Pulmonary effusion & empyema

Question 1

Define pulmonary effusion

Answer 1

• excess amount of fluid in the pleural space (normally up to 25 mL)

Question 2

What causes pulmonary effusion (transudative vs. exudative)?

Answer 2

Transudative:

• CHF
• nephrotic syndrome
• cirrhosis
• PE
• peritoneal dialysis

Exudative:

• Infection
• Malignancy
• Inflammatory
• Trauma

Question 3

How do you distinguish transudative from exudative pulmonary effusion?

Answer 3

Light’s criteria
If at least one criteria is met = exudate. If non is met = transudate.

• Protein pleural/serum: >0.5
• LDH pleural/serum: >0.6
• Pleural LDH: >0.45 uppe limit of normal serum LDH

Question 4

Px of pulmonary effusion

Answer 4

• often asymptomatic
• dyspnea: varies with size of effusion and underlying lung function
• pleuritic chest pain

Question 5

Ix of pulmonary effusion

Answer 5

CXR

- must have >200 mL of pleural fluid for visualization on PA film (blunting of lateral costophrenic angle)
- lateral: >50 mL leads to blunting of posterior costophrenic angle
- Dense opacification of lung fields with concave meniscus
- decubitus: fluid will shift unless it is loculated
- supine: fluid will appear as general haziness

• pleural biopsy: indicated if suspect TB, mesothelioma, or other malignancy (and if cytology negative)

Question 6

Rx of pulmonary effusion

Answer 6

• thoracentesis (removal of pleural cavity fluid with a needle)
• treat underlying cause
• consider indwelling pleural catheter or pleurodesis (pleural space is artificially obliterated) in refractory effusions

Question 7

pulmonary effusion O/E

Answer 7

• inspection: trachea deviates away from effusion, ipsilateral decreased expansion
• percussion: decreased tactile fremitus, dullness (stony dull)
• auscultation: decreased breath sounds, bronchial breathing and egophony at upper level, pleural friction rub

Question 8

What is complicated effusion?

Answer 8

• persistent bacteria in the pleural space, but fluid is non-purulent
• neutrophils, pleural fluid acidosis (pH

Question 9

Rx of empyema

Answer 9

• antibiotic therapy for at least 4-6 wk (rarely effective alone)
• complete pleural drainage with chest tube
• if loculated, more difficult to drain – may require surgical drainage video-assisted thorascopic surgery (VATS)

Question 10

Px of empyema

Answer 10

• fever

- pleuritic chest pain

Question 11

Causes of empyema

Answer 11

• contiguous spread from lung infection (most commonly anaerobes), or infection through chest wall (e.g. trauma, surgery)