Pleural effusion Flashcards
What is it?
Fluid in the pleural space
Other substances that can enter the pleural space
Blood -> Haemothorax
Pus -> Empyema
Chyle (lymph with fat) -> Chylothorax
Blood and air -> haemopneumothorax
Types
Transudate (protein concentration <25g/L)
Exudate (protein concentration >35g/L)
Chylothorax (less common)
What is chylothorax
Lymph formed in digestive system enters the pleural cavity
Aetiology of transudate
Increased venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
Hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)
Hypothyroidism (right pleural effusion and ovarian fibroma)
Aetiology of exudate
Pneumonia
Malignancy
Pulmonary embolus with infarction
Aetiology of chylothorax
Neoplasm Trauma TB Sarcoidosis Cirrhosis
Pathophysiology of transudate
Disruption of the hydrostatic and oncotic forces operating across the pleural membranes
Pathophysiology of exudate
Increased permeability of the pleural surface and/or capillaries (inflammation)
Pathophysiology of chylothorax
Due to either disruption or obstruction of the thoracic duct
Symptoms
Asymptomatic
or dyspnoea or pleuritic chest pain
Signs
Reduced chest wall movement/expansion
Dull ‘stony’ percussion
Diminished breath sounds (on affected side)
Reduced vocal resonance
Diagnostic tests
CXR
Ultrasound (good at identifying presence of pleural fluid and guiding aspiration)
Diagnostic Aspiration
Pleural biopsy
What would imply the presence of a pneumothorax on CXR
completely flat horizontal upper border
Describe process of diagnostic aspiration
Percuss the upper border of pleural effusion and choose a site 1 or 2 intercostal spaces below it
Infiltrate the pleura with some lidocaine
Using a needle and syringe, without some pleural fluid and send to lab for clinical chemistry, bacteriology, cytology and immunology if indicated
What would you be assessing if sent sample to lab for clinical chemistry analysis
Protein Glucose pH LDH Amylase
What would you be assessing if sent sample to lab for bacteriology analysis
Microscopy and culture
Auramine stain
TB culture
What would you be assessing if sent sample to lab for immunology analysis
Rheumatoid factor
ANA (Antinuclear antibody for SLE)
Complement levels
What in sample is measured in cytology
Neutrophils Lymphocytes Mesothelial cells Abnormal mesothelial cells Multi-nucleated giant cells Lupus erythematosus cells (for SLE) Malignant cells (for Malignancy)
What would presence of abnormal mesothelial cells be indicative of in cytology analysis
Mesothelioma
What would presence of multi-nucleated giant cells be indicative of in cytology analysis
Rheumatoid arthritis
What would presence of high mesothelial cells be indicative of in cytology analysis
Pulmonary infarction
What could presence of high neutrophils be indicative of in cytology analysis
Parapneumonic effusion
Pulmonary Embolism
What could presence of high lymphocytes be indicative of in cytology analysis
Malignancy TB RA SLE Sarcoidosis
In pleural fluid analysis, what gross appearance suggests a cause of transudate or exudate pleural effusion
Clear, straw-coloured appearance
Describe management of pleural effusion
Drainage (if symptomatic)
Pleurodesis
Intra-pleural alteplase and dornase alfa (for empyema)
Surgery if persistent collections and increasing pleural thickness (seen on ultrasound)
