Pleural Effusions

Question 1

Pleural fluid (normal function)

Answer 1

Allows the parietal and visceral pleura layers to slide smoothly, provides some surface tension so that pleural membranes can stick together.
Too much - problem with production (inflammatory) or problem with lack of absorption.

Question 2

Pleural effusion

Answer 2

Abnormal collection of fluid in the pleural space.

Question 3

Clinical Presentation

Answer 3

Breathlessness
Pleuritic chest pain
Can be asymptomatic

Question 4

Clinical Signs

Answer 4

Palpation: Decreased chest expansion, trachea deviated away from the effusion
Percussion: stoney dull
Auscultation: decreased breath sounds, decreased vocal resonance

Question 5

Investigations

Answer 5

CXR - fluid fills from bottom to top (white), blunt costophrenic angles

US - identifies presence of pleural fluid

Pleural aspiration (thoracentesis) - sample of pleural fluid to visualise the gross appearance

Biopsy - if pleural fluid analysis is negative

Question 6

Transudate

Answer 6

protein < 30 g/L
Bilateral, small effusions
Likely to be due to a pathology out with the lungs :- cardiac failure, cirrhosis, hypoalbuminaemia, hypothyroid

Question 7

Exudate

Answer 7

Protein >30 g/L
Large, unilateral effusions - more worrying
Inflammatory active process
Cause: infection, malignancy, trauma, infarction

Question 8

Pleural fluid colours (pleural effusion)

Answer 8

Straw coloured - cardiac failure, hypoalbuminaemia

Blood coloured - trauma, infection, malignancy, infarction

Question 9

Management

Answer 9

Depends largely on cause.

Repeat aspiration - second sample can increase yield

Drainage (talc) - talc powder inserted in a pleural drain to pleural space and is recognised as ‘non self’ so results in an intense inflammatory reaction which causes pleura and chest wall to bind tightly together.

Drainage (pleural catheter) - patient controls own effusions.