Station 1.10: Pleural effusion

Question 1

Clinical signs

What are the clinical signs of Pleural effusion?

Pleural effusion

This patient has been breathless for 2 weeks. Examine his respiratory system to elucidate the cause.

Answer 1

• Asymmetrically reduced expansion
• Trachea or mediastinum displaced away from side of effusion
• Stony dull percussion note
• Absent tactile vocal fremitus
• Reduced breath sounds
• Bronchial breathing above (aegophony

Question 2

Clinical signs

What are the signs that may indicate the cause of Pleural effusion?

Pleural effusion

This patient has been breathless for 2 weeks. Examine his respiratory system to elucidate the cause.

Answer 2

• Cancer: clubbing; lymphadenopathy; mastectomy (breast cancer being a very common
  cause of pleural effusion)
• Congestive cardiac failure: raised JVP; peripheral oedema
• Chronic liver disease: leuconychia, spider naevi gynaecomastia
• Chronic renal failure: arteriovenous fistula
• Connective tissue disease: rheumatoid hands; butterfly rash of SLE

Question 3

Clinical signs

What are the Causes of a dull lung base in Pleural effusion?

Pleural effusion

This patient has been breathless for 2 weeks. Examine his respiratory system to elucidate the cause.

Answer 3

• Consolidation: bronchial breathing and crackles
• Collapse: tracheal deviation towards the side of collapse and reduced breath sounds
• Previous lobectomy = reduced lung volume
• Pleural thickening: signs are similar to a pleural effusion but with normal tactile vocal fremitus; may have three scars suggestive of previous VATS pleuradesis
• Raised hemidiaphragm ± hepatomegaly

Question 4

Discussion

What are the Causes of Pleural effusion?

Pleural effusion

This patient has been breathless for 2 weeks. Examine his respiratory system to elucidate the cause.

Answer 4

Transudate (protein <30g/L)          Exudate (protein >30g/L)
Congestive cardiac failure            Neoplasm: 1° or 2°
Chronic renal failure                 Infection       
Chronic liver failure                 Infarction
                                     Inflammation: RA and SLE

Question 5

Discussion

What is Pleural aspiration (exudate) in Pleural effusion?

Pleural effusion

This patient has been breathless for 2 weeks. Examine his respiratory system to elucidate the cause.

Answer 5

• Protein: effusion albumin/plasma albumin >0.5 (Light’s criteria)
• LDH: effusion LDH/plasma LDH >0.6
• Empyema: an exudate with a low glucose and pH <7.2 is suggestive

Question 6

Discussion

What is Empyema in Pleural effusion?

Pleural effusion

This patient has been breathless for 2 weeks. Examine his respiratory system to elucidate the cause.

Answer 6

• A collection of pus within the pleural space
• Most frequent organisms: anaerobes, staphylococci and Gram‐negative organisms
• Associated with bronchial obstruction, e.g. carcinoma, with recurrent aspiration; poor
  dentition; alcohol dependence

Question 7

Discussion

What is Treatment for Pleural effusion?

Pleural effusion

This patient has been breathless for 2 weeks. Examine his respiratory system to elucidate the cause.

Answer 7

• Pleural drainage and IV antibiotics intrapleural DNAse plus TPA (MIST 2 Trial)
• Surgical decortication

Question 8

Discussion

What is Treatment for Pleural effusion?

Pleural effusion

This patient has been breathless for 2 weeks. Examine his respiratory system to elucidate the cause.

Answer 8

• Pleural drainage and IV antibiotics intrapleural DNAse plus TPA (MIST 2 Trial)
• Surgical decortication