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
