Unilateral pleural effusion Flashcards

1
Q

Where does fluid collect?

A

Between the parietal and visceral pleura.

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2
Q

Why does fluid accumulate?

A

· A thin layer of fluid is always present in this space.
· If the normal flow of fluid is disrupted, with either too much produced, or not enough removed, then fluid accumulates.
· This results in a pleural effusion.

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3
Q

Which criteria is used for exudate/transudate differentiation?

A

Light’s criteria.

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4
Q

Who is most affected - males or females?

A

Equal between both sexes but also dependent on cause. Although malignancy pleural effusions more common in women due to breast/gynae malignancies.

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5
Q

What is the primary cause?

A

Imbalance between fluid production and fluid removal.

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6
Q

What normally happens with fluid in this space?

A

· 15ml/day of fluid enters this potential space, primarily from the capillaries of the parietal pleura.
· The fluid is then removed by the lymphatics in the parietal pleura.

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7
Q

What abnormally happens with fluid in this space?

A

· Disruption of fluid regulation from local or systemic derangements.
· Local factors:
- High protein and high LDH - EXUDATE.
- Leaky capillaries from inflammation (infection, infarction, tumour).

· Systemic factors:

  • Low protein and low LDH - TRANSUDATE.
  • Elevated pulmonary capillary pressure (heart failure, cirrhosis, nephrotic syndrome).

· In practice, transudates are often multi-factorial.

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8
Q

What are transudate effusions caused by?

A

Factors that alterhydrostaticpressure, pleuralpermeability, andoncoticpressure.

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9
Q

What does the pleural fluid protein have to be to diagnose a transudate effusion?

A

<30g/L.

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10
Q

What are exudate effusions caused by?

A

Changesto thelocalfactorsthat influence theformationand absorption of pleural fluid.

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11
Q

What does the pleural fluid protein have to be to diagnose a exudate effusion?

A

> 30g/L.

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12
Q

What is the aetiology?

A

· Rate of fluid formation is greater than that of fluid removal.

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13
Q

What is the aetiology of a exudative effusion?

A

Inflammatory processes/decreased lymphatic drainage:

· LOCAL DISEASE. HIGH PROTEIN.
· Infection - Pneumonia, empyema, pleuritis, fungal.
· Malignancy - Lung, breast, pleural.
· Vascular - PE.
· Autoimmune - RA, SLE.
· Abdominal - Pancreatitis, intra-abdominal abscess.
· Surgery - Post CABG.

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14
Q

What is the aetiology of a transudative effusion?

A

Imbalance of oncotic and hydrostatic pressures:

· SYSTEMIC DISEASE. LOW PROTEIN.
· Cardiac - CHF (elevated capillary pressures).
· Vascular - PE.
· Liver - Ascites and cirrhosis (elevated portal pressures).
· Ovarian - Meigs syndrome.
· Autoimmune - Sarcoid.
· Renal - Nephrotic syndrome (hypoalbuminaemia), peritoneal dialysis, glomerulonephritis.

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15
Q

List the strong risk factors.

A

· CHF.
· Pneumonia.
· Malignancy.
· Recent CABG surgery.

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16
Q

List the weak risk factors.

A

· PE.
· Recent MI.
· Occupational lung disease - asbestos exposure.
· RA, SLE.
· Renal failure.
· Drug induced - nitrofurantoin, dantrolene, valproate, isotretinoin.
· Chylothorax.

17
Q

List the common signs and symptoms.

A

· Dyspnoea.
· Dullness to percussion over the effusion - compared with the resonant sound of air-filled spaces.
· Pleuritic chest pain - worse on inspiration and exacerbated by cough and movement.
· Cough.
· Quieter breath sounds - over the area of effusion.
· Decreased or absent tactile fremitus - fluid barrier prevents sound waves and vibrations.

18
Q

What investigations would you do if you suspected a patient had a pleural effusion?

A
· PA and lateral CXR - blunting of the costophrenic angles. 
· Pleural USS. 
· Pleural fluid sample.
· FBC, CRP. 
· CT chest.
19
Q

What would you look at in a pleural fluid sample?

A

· LDH and protein – indicates an exudate if the ratio of pleural fluid protein to serum protein is >0.5 – absence of these findings the effusion is likely to be a transudate.
· RBCs.
· WBCs.
· pH - needs to be measured with an ABG machine.
· Glucose - almost 100% of effusions due to empyema and rheumatoid arthritis.

20
Q

Differentials?

A

· Pleural thickening.
· Pulmonary collapse and consolidation.
· Elevated hemidiaphragm - paralysis of the phrenic nerve.

21
Q

What is the treatment for CHF?

A

· Diuretic - furosemide, bumetanide.
· Physio.
· Therapeutic thoracocentesis and oxygen - if symptomatic and large.

22
Q

What is the treatment for an infective effusion?

A
· IV abx - co-amoxiclav and metronidazole. 
· Therapeutic thoracocentesis.
· Physio.
· Oxygen - if symptomatic and large. 
· Tube thoracostomy - if empyema.
23
Q

What is the treatment for a malignant effusion?

A

· Therapeutic thoracentesis.
· Physio.
· Oxygen - if symptomatic and large.

24
Q

What is the treatment for recurrent symptomatic malignant effusions?

A

· Repeated therapeutic thoracocentesis.
· Pleurodesis - with talc.
· Pleural catheter drainage.

25
Q

Complications?

A
· Atelectasis/lobar collapse. 
· Pneumothorax following thoracocentesis. 
· Re-expansion pulmonary oedema. 
· Pleural fibrosis - TB. 
· Trapped lung.