2: Pleural Effusion

Question 1

What is a pleural effusion

Answer 1

Fluid in pleural space

Question 2

How are effusions divided

Answer 2

Into either exudates or transudates depending on protein content

Question 3

What is an exudate

Answer 3

Protein >30g/L

Question 4

What are the 4 etiological categories of exudate

Answer 4

• Infectious
• Malignant
• Autoimmune
• Other

Question 5

What 3 infections can cause exudate

Answer 5

Pneumonia
TB
Empyema

Question 6

What malignancies can cause exudate

Answer 6

Primary lung
Mets
Lymphoma
Mesothelioma

Question 7

What are 4 autoimmune causes of exudate

Answer 7

RA
Sarcioidosis
SLE
Vasculitis

Question 8

What are 4 other causes of exudate

Answer 8

PE
Haemothorax
Chylothorax
Pancreatitis

Question 9

What is a transudate

Answer 9

Protein content less than 30g/L

Question 10

What are the 3 etiological categories of transudates

Answer 10

• Increase venous pressure
• Protein deficiency
• Other

Question 11

What are 3 causes of increase venous pressure

Answer 11

HF
Constrictive pericarditis
Fluid Overload

Question 12

What are 3 causes of protein deficiency

Answer 12

Cirrhosis
Protein-losing enteropathy
Nephrotic syndrome

Question 13

What are 2 other causes of transudate

Answer 13

Hypothyroidism

Meig’s syndrome

Question 14

What is Meig’s syndrome

Answer 14

Ovarian fibroma and right pleural effusion

Question 15

What defines a small pleural effusion

Answer 15

Less than 200ml

Question 16

How do small pleural effusions present

Answer 16

Asymptomatic

Question 17

How do large pleural effusions present

Answer 17

• Dyspneoa
• Pleuritic chest pain
• Dry non-productive cough

Question 18

Why do large pleural effusions cause dyspneoa

Answer 18

Compress lung

Question 19

In large effusions, explain position trachea

Answer 19

Will be deviated away from the lesion

Question 20

What is first-line investigation for pleural effusion

Answer 20

PA CXR

Question 21

When can pleural effusion only be seen on CXR

Answer 21

> 600ml

Question 22

How does pleural effusion present on CXR

Answer 22

• Blunting costophrenic or cardiophrenic angle
• Fluid in horizontal or oblique fissures
• Visible meniscus
• Mediastinal shift away from side affected - if large

Question 23

What is second-line for pleural effusion

Answer 23

US-Guided needle aspiration

Question 24

What criteria may be used to evaluate pleural effusion

Answer 24

Light’s Criteria

Question 25

When is lights criteria used

Answer 25

If protein in fluid is borderline 25-35g/L

Question 26

What does lights criteria state

Answer 26

That if any of the following are present, the fluid is more likely a exudate than transudate: 1. Pleural protein/Serum protein >0.5 2. Pleural LDH/Serum LDH >0.5 3. Pleural LDH in upper 2/3rd of normal LDH

Question 27

What does low glucose in pleural fluid imply

Answer 27

- TB | - RA

Question 28

What does raised amylase in pleural fluid indicate

Answer 28

- Pancreatitis | - Oesophageal perforation

Question 29

What does blood stained pleural effusion indicate

Answer 29

- TB - PE - Mesothelioma

Question 30

What is third-line investigation for pleural effusion

Answer 30

Contrast CT

Question 31

How are pleural effusions managed

Answer 31

Treat cause | May use chest drain

Question 32

What are 3 indications for placing a chest tube in pleural effusion

Answer 32

1. Cloudy fluid 2. pH less than 7.2 3. Symptomatic

Question 33

At what rate should fluid be removed from chest tube in pleural effusion

Answer 33

1.5L per 24h

Question 34

What are methods to manage recurrent pleural effusions

Answer 34

- Recurrent aspiration - Pleurodesis - Indwelling catheter - Opioids to relieve breathlessness