Pleural effusions

Question 1

What are some of the clinical features of pleural effusion?

Answer 1

Dyspnea, cough, chest pain and fever

pleuritic pain and fever more common in benign disease, dull pain more common in malignant

Question 2

what might a pleural effusion look like in a supine film?

Answer 2

We would see apical capping, homogeneous density superimposed over the lung,

Question 3

How can thoracentesis help in pleural effusions?

Answer 3

it allows expansion of lung, improves length-tension relationship of chest wall muscles and diaphragm

Question 4

Light’s criteria

Answer 4

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!

Question 5

What are the primary causes of exudates?

Answer 5

pneumonia, malignancy, PE and GI disease

Question 6

What are transudates from?

Answer 6

due to hydrostatic/colloid pressure imbalance

CHF, PE and cirrhosis

Question 7

What are clear, straw colored odorless fluids usually?

Answer 7

transudates

Question 8

Bloody fluid ddx

Answer 8

cancer, pulmonary infarction, trauma, recent surgery, infection

Question 9

turbid fluid ddx

Answer 9

orange/milky= chylothorax

gross pus= empyema

Question 10

lymphocytes in pleural effusions are indicative of what?

Answer 10

MALIGNANCY and rarely TB

other etiologies: post CABG, chylothorax, yellow nail syndrome, chronic rheumatoid effusions, sarcoidosis

Question 11

ddx of Glucose< 40

Answer 11

parapneumonic or empyema, rheumatoid, malignancy, TB, esophageal rupture

Question 12

LDH>1000

Answer 12

complicated paraneumonic effusions, malignancies, paragonimiasis

Question 13

ddx amylase

Answer 13

pancreatitis, esophageal rupture, and malignant effusions

Question 14

purulent, odorous effusion, pleural LDH>3200, serum 400

Answer 14

empyema

Question 15

large exudative effusions

Answer 15

malignancy, trauma, parapneumonic effusions, chylothorax, TB

Question 16

malignant pleural effusions usually from? causes?

Answer 16

lung, breast, lymphoma

pleural mets increase permeability and can cause obstruction of pleural lymphatics

Question 17

thoracentesis turns out milky white with high TG

Answer 17

chylothorax

Question 18

pleural fluid accum due to disruption of the thoracic duct due to trauma or tumor

Answer 18

chylothorax

Question 19

pleural fluid comes from

Answer 19

pleural capillaries, interstitium, intrathroracic lymphatics, peritoneal cavity

Question 20

Compare the hydrostatic and oncotic pressure gradients in the pleural space

Answer 20

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

Question 21

Physical exam in someone with a pleural effusion may have:

Present or absent?
fremitus
percussion sound
expansion
breath sounds

Answer 21

absent fremitus

dullness to percussion

reduced expansion on affected side

reduced/absent breath sounds

Question 22

parapneumonic effusions arise as a result of? What are the 3 subclasses?

Answer 22

pneumonia, lung abscess, or bronchiestasis

uncomplicated effusions, complicated effusions, and empyema

Question 23

if you see a loculated effusion, automatically think

Answer 23

empyema

Question 24

If a pleural effusion is milky white and had high cholesterol levels (>200), what would we be worried about?

Answer 24

chyliform effusion (high chol, not TG)

implies long standing effusion

often seen with TB and rheumatoid effusions

Question 25

what are some clinical exam findings in a pneumothorax? treatment?

Answer 25

decreased breath sounds, decreased fremitis, hyper resonance, tracheal deviation, hypotension, tachycardia

tube thoracostomy

Question 26

if you were analyzing a pleural effusion, and saw increased ADA (>70 U/L), what would you think of?

Answer 26

Tuburculosis

Question 27

pH of transudates and exudates?

Answer 27

transudates alkaline and exudates acidic

Question 28

what are some etiologies for eosinophils in pleural effusions?

Answer 28

air and blood most common etiologies

parapneumonic, drugs, asbestos, parasites