Pleural Effusion

Question 1

What is pleural effusion? Different types?

Answer 1

Fluid in the pleural space

Exudate (>35g/L protein) or transudate (<25g/L protein)

Blood- haemothorax
Pus - empyema
Chyle (lymph with fat) - chylothorax
Blood and har - haemiopneumothroax

Question 2

What causes transudate pleural effusions?

Answer 2

Increased venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
Hypoproteinaemia (cirrhosis, nephrotic syndrom, malabsorption)
Hypothyroidism

Question 3

What causes exudate pleural effusions?

Answer 3

Increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy

Pneumonia
TB
Pulmonary infarction
RA
SLE
Bronchogenic carcinoma
Malignant metastases
Mesothelioma

Question 4

What are symptoms of pleural effusion?

Answer 4

Asymptomatic or dyspnoea, pleuritic chest pain

Question 5

What are signs of pleural effusion?

Answer 5

Decreased expansion
Stony dull percussion
Diminished breath sounds
On affected side

Tactile vocal fremitus and vocal resonance are reduced

Above effusion where lung is compressed, there may be bronchial breathing

Large effusions - tracheal deviation away from effusion

Signs of associated disease:
Malignancy (cachexia - weakness/wasting, clubbing, lymphadenopathy, chronic liver disease, cardiac failure, hypothyroidism, RA, SLE)

Question 6

What might you see in a large pleural effusion?

Answer 6

Tracheal deviation away from affected side

Question 7

What Ix for pleural effusion?

Answer 7

CXR:
Small - blunt costophrenic anglres
Large: water dense shadows with concave upper borders
Flat upper border implies there is also a pneumothorax

USS - identify presence of pleural fluid and guiding diagnostic or therapeutic aspiration

Diagnostic aspiration

Pleural biopsy if diagnostic aspiration analysis is inconclusive

Question 8

What will you see on CXR? What if flat upper border?

Answer 8

Small - blunt costophrenic anglres
Large: water dense shadows with concave upper borders
Flat upper border implies there is also a pneumothorax

Question 9

How do you perform a diagnostic aspiration of pleural effusion?

Answer 9

Percuss upper border of pleural effusion and go 1/2 intercostal spaces below it.
Infiltrate with 5-10ml 1% lignocaine
21G needle insert above upper border of rib (avoids neuromuscular bundle)
Draw off 10-30 ml and send to lab for clinical chemistry, bacteriology, cytology, immunology.

Question 10

How do you manage pleural effusion?

Answer 10

Drainage:
If symptomatic drain repeatedly if necessary.
Remove fluid slowly
Empyema best drained with chest drain

Question 11

Cause of clear/straw coloured effusion? Yellow, turbid effusion? Haemorrhagic effusion?
High neutrophils? High lymphocytes?

Answer 11

Clear/straw - transudate/exudate
turbid yellow - empyema/parapneumonic effusion
Haemorrhages - trauma, malignancy, pulmonary infarction.

Neutrophils - parapneumonic effusion/PE
Lymphocytes - malignancy, TB, RA, SLE, sarcoidsois