Pleural Effusion Flashcards
What are the causes of a transudate pleural effusion?
Imbalance of the hydrostatic forces
Common causes = left ventricular failure, liver cirrhosis, hypoalbuminaemia and peritoneal dialysis
Less common causes = hypothyroidism, nephrotic syndrome, mitral stenosis and pulmonary embolism
Rare causes = meigs disease, ovarian hypersensitivity syndrome and constrictive pericarditis.
What are the exudate causes of pleural effusion?
Increase in permeability of the pleural surface and/or local capillaries
Common causes = malignancy (pleura, breast, lung) and parapneumonic (sub phrenic pneumonia)
Less common causes = pulmonary embolism, rheumatoid arthritis, autoimmune diseases, benign asbestos infusion, pancreatitis and post MI
Rare causes = yellow nail syndrome and drugs (carbamazepine, nitrofurantoin, phenytoin, penicillamine, amiadarone etc.)
What are the symptoms of a pleural effusion?
Asymptomatic is small and accumulates slowly
Dry cough
Increasing breathlessness
Dull ache
Pleuritic chest pain
Malaise, Pyrexia, night sweats, weight loss
Enquire about - nocturnal dyspnoea, liver disease, orthopnoea, peripheral oedema
What are the clinical signs of a pleural effusion?
On the affected side: decreased breath sounds with band of bronchial breathing, decreased vocal resonance, stony dullness to percussion and decreased chest expansion
Other signs: clubbing, tar staining, lymphadenopathy, trachea shift to opposite side and increased jugular venous pressure.
Describe the investigations that may need to be carried out to diagnose a pleural effusion.
May not need investigations if transudate as the clinical picture is clear.
Initial chest x-ray (but there needs to be at least 200ml for it to show up, therefore if small you wont see it).
CT- defines malignancy if exudate. Also nodular, mediastinal and parietal pleural thickening.
Pleural aspiration - 20ml syringe, 20G needle and lidocaine anaesthetic. Asses aspiration, blood gas analyses and send to labs for further investigation (microbiology, cytology, biochemistry)
Pleural biopsy - Adams needle for blind biopsy or tru cut for CT guided. Always cut downwards and just above the rib to avoid touching/damaging the neurovascular bundle.
If there is still no diagnosis then surgical thoracoscopy or video assisted thoracoscopy
What are the treatments for pleural effusion?
Treatment is based on the cause.
Chemotherapy, anti tuberculosis chemotherapy, pleurodhesis
Palliative management - pleural aspiration no more than 1-1.5 liters at any given time. Patients who receive palliative management are hospitalized.
Explain the treatment of pleural effusion by pleurodhesis.
Patients lies on their side at 45 degree angle with arm on top of their head.
Insert lignocaine anesthetic
Mark2-3cm transverse incision 4th intercostal space mid axillary line
Clamp thoracostomy tube and insert through incision into pleural space.
Attach thoracostomy tube to underwater seal and unclamp tube.
Drain 500ml/hr to dryness, then chest with CXR
If lung re expands then instill 3mg/kg lignocaine and instill talc slurry (2-5g)
Clamp and drain for 1 hr
This induces chemical pleurisy and the pleurae stick together closing the pleural space.
Remove drain after 12-72 hrs if lung remains re expanded.
if someone has an effusion but their tracheal position is unchanged, then what does this indicate?
Collapse of underlying lung
Lung cancer?
What condition causes a right sided pleural effusion?
And what type of effusion is this - transudate or exudate?
Meigs’ syndrome
Transudate pleural effusion
What can cause constructive pericarditis?
What type of pleural effusion can this cause?
Previous TB and connective tissue diseases
Transudate pleural effusion
What can cause a pleural effusion - hypothyroidism or hyperthyroidism?
What type of effusion?
Hypothyroidism
Transudate pleural effusion
What is the protein content of transudate?
< 30g/l
What is the protein content of exudate?
> 30g/l
When would you investigate a diagnosed pleural effusion?
Unusual features
Failure to respond to treatment
What type of valvular disease can cause a pleural effusion and what type of effusion?
Mitral stenosis can cause a transudate pleural effusion
