Pleural effusion

Question 1

Definition

Answer 1

Fluid in pleural space

Transudates = 25g/L

Question 2

Empyema

Answer 2

Pus in pleural space

Question 3

Causes- transudates

Answer 3

Transudates

1. +Venous pressure
   a. Cardiac failure
   b. Constrictive pericarditis
   c. Fluid overload
2. Hypoproteinemia
   a. Cirrhosis
   b. Nephrotic
   c. Malabsorption
   d. Hypothyroidism
   e. Meigs (right pleural effusion and ovarian tumor)

Question 4

Causes exudates

Answer 4

+Leakiness of pleural capillaries secondary
1. Infection
a. Pnuemonia
b, TB

2. Inflammation
   a. Pulmonary infarction
   b. Rheumatoid arthritis
   c. SLE
3. Malignancy
   a. Bronchogenic carcinoma
   b. Malignant metastases
   c. Lymphoma
   d. Medothelioma

Question 5

Symptoms

Answer 5

1. May be asymptomatic
2. Dyspnea
3. Pleuritic chest pain

Question 6

Signs

Answer 6

1. Decreased chest wall expansion
2. Stony dullness to percussion
3. No breath sounds at effusion
4. Bronchial breathing on effusion side
5. Tactile fremitus and vocal resonance -ve
6. If large->tracheal deviation
7. Looks for signs of underlying disease->inflammation, malignancy, infection, thyroid, RA, CCF

Question 7

Investigations

Answer 7

1. CXR: blunting of costophrenic angles, larger->water dense shadows with concave upper borders
2. USS->useful to determine presence of pleural fluid and guide aspiration

Question 8

Diagnostic aspiration

Answer 8

1. Percuss upper border of effusion
2. Choose site 1-2 intercostals below
3. Lidocaine
4. 21G needle, insert just above level f appropriate rib
5. Draw off fluid and send for chemistry= protein, glucose, LDH, pH amylase; MCS; cytology; immunology if indicated

Question 9

Option if pleural fluid analysis not good

Answer 9

Pleural biopsy

Question 10

Management

Answer 10

Is of the underlying disease

Question 11

Fluid analysis->gross and cytology

Answer 11

1. Gross appearance
Clear, straw->transudate
Turbid/yellow->empyema, parapneumonic effusion
Hemorrhagic->trauma, malignancy, infarction
2. Cytology
Neutrophils->PE, empyema
LymphoC->MaligN, TB, RA, SLE, sarcoid
Mesothelial->infarction
Giant cells->RA
Lupus->SLE

Question 12

Fluid analysis- clinical chemistry

Answer 12

1. Protein
   Low= trans
   High= ex
   N, protein:serum p >0.5= ex
2. Glucose, pH, LDH
   Low glucose, acidic, ++LDH= empyema, malignancy, TB, SLE
3. Elevated amylase->pancreatitis, Ca, pneumonia, esophageal rupture