Pleural Effusions

Question 1

What is pleural effusion?

Answer 1

Accumulation of fluid within the pleural space

Question 2

What are the causes of transudative pleural effusion?

Answer 2

Too much fluid leaves capillaries and goes to the pleural space due to a decrease in oncotic pressure.

Common causes include cardiac failure, cirrhosis, liver stuff, malnutrition and Nephrotic syndrome

Question 3

Explain exudative pleural effusion and its causes.

Answer 3

Exudative effusion has a higher protein content (>30g/L) than transudative and is often associated with inflammation of pulmonary capillaries, making them more leaky.

Common causes include infections and adenocarcinoma.

Question 4

What are the symptoms of pleural effusion?

Answer 4

Chest pain
Dry cough
Dyspnea
Difficulty taking deep breaths

Question 5

What signs might be observed in a patient with pleural effusion?

Answer 5

Reduced chest expansion on the affected side
Stony dull percussion

Question 6

What investigation is used to confirm the presence of pleural effusion?

Answer 6

Chest X-ray (CXR)

= 500ml of fluid will cause a clear fluid level on CXR

Question 7

What procedure is performed to sample pleural fluid?

Answer 7

Thoracentesis/ aspiration

Question 8

Describe the difference between the fluids for transudative pleural effusion and exudative pleural effusion

Answer 8

T - clear
E - cloudy > full of immune cells

Question 9

What is Thoracicentesis?

Answer 9

To remove fluids, relieve symptoms and find cause

Question 10

Straw coloured could indicate what?

Answer 10

cardiac failure, hypoalbuminaemia

Question 11

Bloody could indicate what?

Answer 11

trauma, malignancy, infection, infarction

Question 12

Turbid/milky could indicate what?

Answer 12

empyema, chylothorax

Question 13

Foul smelling fluid could indicate what?

Answer 13

anaerobic empyema

Question 14

Food particles within fluid could indicate what?

Answer 14

oesophageal rupture

Question 15

What could the presence of lymphocytes indicate?

Answer 15

malignancy or TB

Question 16

What could the presence of neutrophils indicate?

Answer 16

an acute process

Question 17

What are the diagnostic thresholds for pH in pleural fluid?

Answer 17

7.2 = simple effusion
<7.2 = complicated effusion

Question 18

When is a pleural biopsy indicated?

Answer 18

If diagnosis is not possible from fluid sampling alone

Question 19

What is the management approach for pleural effusion caused by infection?

Answer 19

Simple effusion (pH >7.2) can be treated with antibiotics alone.

Complicated effusion (pH <7.2) requires a chest drain and antibiotics.

Question 20

What is the significance of glucose levels in pleural fluid?

Answer 20

Low glucose levels may indicate infection, tuberculosis, or malignancy.

Question 21

How is a pleural effusion diagnosed as transudative or exudative?

Answer 21

This is determined by the protein content of the fluid:

Transudative effusions have a protein content of < 30 g/L, while exudative effusions have a protein content of>30g/L.

Question 22

What imaging technique is commonly used to identify pleural effusion?

Answer 22

CXR

Question 23

What does stony dull percussion indicate in pleural effusion?

Answer 23

It indicates the presence of fluid in the pleural space.

Question 24

How is a pleural effusion treated when it is associated with cardiac failure or cirrhosis?

Answer 24

Treating the underlying cardiac or hepatic condition is crucial

Question 25

A 65-year-old male patient presents to the general practitioner with a 2-month history of worsening shortness of breath and 3 episodes of haemoptysis. He also notes a 3kg weight loss. He has smoked 20 cigarettes per day for 50 years.

On physical examination, there is reduced chest expansion on the right side and dullness to percussion at the right base and associated absent breath sounds.

What is the likely diagnosis?

Answer 25

Exdative pleural effusion

Question 26

What is positive hepato-jugular reflux?

Answer 26

Distension of neck veins when pressure is applied over the liver

Question 27

A 50-year-old female patient presents to the general practitioner with a 2-week history of worsening shortness of breath. She also complains of stiffness and pain in her wrists and fingers, particularly in the morning.

On physical examination, there is dullness to percussion at the right lung base with associated reduced breath sounds. There is also tenderness and boggy swelling at the metacarpophalangeal joints bilaterally.

What would find in this patient?

Answer 27

Pleural fluid glucose levels low

Question 28

A 60-year-old male patient is brought to the emergency department by his wife with confusion. His wife also reports that he has lost approximately 5 kg in the last 2 months and has been complaining of a cough. He has no past medical history of note. He smokes 15 cigarettes per day.

The patient is tachypnoeic but apyrexial. Physical examination reveals dullness to percussion and quiet breath sounds over the right lung base.

Given the most likely diagnosis, which pleural fluid investigations are likely to be abnormal?

Answer 28

Cytology of pleural fluid

Question 29

What does Pyrexia suggest?

Answer 29

Infection - exudative

Question 30

What do Cachexia and clubbing suggest?

Answer 30

Malignancy - exudative

Question 31

What does a raised JVP and ankle oedema suggest?

Answer 31

HF - transudative

Question 32

pH – <7.2 what does this indicate?

Answer 32

emphyseia

Question 33

• The pleural fluid to serum protein ratio is >0.5
• Pleural fluid/serum LDH >0.6
• Pleural fluid LDH >2/3 upper limit of normal serum LDH

What does this tell us?

Answer 33

Tells us that the pleural effusion is exudate

Only has to have 1

Question 34

A 20-year-old female of Asian ethnicity is referred to the respiratory clinic with a 2-week history of shortness of breath. She has also noticed fatigue, musculoskeletal pain, and a facial rash over the last 2 months.

On physical examination there is an erythematous rash over the bridge of the nose, sparing the nasolabial folds, and multiple oral ulcers. On examination of the chest, there is a dull percussion note and reduced breath sounds at the left lung base.

Given the most likely underlying diagnosis, what pleural effusion is this and why?

Also, what is most likely to be present in the pleural fluid?

Answer 34

Edudative

SLE may cause exudative pleural effusions with raised anti-nuclear antibody (ANA) and low complement

Low complement

Question 35

For a transudative pleural effusion (typically bilateral) what is the initial management? if you don’t aspirate.

Answer 35

Trial of furosemide therapy

Question 36

A 76-year-old man has presented to the emergency department feeling very unwell. He was recently treated for community-acquired pneumonia (CAP) which appeared to be resolving but he has been feverish over the past few days. A chest X-ray in the emergency department shows a large left-sided pleural effusion and he is transferred to the acute medical unit where a chest drain is inserted. What investigation of the drained fluid in the first instance will support the most likely diagnosis?

Answer 36

PH

Question 37

A 45-year-old woman has recently been diagnosed with a benign ovarian tumour (a fibroma) and has presented to the emergency department with shortness of breath and pleuritic chest pain. On examination of the chest, the right lower zone is stony dull to percussion, with reduced air entry and reduced vocal resonance. The abdomen is distended but soft and non-tender. What is the most likely diagnosis?

Answer 37

Meigs syndrome

Question 38

The patient has presented with a large pleural effusion and is critically symptomatic with high oxygen requirement and significant respiratory distress. This patient requires what?

Answer 38

Pleural Chest Drain insertion

Question 39

When you see bilaterally you know its what?

Answer 39

Transudative pleural effusions

Question 40

A 73-year-old female patient presents to the Emergency Department with decreased exercise tolerance and shortness of breath over the past week. She denies any history of fevers or cough. On examination of the chest, she has stony dullness on percussion over the right base.

Given the most likely diagnosis, which investigation would be most useful to identify it’s underlying aetiology?

Answer 40

Aspiration with testing of the sample for protein and lactate dehydrogenase (LDH) + culture

If Edudative - 1 of the following list will appear;

Pleural fluid protein/ serum protein >0.5
Pleural fluid/serum LDH >0.6
Pleural fluid LDH >2/3 upper limit of normal serum LDH

Question 41

A 67-year-old male with known congestive heart failure is brought to the emergency department due to the acute onset of shortness of breath. He has difficulty breathing, pain upon inspiration, a dry, nonproductive cough, and a blue tint on his fingertips. On physical examination, he has asymmetrical chest expansion, reduced tactile fremitus, and faint breath sounds bilateral. The physician confirms the presence of a pleural effusion with a chest X-ray and orders a thoracentesis to drain the excess fluid from the pleural cavity. To perform the thoracentesis, the needle must be inserted where?

Answer 41

Costodiaphragmatic recess