- Better quantification of fluid compared to CXR
What is usually sufficient for a chest CT procedure?
Chest CT without IV contrast
IV contrast is used to detect underlying malignancies.
What additional information does a CT angiogram provide?
Helps to identify vascular pathology
Examples include dissection or arteriovenous malformations (AVM).
What is the minimum amount of fluid that a chest CT can detect?
> 3-5 mL of fluid
What can fluid density measurement help differentiate?
Pleural effusion from empyema and hemothorax
True or False: Chest CT is the preferred method for quantifying pleural effusions compared to CXR.
True
Fill in the blank: Chest CT with IV contrast allows for the detection of underlying _______.
[malignancy]
Whats in difference between the exudate and transudate in the context of appearance and glucose level in pleural fluid analysis?
Exudate: cloudy < 60 mg
Transudate: clear > 60 mg
What is the WBC count in pleural fluid for a parapneumonic effusion?
> 10,000 cells/mm3
This indicates a significant inflammatory response in the pleural space.
What percentage of neutrophils is typically found in pleural fluid during an acute infection?
> 50% of total leukocytes
High neutrophil counts suggest a bacterial infection in the pleural space.
What leukocyte count is indicative of a lymphocytic predominance in exudative effusions?
> 50% of total leukocytes
This is associated with malignant effusions or chronic infections.
What RBC count in pleural fluid is suggestive of a malignant effusion?
> 5,000 cells/uL
This may indicate bleeding from a tumor.
What hematocrit level indicates a hemothorax in pleural fluid analysis?
> 0.5 x peripheral hematocrit
This suggests significant bleeding into the pleural space.
What pH level in pleural fluid is associated with a malignant effusion?
< 7.2
Low pH can also indicate empyema or esophageal perforation.
What glucose level in pleural fluid is indicative of rheumatoid pleurisy?
< 60 mg/dL
Low glucose levels can also signify tuberculous pleurisy or esophageal rupture.
What finding in pleural fluid indicates a parapneumonic effusion?
Positive Gram stain or culture
This suggests bacterial infection in the pleural space.
What adenosine deaminase level in pleural fluid suggests a tuberculous effusion?
> 50 mcg/L
Elevated levels indicate a high probability of tuberculosis.
What amylase level in pleural fluid can indicate esophageal perforation?
> 200 mcg/dL
This can also be seen in malignant effusions.
What is a key indicator of collagen vascular diseases in pleural fluid?
Positive rheumatoid factor, ANA
These tests help in diagnosing conditions like lupus pleuritis.
What triglyceride level suggests the presence of chylothorax?
> 110 mg/dL
Elevated triglycerides indicate lymphatic obstruction or injury.
What total cholesterol level is associated with pseudochylothorax?
Total cholesterol 55-200 mg/dL
This may indicate the presence of cholesterol crystals.
What appearance of pleural fluid is described as cloudy and milky?
Chylothorax
This appearance is due to the presence of chyle.
What is the typical appearance of empyema in pleural fluid?
Purulent
Empyema results from infection and leads to pus formation.
What appearance in pleural fluid is indicative of a malignant effusion?
Bloody
Malignant effusions can often present with blood due to tumor invasion.
Whats the possible causes of blood in pleural effusion?
- Hemothorax
- Malignancy effusion
Difference between exudate and transudate?
Transudate is usually clear, has a decreased cell count, and has low levels of protein, albumin, and LDH. Exudate typically appears cloudy, has an increased cell count, and has high levels of protein, albumin, and LDH.
In what conditions have low amount of glucose?
Malignancy, Empyema, Arthritis (rheumatoid pleurisy), and Tuberculosis are causes of pulmonary effusion associated with low glucose levels.
What is pleural effusion?
An accumulation of fluid in the pleural space.
What should be done for unstable patients with pleural effusion?
Begin respiratory support and perform urgent therapeutic thoracentesis.
What is the first step in managing all patients with pleural effusion?
Identify and treat the underlying condition.
What are the indications for urgent therapeutic thoracentesis?
- Respiratory distress signs
- Hemodynamic compromise secondary to the effusion.
What life-threatening causes of pleural effusion should be identified and treated?
- Pulmonary embolism
- Esophageal rupture
- Hemothorax.
What initial management steps should be taken in case of esophageal rupture?
Consult surgery and start empiric antibiotics.
What should be done for patients with sepsis related to pleural effusion?
Begin sepsis management.
What diagnostic tools can be used to evaluate effusion size?
- Portable upright chest X-ray
- Lung ultrasound.
What are the next steps if clinical improvement occurs after managing pleural effusion?
Continue detailed clinical evaluation and obtain additional diagnostics.
What should be done for clinically deteriorating patients with pleural effusion?
Optimize oxygenation and consult a specialist for admission.
What is the recommended disposition for unstable patients with pleural effusion?
ICU admission.
What conditions may require admission for stable patients with pleural effusion?
- Parapneumonic effusion or empyema
- Underlying disease requiring inpatient treatment
- Large effusion of unknown etiology.
Under what conditions can a patient be discharged after therapeutic thoracentesis?
If there is a known and stable underlying condition with no complications.
Fill in the blank: For discharge, there must be a known and self-limited etiology of pleural effusion, no signs of ________, and ability to adhere to discharge instructions.
respiratory distress.
True or False: Emergency blood transfusion is indicated for massive hemothorax.
True.
Who are patients that have pleural effusion and unstable?
Respiratory distress
Respiratory failure
Hemodynamically unstable
What are the signs of respiratory distress ?
- Tachypnea
- use of accessory muscles of respiration
- nasal flaring
- cyanosis
- and an inability to lie flat caused by increased work of breathing to meet oxygen
What are the complications of thoracocentesis ?
- reexpansion pulmonary edema
- infection
- injury.
Re- expansion pulmonary edema?
Self-limiting noncardiogenic pulmonary edema that develops within 24 hours following rapid reexpansion of lung tissue that has collapsed as a result of air, pleural fluid, or mucus plugging; most commonly occurs as a complication of therapeutic thoracentesis.
What are the clinical features of re- expansion pulmonary edema?
- Cough
- Dyspnea
- increased work of breathing
- Tachycardia, tachypnea, hypoxemia
How to diagnose re- expansion pulmonary edema?
Diagnosis: confirmed by CXR or bedside ultrasound
Whats the treatment and how to prevent re-expansion pulmonary edema?
- Supplemental oxygen and in Severe cases: NIPPV or invasive mechanical ventilation
- Prevention
Limit pleural fluid removal to < 1.2–1.5 L at a time.
Avoid pleural pressures < -20 cm H2O.
Stop therapeutic thoracentesis if patients develop chest discomfort, cough, or hypoxia, as this could represent reexpansion pulmonary edema
