Pleural Effusions -GOya

Question 1

Which pleura produces fluid? Which reabsorbs fluid?

Answer 1

Parietal produces pleural fluid and receives blood supply from systemic capillaries

visceral pleura is supplied by bronchial circulation and reabsorbs the pleural fluid

Question 2

How does the parietal pleura communicate with the pleural space?

Answer 2

Stomas

Question 3

Which pleura has nerve innervation?

Answer 3

Parietal ONLY

visceral does not have pain fibers

Question 4

What is the leading cause of pleural effusion in the united states? What kind of effusion is this?

Answer 4

CHF

Transudate

Question 5

What is the difference between transudative and exudative effusion? Which is an inflammatory response?

Answer 5

Transudative Effusion:

• Abnormalities in the Starling law
• Fluid will accumulate until pleural fluid formation is equal to absorption
• ex: heart failure

Exudative Effusion:

• Increase permeability of pleural space to proteins with impaired lymphatic flow
• inflammatory*
• ex: parapneumonic, malignancy

Question 6

What are some symptoms of pleural effusion?

Answer 6

pleural chest pain

inflammation of the diaphragm –> ipsilateral shoulder pain

nonproductive cough

dyspnea

Question 7

What are some PE findings associated with Pleural effusions?

Answer 7

Dullness to percussion

Decrease tactile fremitus

Decrease breath sounds

Pleural friction rub

Question 8

What chest x-ray findings would you expect in pleural effusion?

Answer 8

Effusions appear as a homogeneous density through which lung markings maybe seen

Upper margins of fluid forms a meniscus at the lateral chest wall

200 cc needed to blunt costophrenic angle

Question 9

What is a chest ultrasound good for?

Answer 9

Localizing pleural fluid

provide the best spot for biopsy or thoracentesis

Question 10

What is a chest CT helpful in determining?

Answer 10

distinguishing lung abscess from empyema

Question 11

How can you determine exudative vs transudative effusion?

Answer 11

thoracentesis
(should be performed in all newly diagnosed pleural effusions)

35-50 cc needed for analysis

exudative meets at least one of the criteria:

• Pleural fluid protein/serum protein ratio > 0.5
• Pleural fluid LDH/serum LDH ratio > 0.6
• Pleural fluid LDH > 2/3 upper limit for serum LDH

Question 12

In our patient thoracentesis is performed which reveals the following information:
•Cell count-RBC 150,000; WBC 980 with 20% neutrophils, 55% lymphocytes, 10% mesothelial cells & 15% eosinophils
•Total protein 4.5 mg/dl
•LDH 1200U/L, Glucose 45 mg/d, pH 7.2
•Pleural fluid gram stain is negative, cultures & cytology pending

Is the pleural fluid exudate or a transudate?

Answer 12

exudative

Question 13

What can whitish pleural fluid be due to? Brown fluid? Black pleural fluid?

Answer 13

Whitish: chyle, cholesterol, empyema

brown: ameobic liver abscess

black =aspergillus

Question 14

If the pleural fluid LDH is > 1000 (IU/L), what should be suspected ?

Answer 14

empyema

TB pleurisy

Question 15

What does pleural fluid with low glucose levels typically have? What can cause this?

Answer 15

normally also has low pH and high LDH

causes:
- parapneumonic effusion (empyema)
- malignant pleural effusion
- TB

Question 16

What can elevated pleural fluid amylase indicate?

Answer 16

• Acute pancreatitis
• Pancreatic pseudocyst (amylase levels >100,000U)
• Esophageal rupture-50% mortality if not repaired in 24 hrs
• Malignant disease
• Rupture ectopic pregnancy

Question 17

What does a high lymphocyte count (>50%) in the pleural effusion suggest?

Answer 17

TB

TB effusion may occur in the absence of CXR evidence of active TB

Question 18

What does a high WBC count suggest?

Answer 18

empyema/ infection

Question 19

What can a bloody pleural effusion indicate?

Answer 19

Trauma

Pulmonary Embolus

Malignancy

Asbestos Pleural Effusion

Question 20

What diagnostic test is 92% diagnostic for malignancy and 100% for TB? What are some side effects of this test?

Answer 20

thoracoscopy

SE:
pneumothorax, hemothorax, site pain, transient fever, empyema, subcutaneuous emphysema

Question 21

What is the standard of care for affections Pleural effusion?

Answer 21

Pleurodesis

Question 22

What kind of pleural effusion will be seen in CHF?

Answer 22

normally bilateral, transudative effusion

Question 23

What are the characteristics of liver cirrhosis leading to pleural effusion?

Answer 23

normally on the right side

fluid moves from peritoneal to pleural cavity by diaphragm defects

transudate effusion

Question 24

What is the difference between parapneumonic effusion and empyema?

Answer 24

Complicated parapneumonic effusion:

• pH < 7.20
• LDH > 3x upper limit for serum levels
• Glucose < 60 mg/dl

Empyema: (in addition to the symptoms above)

• Positive gram stain/culture
• Frank pus

Question 25

When should an empyema or parapneumonic effusion be drained?

Answer 25

- Fluid layer > 1cm on decubitus films - Loculated fluid on imaging( need thoracoscopy with breakdown of adhesions) - Effusion > 50% of hemithorax - Persistent signs of infection/SOB after treatment

Question 26

What primary tumors are the most common to metastasize to the pleura? What are these carcinomatous effusions like?

Answer 26

lung, breast, stomach & ovary normally involve the mediastinum, moderate to massive in size, frequently hemorrhagic and always exudative

Question 27

What are some characteristics of a rheumatoid effusion?

Answer 27

found in men with rheumatoid nodules and high serum rheumatoid factors effusions may not produce symptoms low glucose and pH exudative

Question 28

What are the characteristics of chylothorax? What are the causes?

Answer 28

milky pleural fluid > triglycerides > 110 > cholesterol chylomicroms from: lymphoma and trauma to the thoracic duct