Pleural Effusion

Question 1

What are the types of pleural effusion?

Answer 1

Transudate & exudate.
Transudate < 30g/L protein (generally bilateral)
Exudate > 30g/L protein (usually unilateral)

Question 2

What causes a transudate effusion?

Answer 2

An imbalance of hydrostatic forces
Commonly:
LVF - Liver Cirrhosis - Hypoalbuminaema

Less Commonly:
PE - Mitral Stenosis - Hypothyroidism - Constrictive Pericarditis

Question 3

What causes an exudate effusion?

Answer 3

An increase in capillary and/or pleural permeability:
Commonly:
Malignancy - Pneumonia - Bronchiectasis - Lung Abscess

Less Commonly:
PE/Infarction - Rheumatoid Arthritis - Autoimmune - Pancreatitis - Post MI syndrome - Medications

Question 4

How does a pleural effusion present?

Answer 4

Increasing SOB
Pleuritic Chest Pain [starts early = inflammatory/steadily increases = malignant]
Dull Ache
Dry Cough
Malaise/Fever/WeightLoss/Night Sweats

Reduced Chest Expansion
Reduced Breath sound/Bronchial Breathing
Increased stony dullness to percussion
Reduced Vocal Resonance

Clubbing - tar staining - Raised JVP - Cervical Lymphadenopathy - Tracheal Deviation - Peripheral Oedema - Orthopnoea/Paroxysmal Nocturnal Dyspnoea

Question 5

How do we investigate a pleural effusion?

Answer 5

CXR - To confirm
Contrast CT - to differentiate between malignant & benign
Pleural Aspiration & Biopsy (Blind or CT guided)
Thoracoscopy

Question 6

How is a pleural effusion treated?

Answer 6

Drained with a chest drain then pleurodhesis.

Other rteatment directed at cause

Question 7

How do we analyse a sample of pleural aspiration?

Answer 7

Look & Smell:
Foul smell --- Anaerobic Empyema
Pus --- Empyema
Milky --- Chylothorax, Lymphoma
Blood Stained --- ~Malignancy
Bloody --- Haemothorax, Trauma
Food --- Oesophageal Rupture

Cytology:

• Malignant Cells
• Eosinophils
• Lymphocytes

Microbiology:

• Microscopy, Culture & Sensitivities
• Gram & ZN staining

Biochemistry:

• Protein
• LDH
• Amylase (rise indicates pancreatitis)
• Glucose