Pleural Effusion Flashcards
Light’s Criteria
Any 1 of the following 3 diagnoses Exudative effusion:
Pleural protein/serum protein ratio >0.5
Pleural fluid LDH/Serum LDH >0.6
Pleural LDH > 2/3 upper limit of normal
Chest tube insertion
Required for drainage of parapneumonic effusion when pH <7.2, LDH >1000, Pleural glucose <40, loculated pleural effusion
Indication for VATS
Loculated Emphyema that is not draining from chest tube despite being in place for several days.
BAPE
Benign Asbestos related pleural effusion
- Can be asx or present with pleuritic pain etc. (sx that one would expect)
- Latency of 15 years from asbestos exposures
- PF: exudative, 1/3 eosinophilic, >½ bloody
- Need pleural biopsy to r/o malignancy
- no prognostic implication for developing malignancy
TB pleural Effusion
Hypersensitivity reaction to the TB.
Fluid:
- Lymphocytic
- Low glucose
- Exudative
- Elevated ADA >40
—– if ADA negative- then good NPV
—– ADA alone is okay, but positive IFN and ADA is better to dx TB
Do HIV test is positive
Culture is not positive for AFB very often
Better to dx with pleural biopsy-
Look for caseating granulomas
ADA positive
Para-pneumonic effusion
Rheumatoid effusion
CTD
Lymphoma
Malignant effusions
Surgical Management for PTX
Persistent air leak for 72 hours
Unable to expand lung
High risk occupation (pilot)
recurrent PTX (Ipsilateral/CL)
Bilateral Tension PTX
hemoPTX
Eosinophilic Causes for pleural effusion
- > 10%
- PTX (within hours- air causes IL-5 response)
- Hemothorax (10-14 days following)
- Fungal infections
- Parasitic infections
—— paragonimiasis (low pH) - pulmonary infarction
- Drugs
- lymphoma
- Carcinoma
Drugs that cause eosinophilic effusion
- Amiodarone
- B-blockers
- Dasatinib
- D-penicillamine
- Gemcitabine
- Methotrexate
- Nitrofurantoin
- phenytoin
- Sulfasalazine
Two test Rule for Exudate
Cholesterol > 45
LDH >45% ULN
½ only needed for positive test
Three test rule for Exudate
Protein >2.9
cholesterol > 45
LDH >45% ULN
Suspect HF pleural effusion but on diuretics
Serum- Effusion albumin gradient >1.2
Serum -effusion protein gradient > 3.1
Pleural Fluid BNP 1500
Hepatohydrothorax
- If exudative but feel like hepatohydrothorax- can confirm if:
—– PF/S Albumin gradient <0.6
Consider spontaneous pleural fluid infection if:
- PF NT >250 with negative culture
- PF NT >500 negative culture
Tx with antibiotics- will likely resolve. Avoid chest tube placement.
Pleural Fluid DDX
- LDH >1000
Empyema
Complicated para-pneumonic effusion
Cholesterol effusion
Rheumatoid pleurisy
Primary pleural Lymphoma
paragonimiasis
Pleural Fluid DDx
- Low Glucose
Empyema
Paragoniamiasis
TB
Chronic rheumatoid pleuritis
Acute lupus pleuritis
Malignancy
Pleural Fluid DDx
- High Amylase
Pancreatitis
Esophageal rupture
Malignancy
Pleural Fluid DDx
- Total Protein >7
Multiple Myeloma
Waldenstroms
Macroglobinemia
Rheumatoid Pleurisy
Lymphocytic Pleural Fluid DDX
Sarcoidosis
TB
Malignancy
Lymphoma
Chronic rheumatoid pleurisy
Uremic pleural effusion
Yellow nail syndrome
Cylothorax
Post CABG
Neutrophilic Pleural Fluid DDX
Acute pleural injury
infection
inflammation
pulmonary embolism
acute esophageal rupture
cholesterol effusion
Acute lupus pleurisy
Eosinophilic pleural fluid DDX
PTX (within hours)
Hemothorax (10-14days)
Pulmonary infarction
parasitic infection
fungal infection
Drug induced
Carcinoma
Lymphoma
Low pH <7.30 pleural fluid DDX
Empyema
TB
Paragonomiasis
Chronic rheumatoid pleurisy
Acute lupus pleurisy
Malignancy
Esophageal rupture
Cholesterol effusion
Solitary Fibrous Tumor
Pleural based tumor incidentally found.
Mesenchymal cell origin
May be mobile
Sx typically related to compressive sx. Typically found incidentally
Can have hypoglycemia due to ILGF
Can have HPO
Resection
Low incidence of recurrence
