pleural effusion

Question 1

pleural effusion overview

Answer 1

Pleural space
lies between the lung and chest wall
contains typically a thin layer of fluid
fluid enters pleural space from capillaries, then
removed from lymphatics in the parietal pleura

The pleural fluid formation exceeds pleural fluid absorption

excess quantity of fluid in pleural space
pleural effuxion occurs

Question 2

pleural effusion treatment

Answer 2

suspect pleura effusion
chest imaging to diagnose the extent
chest ultrasound
CT scan
CT x-ray

significant pleural effusion
thoracentesis
bedside or IR
chest tube or video-assisted thoracotomy

late treatment or complex cases
pleural fluid analysis

Question 3

pleural effusion etiology transudate

Answer 3

Transudate: change in systemic factors
CHF : most common cause LV failure
Cirrhosis
nephrotic syndrome
SVC obstruction
myxedema
urinothorax ( rare urine in plura)

Question 4

pleuarl effusion exudate

Answer 4

neoplastic diseases
infectious diseases
pulmonary embolism or infarction
trauma

Question 5

pleural effusion fluid analysis

Answer 5

normal pleural fluid
appearence clear
PH 7.60-7.64
protein < 2%
white blood cells < 1,000
glucose similar as plasma
LDH 30-110
triglcerides <2

Question 6

lights criteria
exudate vs transudate

Answer 6

1. pleural fluid protein/serum protein > 0.5
2. pleural fluid LDH/Serum LDH > 0.6
3. pleural fluid LDH > 2/3 normal upper limit for serum

serum protien / plural fluid protien
gradient > 3.1 g /dl
transudate

Check protein levels for dx

Question 7

diagnostic approach

Answer 7

transudate
treat underlying condition

Exudate:
pleural fluid glucose , cytology cell count, culture and gram stain, TB marker
—-glucose > 60
consider malignancy vs bacterial infections vs. rheumatoid pleuritis

work up coming back negative
consider PE workup

work up negative again
consider TB

work up still negative
consider thoracoscopy or pleural biopsy

absolute findings
PH < 7.2 glucose < 60 consider LDH > 1000 bacteria cultured
complete drainage needed

Question 8

most common cause of plueral effusion

Answer 8

LVH
due to HF
abnormal presentation
thoracentesis needed
not bilateral and comparable
febrile
pleuritic chest pain

treat underlying heart failure
failure of therapy
thoracentesis

fluid analysis
NT pro - BNP > 1500 diagnosis secondary to HR
CHF

Question 9

pleural effusion due to hepatic hydrothroax

Answer 9

cirrhosis
5% develop effusion
predominant mechanism
direct movement of the peritoneal fluid into the pleural space
right-sided effusion

Question 10

pleural effusion due to parapneumonic

Answer 10

most common exudative pleural effusion

Underlying causes:
Bacterial pneumonia, lung abscess or bronchiectasis

clinical presentaion:
Aerobic infection:
acute febrile illness , chest pain, sputum production, and leukocytosis

Anaerobic infection:
Subacute illness, weight loss, mild anemia, and aspiration factor

grossly purulent effusion
refers to empyema

Question 11

treatment of parapneumonic pleural effusion

Answer 11

management considerations
free fluid separating lungs from chest wall > 10mm
thoracentesis needed

loculated pleural fluid
PH < 7.20 glucose < 60 gram stain + or puss
invasive approach

Recurrence of effusion:
thoracentesis, then a repeat should be done
chest tube and instilling a fibrinolytic agent
tissue plasminogen activator (TPA)
deoxyribonuclease ( DNase ) 5mg
thoracoscopy with breakdown of adhesions
decortication

Question 12

pleural effusion due to malignancy

Answer 12

second most common exudative effusion

tumor causes:
lung carcinoma
breast carcinoma
lymphoma

Clinical findings:
dyspnea out of proportion
diagnosis supported by cytology
Negative results?
consider throasocpy

Question 13

treatment of pleural effusion from malignancy

Answer 13

confirming diagnosis
thorax
pleurodesis
CT or US-guided needle bx

Treatment:
symptomatic relief
thoracostomy tube
sclerosing agent: doxycycline 5000mg

Question 14

pleural effusion chylothorax

Answer 14

Etiology:
disruption of the thoracic duct
chyle ( milky fluid that contains fat droplets and lymph) accumulates in pleural space

Most common cause:
trauma
thoracic surgery
mediastinal tumors
lymphagiogram and mediastinal CT scan

clinical finding
dyspnea
large milkey effusion
triglyceride >110

Question 15

treatment chylothorax

Answer 15

medial management
chest tube
avoid prolonged insertion and drainage

octreotide 50-100mcg SQ TID
minimized lymphatic fluid excretion

Nutrition;
TPN VS oral feeding
surgical approach
percutaneous transabdominal thoracic duct blockage
ligation of the thoracic duct