Pleural Effusions

Question 1

What is pleural effusion?

Answer 1

Pathological accumulation of fluid in the pleural space

Question 2

What are the main types of pleural effusion?

Answer 2

• Exudative pleural effusion
• Transudative pleural effusion
• Haemothorax
• Chylothorax
• Empyema

Question 3

Define exudative pleural effusion.

Answer 3

Pleural effusion of exudate caused by local processes that increase capillary permeability

Question 4

What are common causes of exudative pleural effusion?

Answer 4

• Malignancies (breast, lung, ovarian, mesotheliomas)
• Infections (pneumonia, TB)
• Connective tissue diseases
• Gastrointestinal diseases (e.g., pancreatitis)
• Drug-induced causes

Question 5

List some mechanisms that can lead to transudative pleural effusion.

Answer 5

• Increased hydrostatic pressure
• Fluid leakage
• Decreased colloid osmotic pressure

Question 6

What is the protein content and cellular composition of transudate?

Answer 6

Low protein content, few cells

Question 7

What is the protein content and cellular composition of exudate?

Answer 7

High protein content, may contain some white and red cells

Question 8

What is a haemothorax?

Answer 8

Pleural effusion caused by blood that has more than 50% of the peripheral blood haematocrit

Question 9

What are some pulmonary causes of haemothorax?

Answer 9

• Lung cancer
• Malignant pleural mesothelioma
• Thoracic surgery
• TB
• Pulmonary infarction

Question 10

What are some haematological causes of haemothorax?

Answer 10

• Haemophilia

Question 11

Define chylothorax.

Answer 11

Pleural effusion of chyle, a type of lipid-rich lymph

Question 12

List haematological causes of chylothorax.

Answer 12

• Lymphoma
• Chronic lymphocytic leukaemia (CLL)

Question 13

What are some pulmonary causes of chylothorax?

Answer 13

• Lung cancer
• TB

Question 14

What are some esophageal causes of chylothorax?

Answer 14

• Kaposi’s sarcoma
• Oesophageal cancer

Question 15

Define empyema.

Answer 15

Pleural effusion of purulent fluid (pus), most commonly caused by pneumonia

Question 16

What is the pathophysiology of exudative pleural effusion?

Answer 16

Inflammation in pleural vascular capillaries causes increased permeability, leading to exudate fluid leakage into the pleural space

Question 17

What characterizes exudate fluid?

Answer 17

Protein-rich fluid that is cloudy and contains cells and cell debris

Question 18

What is a transudative pleural effusion?

Answer 18

Pleural effusion of transudate fluid caused by conditions that increase capillary hydrostatic pressure and decrease osmotic pressure.

Question 19

What are the common causes of transudative pleural effusion?

Answer 19

Mostly due to congestive heart failure, also associated with cirrhosis, hypoalbuminemia, and nephrotic syndromes.

Question 20

What is the mortality rate comparison between transudative and exudative pleural effusions?

Answer 20

Transudative pleural effusions have a higher mortality than exudative pleural effusions.

Question 21

What are the two main pathophysiological factors for transudative pleural effusion?

Answer 21

1. Decrease osmotic pressure (e.g., hypoalbuminemia)
2. Increase hydrostatic pressure (e.g., congestive heart failure, renal disease)

Question 22

What is the nature of transudate fluid?

Answer 22

Protein-poor fluid that is thin and watery.

Question 23

What are the common symptoms of pleural effusion?

Answer 23

Dyspnea, dry cough, pleuritic chest pain, or no chest pain.

Question 24

What are the exam findings for pleural effusion?

Answer 24

1. Reduced breath sounds on auscultation
2. Pleural friction rub on auscultation
3. Dull percussion
4. Clubbing

Question 25

How does transudative pleural effusion typically present in terms of laterality?

Answer 25

Transudative is usually bilateral, while exudative is usually unilateral.

Question 26

What are the key radiographic findings for pleural effusion?

Answer 26

1. Costophrenic angle blunting (Meniscus sign)
2. Ipsilateral tracheal deviation (large effusion)
3. Fluid in fissures (seen on lateral views)

Question 27

What investigations should be performed for pleural effusion?

Answer 27

Check organ functions: FBC, coagulation screen, LFTs, U&Es, B-type natriuretic peptide test.

Question 28

What is diagnostic pleural aspiration by thoracentesis?

Answer 28

A needle decompression procedure to drain fluid from the pleural space.

Question 29

What are the two points to confirm during diagnostic pleural aspiration?

Answer 29

1. Fluid assessment for infectious agents, inflammatory markers, cancer cells.
2. Light’s criteria: A diagnostic scoring system that distinguishes between transudative and exudative pleural effusions.

Question 30

What are Light’s criteria for confirming exudative pleural effusion?

Answer 30

If at least one is met, exudative pleural effusion is confirmed:
1. Effusion protein to serum protein ratio is more than 0.5.
2. Effusion LDH to serum LDH ratio is more than 0.6.
3. Effusion LDH is greater than ⅔ the upper limit of normal serum LDH (greater than 200 IU).

Question 31

What is the management approach for pleural effusion?

Answer 31

Should treat the underlying cause then the effusion itself.

Question 32

What is ultrasound-guided thoracentesis?

Answer 32

Needle decompression to remove extra fluid from the pleural space.

Question 33

What is indicated in large pleural effusions if pleural tap is ineffective?

Answer 33

Chest tube placement (thoracostomy) in a safe triangle.

Question 34

What are some treatment options for pleural effusion?

Answer 34

1. Chemical pleurodesis.
2. Indwelling pleural catheter: Preferred for ongoing drainage and can be used at home by patients.
3. Pharmacotherapy e.g., antibiotics, chemotherapy.
4. Pleurectomy.

Question 35

What is the common need for patients with pleural effusion?

Answer 35

Most cases need recurrent thoracentesis.