Pleural Effusion Flashcards
occurs when systemic factors that influence the formation and absorption of pleural fluid are altered. The leading causes of are left ventricular failure and cirrhosis
transudative pleural effusion
occurs when local factors thatinfluence the formation and absorption of pleural fluid are altered. The leading causes are bacterial pneumonia,malignancy, viral infection, and pulmonary embolism.
exudative pleural effusion
Exudative pleural effusions meet at least one of the Following criteria, whereas transudative pleural effusions meet none:
- Pleural fluid protein/serum protein >0.5
- Pleural fluid LDH/serum LDH >0.6
- Pleural fluid LDH more than two-thirds the normal upper limit for Serum
These criteria misidentify ~__% of transudates as exudates.
~25%
If one or more of the exudative criteria are met and the patient is clinically thought to have a condition producing a transudative effusion, the difference between the protein levels in the serum and the pleural fluid should be measured. If this gradient is >___, the exudative categorization by these criteria can be ignored because almost all such patients have a transudative pleural effusion.
> 31 g/L (3.1 g/dL)
The most common cause of pleural effusion is
left ventricular failure
In heart failure, diagnostic thoracentesis should be performed if the effusions are
not bilateral and comparable in size,
if the patient is febrile,
or-if the patient has pleuritic chest pain
A pleural fluid N-terminal pro-brain natriuretic peptide(NT-proBNP) value of ____ is virtually diagnostic that the effusion is-secondary to congestive heart failure.
> 1500 pg/mL
The effusion is usually right-sided and frequently is large enough to produce severe dyspnea. Pleural effusions occur in ~5% of patientswith cirrhosis and ascites.
Hepatic Hydrothorax
Efffusion that are associated with bacterial pneumonia, lung abscess, or bronchiectasis and are probably the most common cause of exudative pleural effusion in the “United States. “
Parapneumonic Effusion
refers to a grossly purulent effusion
Empyema
Patients with pleural effusion that presents with an acute febrile illness consisting of chest pain, sputum production, and leukocytosis.
aerobic bacterial pneumonia
Patients with present with a subacute illness with weight loss, a brisk leukocytosis, mild anemia, and a history of some factor that predisposes them to aspiration
anaerobic infections
If the free fluid separates the lung from the chest wall by >__ mm, a therapeutic thoracentesis should be performed
> 10mm
Factors indicating the likely need for a procedure more invasive than a thoracentesis or CTT (in increasing order of importance) include the following: increasing order of importance
- Loculated pleural fluid
- Pleural fluid pH <7.20
- Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
- Positive Gram stain or culture of the pleural fluid
- Presence of gross pus in the pleural space
If the fluid recurs after the initial therapeutic thoracentesis and if any of the factors or characteristics is present, what should be performed?
a repeat thoracentesis
If the fluid cannot be completely removed with the therapeutic thoracentesis, consideration should be given to:
inserting a chest tube and instilling the combination of a fibrinolytic agent (e.g., tissue plasminogen activator, 10 mg) and deoxyribonuclease (5 mg) or performinga thoracoscopy with the breakdown of adhesions.
should Be considered when ( inserting a chest tube and instilling the combination of a fibrinolytic agent and deoxyribonuclease or performing a thoracoscopy with the breakdown of adhesions)these measures are ineffective:
Decortication
are the second most common Type of exudative pleural effusion.
Malignant pleural effusions secondary to metastatic disease
The three tumors that cause ~75%of all malignant pleural effusions are
- lung carcinoma
- breast carcinoma
- lymphoma
The diagnosis usually is made via cytology of the pleural fluid. If the initial cytologic examination is negative,what is the best next procedure if malignancy is strongly suspected.
thoracoscopy
Or
Need biopsy of the pleura
True or false
most malignancies associated with pleural effusion Are not curable with chemotherapy.
True
In effusion sec to malignancy, If the patient’s lifestyle is compromised by dyspnea and if the dyspnea is relieved with a therapeutic thoracentesis, one of the following procedures should be considered:
1) insertion of a small indwelling catheter or
2) tube thoracostomy with the instillation of a sclerosing agent such as doxycycline (500 mg).
The chest radiograph reveals a pleural effusion, generalized pleural thickening, and a shrunken hemithorax and most are related to asbestos exposure
Mesothelioma
Effusion Secondary to Pulmonary Embolization is diagnosed by
spiral CT scan orpulmonary arteriography
In many parts ofthe world, the most common cause of an exudative pleural effusion
Tuberculous pleuritis
In tuberculous pleuritis, The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid
adenosine deaminase >40 IU/L
or
Gamma interferon γ >140 pg/mL)
occurs when the thoracic duct is disrupted and chyle accumulates in the pleural space.
chylothorax
What is the most common cause of chylothorax is (most frequently thoracic surgery) but it also may result from tumors in the mediastinum
trauma
The Thoracentesis of chylothorax reveals milky fluid, and biochemical analysis reveals a triglyceride level that exceeds
1.2 mmol/L(110 mg/dL)
Patients with chylothorax and no obvious trauma should have what diagnostics to assess the mediastinum for lymph nodes?
lymphangiogram and a mediastinal CT scan
The treatment of choice for most chylothoraxes is
insertion of a chest tube plus the administration of octreotide
Alternative treatment for chylothorax are
- Implantation of pleuroperitoneal shunt or percutaneous transabdominal thoracic duct blockage
- ligation of the thoracic duct.
Patients with chylothoraxes should not undergo prolonged tube thoracostomy with chest tube drainage because this will lead to
malnutrition
and
immunologic incompetence
When a diagnostic thoracentesis reveals bloody pleural fluid, a hematocrit should be obtained on the pleural fluid. If the hematocrit is more than one-half of that in the peripheral blood, thepatient is considered to have a
hemothorax.
If the bleeding in hemothorax exceeds 200 mL/h, consideration should be given to
angiographic coil embolization, thoracoscopy or thoracotomy
Most patients with hemothorax should be treated with what procedure which allows continuous quantification of bleeding
tube thoracostomy
In patients with pleural effusion , if the patient is febrile, has predominantly polymorphonuclearcells in the pleural fluid, and has no pulmonary parenchymal abnormalities, what should be considered?
an intraabdominal abscess
Transudative Pleural Effusions
- Congestive heart failure
- Cirrhosis
- Nephrotic syndrome
- Peritoneal dialysis
- Superior vena cava obstruction
- Myxedema
- Urinothorax
