Pleural effusions Flashcards
What are some of the clinical features of pleural effusion?
Dyspnea, cough, chest pain and fever
pleuritic pain and fever more common in benign disease, dull pain more common in malignant
what might a pleural effusion look like in a supine film?
We would see apical capping, homogeneous density superimposed over the lung,
How can thoracentesis help in pleural effusions?
it allows expansion of lung, improves length-tension relationship of chest wall muscles and diaphragm
Light’s criteria
Pleural fluid protein/serum protein > 0.5
Pleural fluid LDH/serum LDH > 0.6
Pleural fluid LDH > 163
The presence of any one of these identifies an exudate!
What are the primary causes of exudates?
pneumonia, malignancy, PE and GI disease
What are transudates from?
due to hydrostatic/colloid pressure imbalance
CHF, PE and cirrhosis
What are clear, straw colored odorless fluids usually?
transudates
Bloody fluid ddx
cancer, pulmonary infarction, trauma, recent surgery, infection
turbid fluid ddx
orange/milky= chylothorax
gross pus= empyema
lymphocytes in pleural effusions are indicative of what?
MALIGNANCY and rarely TB
other etiologies: post CABG, chylothorax, yellow nail syndrome, chronic rheumatoid effusions, sarcoidosis
ddx of Glucose< 40
parapneumonic or empyema, rheumatoid, malignancy, TB, esophageal rupture
LDH>1000
complicated paraneumonic effusions, malignancies, paragonimiasis
ddx amylase
pancreatitis, esophageal rupture, and malignant effusions
purulent, odorous effusion, pleural LDH>3200, serum 400
empyema
large exudative effusions
malignancy, trauma, parapneumonic effusions, chylothorax, TB
malignant pleural effusions usually from? causes?
lung, breast, lymphoma
pleural mets increase permeability and can cause obstruction of pleural lymphatics
thoracentesis turns out milky white with high TG
chylothorax
pleural fluid accum due to disruption of the thoracic duct due to trauma or tumor
chylothorax
pleural fluid comes from
pleural capillaries, interstitium, intrathroracic lymphatics, peritoneal cavity
Compare the hydrostatic and oncotic pressure gradients in the pleural space
hydrostatic pressure pushing out is greater than oncotic pulling back into capillary, so there’s a net efflux of fluid.
However, lymphatic clearance is 28X higher than fluid formation so this isn’t a problem
Physical exam in someone with a pleural effusion may have:
Present or absent? fremitus percussion sound expansion breath sounds
absent fremitus
dullness to percussion
reduced expansion on affected side
reduced/absent breath sounds
parapneumonic effusions arise as a result of? What are the 3 subclasses?
pneumonia, lung abscess, or bronchiestasis
uncomplicated effusions, complicated effusions, and empyema
if you see a loculated effusion, automatically think
empyema
If a pleural effusion is milky white and had high cholesterol levels (>200), what would we be worried about?
chyliform effusion (high chol, not TG)
implies long standing effusion
often seen with TB and rheumatoid effusions
what are some clinical exam findings in a pneumothorax? treatment?
decreased breath sounds, decreased fremitis, hyper resonance, tracheal deviation, hypotension, tachycardia
tube thoracostomy
if you were analyzing a pleural effusion, and saw increased ADA (>70 U/L), what would you think of?
Tuburculosis
pH of transudates and exudates?
transudates alkaline and exudates acidic
what are some etiologies for eosinophils in pleural effusions?
air and blood most common etiologies
parapneumonic, drugs, asbestos, parasites
