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RESPIRATORY > PLEURAL EFFUSIONS > Flashcards

PLEURAL EFFUSIONS Flashcards

1
Q

What is pleural effusion?

A

An abnormal collection of fluid within the pleural cavity

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2
Q

What is a haemothorax?

A

A type of pleural effusion in which there is a collection of blood in the pleural cavity

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3
Q

What is a hydrothorax?

A

I.e. a simple pleural effusion
a type of pleural effusion in which serous fluid accumulates in the pleural cavity
Can be broadly divided into transudates and exudates

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4
Q

What is a chylothorax?

A

A type of pleural effusion where there is an accumulation of lymphatic fluid within the pleural cavity

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5
Q

What is a pyothorax?

A

Aka empyema
A type of pleural effusion where there is an accumulation of pus in the pleural cavity

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6
Q

What is a hydropneumothorax?

A

A type of pneumothorax in which there is an accumulation of both air and fluid in the pleural cavity

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7
Q

Whats the normal amount of fluid in the pleural space?

A

5-15ml

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8
Q

What are the 2 major functions of the pleural fluid?

A

Lubricates the pleural surfaces and generated surface tension

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9
Q

What is the pleural recess? Why is it clinically relevant?

A

two areas where adjacent areas of parietal pleura come into contact because the pleural space is not totally filled by lung tissue. These are the costomediastinal recess and costodiaphragmatic recess.

These areas are where fluid may accumulate in pleural effusions.

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10
Q

What factors contribute to the balance between fluid entry and fluid exit in the pleural space?

A

Hydrostatic pressure - pressure exerted by a fluid against the walls of the pleural space
Oncotic pressure - the force exerted by the concentration of solutes in the fluid

Lymphatic drainage - responsible for removing excess fluid from the pleural cavity

Integrity of the pleural membranes is also crucial for maintaining the balance and any damage or inflammation can lead to increased fluid entry in the pleural cavity

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11
Q

What may cause increased fluid entry into the pleural cavity?

A

Increased vasculature permeability - loss of fluid and macromolecules from leaky vessels e.g. infections or inflammation
Increased hydrostatic pressure e.g. HF, pulmonary hypertension, liver disease
Increased micro vascular pressure - increased venous pressure affects hydrostatic pressure forcing fluid out
Decreased plasma oncotic pressure - hypoproteinaemia leads to accumulation of fluid in pleural space e.g. malnutrition, liver disease

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12
Q

What may cause decreased fluid exit out of the pleural cavity?

A

Alterations in lymphatic drainage
Intrinsic factors include inflammatory mediators, infiltration e.g. cancer or damage e.g. by radiotherapy
Extrinsic factors include physical compression, limitation by respiration motion, decreased intrapleural pressure

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13
Q

What typically causes a haemothorax?

A

Chest trauma

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14
Q

What is a transudate?

A

a fluid with minimal protein or cellular content.
It occurs due to alteration in hydrostatic and oncotic pressures leading to ultrafiltration

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15
Q

What is an exudate?

A

a fluid with a high protein and cellular content.
It occurs due to inflammation and increased capillary permeability

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16
Q

What can cause a transudate?

A

Increased venous pressure - HF, constrictive pericarditis
Hypoalbuminaemia - liver disease, nephrotic syndrome, malabsorption
Hypothyroidism
Meig’s syndrome (ascites and pleural effusion in association with a benign ovarian tumour)
Constrictive pericarditis
Peritoneal dialysis

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17
Q

What causes an exudate?

A

Infection - pneumonia, TB, subphrenic abscess
Inflammayory conditions - RA, SLE
Neoplasia - lung cancer, mesothelioma, mets

Others:
Pancreatitis
PE
Dressler’s syndrome
Yellow nail syndrome

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18
Q

What is a parapneumonic effusion?

A

A pleural effusion secondary to adjacent pneumonia

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19
Q

What are the clinical features of pleural effusion?

A

SOB, non-productive cough, pleuritic chest pain and there may be extra-pulmonary symptoms dependant on the underlying cause

Reduced chest expansion, reduces breath sounds, stony dull percussion, reduced vocal resonance, trachea deviation if large, extra-pulmonary signs dependant on underlying cause.

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20
Q

Generally, how large is a pleural effusion if its causes tracheal deviation?

A

Over 1 L

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21
Q

Whats the diagnostic test for pleural effusion?

A

CXR

22
Q

What is seen on CXR for pleural effusion?

A

Blunting of costophrenic angle
Fluid in lung fissures
Larger effusions will have a meniscus (curving upwards where it meets the chest wall and mediastinum)
Tracheal and mediastinal deviation

23
Q

When should a CT or MRI be done for pleural effusions?

A

If malignancy or pulmonary lesion is suspected

24
Q

Whats the principal investigation for assessment of whether a pleural fluid is transudate or exudate?

A

Pleural paracentesis and analysis

25
Q

How could you suspect a fluid is transudate from the history?

A

They may have extra-pulmonary symptoms suggestive of underlying cause e,g, HF
More likely to be bilateral

26
Q

What are the pleural guidelines from British thoracic society for a unilateral pleural effusion?

A

Clinical assessment - history, examination, chest xray
If likely transudate then treat underlying cause. If not resolved then refer to resp for further testing e,.g. a pleural aspiration
If likely exudate then refer to resp for further tests e.g. pleural aspiration

If referred to resp then they get pleural aspiration US-guided, biochem, microbiology and cytology done. If transudate then treat underlyign cause. If exudate confirmed then treat appropriately. If not confirmed/cancer suspected then CT thorax and further investigations

27
Q

Outline the process of pleural paracentesis?

A

Percussion the upper border of pleural effusion and choose a site 1 or 2 intercostal spaces below it.
Infiltrate down to the pleura with 5-10ml of 1% lidocaine
Under US-guidance, use a 21G needle and syringe and insert it just above the border of an appropriate rib (this avoids neurovascular bundle)
Draw 10-130ml pleural fluid and send it to the lab

If completing as a theurapeutic pleural aspiration remove 1-1.5 L of fluid for symptomatic relief. Repeat if necessary.

28
Q

What are the complications of thoracocentesis?

A

Pneumothorax - most common
Haemothorax - rare
Infection
Re-expansion pulmonary oedema
Subcutaneous emphysema
Pain
Vasovagal reactions
Nerve injury
Haematoma

29
Q

How can you differentiate pleural fluids from aspiration?

A

Transudate <30g/L protein
Exudate - >30g/L protein

30
Q

What tests should be completed on all pleural samples?

A

PH
Protein count
LDH
MC&S
Cytology

You can also do gram stain, TB investigations, lipid testing (for chylothorax), glucose, amylase, HCT (for haemothorax), nucleated cell count

31
Q

What critwria can be used to help distinguish between a transudate or exudate when the level of protein in pleural fluid is 25-35g/L?

A

Lights criteria

32
Q

What is Lights criteria?

A

Pleural fluid is an exudate if one or more of the following criteria are met:

Pleural fluid protein/serum protein is > 0.5
Pleural fluid LDH/serum LDH is >0.6
Pleural fluid LDH >2/3 the upper limits of laboratory normal value for serum LDH

33
Q

What imagine should be done for pleural effusion?

A

PA chest X-RAY in all pt
US is recommended as it increases the likelihood of successful pleural aspiration and is sensitive for detecting pleural fluid septations
Contrast CT is increasingly performed to investigate underlying cause

34
Q

What may cause heavy blood staining of pleural fluid as seen on aspiration?

A

Trauma
Malignancy e.g. mesothelioma
PE
TB or severe pneumonia
Coagulopathy

35
Q

What does low glucose in pleural fluid suggest?

A

Bacterial infections e.g, TB
Malignancies
RA
Pancreatitis

36
Q

What does raised amylase in pleural fluid suggest?

A

Pancreatitis
Oesophageal rupture (boerhaave syndrome)

37
Q

How should you manage pleural effusion?

A

Address underlying cause
Pleural aspiration and/or chest drains
Pleurodesis
Surgical intervention

38
Q

What are signs of pleural infection in the pleural fluid?

A

Purulent or cloudy pleural fluid
PH <7.2

39
Q

What should you do if pleural fluid looks purulent, cloudy or has a pH <7.2?

A

Place a chest tube to allow drainage

40
Q

What are the 2 principal options for pleural intervention?

A

Therapeutic paracentesis - removal of 1-1.5L of pleural fluid
Chest drain insertion - drainage over hours-days

41
Q

What is re-expansion pulmonary oedema? And how can you prevent it?

A

The development of pulmonary oedema on re-expansion of the lung.
To reduce the risk carry out procedure under US guidance, patients should be monitored for symptoms and drainage limited to 1-1.5 L at any time. If symptoms develop at a lower drainage volume, the drain can be clamped and patients reassessed before continuation.

42
Q

What is pleurodesis?

A

a procedure to obliterate the pleural space and prevent re-accumulation of fluid or air. It involves inducing pleural inflammation and fibrosis usually with talc

43
Q

What are indications for pleurodesis?

A

Pt with recurrent pleural effusions or patients with malignant pleural effusion that is likely to re-accumulate after drainage.

44
Q

What are the 3 stages of parapneumonic effusion?

A

Simple effusion - fluid is sterile
Complication effusion - fluid has become infected with a microorganism
Empyema - a collection of pus within the pleural space. Patients are very unwell and need urgent drainage

45
Q

What is a complex parapneumonic effusion?

A

An effusion that has internal loculations known as septa that separate the effusion into different pockets making it difficult to drain.

46
Q

What is a uniloculated effusion?

A

a type of pleural effusion where the fluid is confined to a single space or compartment within the pleural cavity.
In contrast, a multiloculated effusion refers to a pleural effusion where the fluid is contained in multiple compartments.

47
Q

How should you manage a parapneumonic effusion?

A

If simple - antibiotics
If complicated or empyema then drainage as soon as possible and antibiotics

48
Q

When should you suspect an empyema?

A

An improving pneumonia but new or ongoing fever.
Pleural aspiration shows pus, pH < 7.2, low glucose and high LDH.

49
Q

When might someone with pleural effusion need surgery?

A

If they get persistent collections and increasing pleural thickness on ultrasound

50
Q

What are the BTS duidelines for placing a chest tube in for pleural infection?

A

Pt with frankly purulent or turbid/cloudy pleural fluid on sampling
Presence of organisms identified by gram stain and or culture
Pleural fluid pH <7.2

RESPIRATORY (22 decks)

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