Week 2 - Pleural Disease and chest tubes Flashcards
What is Light’s criteria?
Diagnostic criteria for EXudative pleural effusions:
Total protein ratio >0.5 (fluid:serum)
LDH ratio >0.6 (fluid:serum)
LDH fluid level >2/3 ULN
What instances is Light’s Criteria inaccurate?
Pt’s who are on diuretics, add a fluid albumin level to assess for albumin gradient less than or equal to 1.2 is c/w exudate
What are the most common causes of pleural effusions?
Cardiac failure, pneumonia (e.g. parapneumonic), malignancy
What past medical hx suggests a transudative pleural effusion?
Cardiac hx/HF, renal insufficiency, liver disease, hypoalbuminemia – supported if there are bilateral effusions
What is the DDx for pt who presents with trauma and new pleural effusion?
Hemothorax, chylothorax
What are indications for urgent thoracentesis?
Fever and pleurisy r/o empyema
Trauma or on anticoagulation r/o hemothorax
Effusions not responsive to diuresis
Pleural fluid appearance: milky white
chylothorax
Pleural fluid appearance: bloody
hemothorax
What is the diagnostic criteria of hemothorax?
Hct ratio 0.5 or greater (fluid:peripheral)
Pleural fluid appearance: putrid/turbid
empyema, supported by pH <7.20
Pleural fluid appearance: black
aspergillus infection
Pleural fluid appearance: food particles
esophageal rupture
Pleural fluid cell count differential: lymphocyte predominant
malignant, TB, chylothorax, RA, sarcoidosis
Pleural fluid cell count differential: neutrophil predominant
PE, parapneumonic, acute TB, benign effusion 2/2 asbestos exposure
Pleural fluid cell count differential: eosinophil predominant
unclear significance, up to 1/3 of these effusions goes undiagnosed
What percentage of malignant pleural effusions have negative cytology on initial diagnostic tap?
40%
If pleural effusion 2/2 to tuberculosis is suspected, what lab should you send off the pleural fluid?
Adenosine deaminase (can be normal in HIV+ pts with TB)
What is the next step for pleural effusions of unclear etiology and fluid analysis has not been helpful?
Pleural biopsy
When is bronchoscopy indicated to eval pleural effusions?
Typically it is not indicated unless pt with hemoptysis or suspected malignant neoplasm on chest imaging
What are indications for chest tube over thoracentesis?
1) PTX
2) hemothorax, chest trauma
3) empyema/parapneumonic effusions
4) large pleural effusions
5) coagulopathy/increased risk of bleeding
6) bronchopleural fistula
What are the common complications of thoracentesis?
1) PTX, rare and seldom requires subsequent chest tube
2) infection
3) bleeding
4) pleurisy
5) re-expansion pulmonary edema
How is re-expansion pulmonary edema avoided?
Limit total amount of pleural fluid removed to 1.5L
What are contraindications to thoracentesis?
1) coagulopathy
2) infection of overlying skin at point of incision
What are the benefits of tPA-dornase therapy for empyema compared to single agent alone?
1) increased pleural fluid output
2) decreased hospital stays
3) lower requirement of surgical referrals
What was the dose, frequency, and duration of intrapleural fibrinolysis therapy in MIST2 that demonstrated improved outcomes for empyema?
tPA 10mg and dornase 5mg BID x 3 days
A normal pleural space is filled with how much pleural fluid
7-14mL of low-protein fluid to lubricate the lining of the lungs
What aspects of fluid sampling falsely raises pleural fluid pH?
Air in syringe, prolonged time prior to processing, presence of lidocaine
What is trapped lung?
Fibrous visceral pleural thickening that prevents lung re-expansion, thoracentesis alone will not relieve sxs
