Pleural Effusion

Question 1

What is the pleurisy?

Answer 1

inflammation of the pleura that causes sharp pain with breathing.

Question 2

What is the pleural effusion?

Answer 2

excess fluid in the pleural space

Question 3

What is empyema?

Answer 3

collection of pus in the pleural space. ‘

Question 4

What is he hemothorax?

Answer 4

buildup of blood in the pleural space.

Question 5

What is the pneumothorax?

Answer 5

buildup of air or gas in the pleural space.

Question 6

What is pleural space (cavity), the parietal pleura and visceral pleura?

Answer 6

Pleural space (cavity) in a healthy
patient is a potential space sandwiched between the parietal and visceral pleurae.

• The parietal pleura completely
lines the inner chest wall surface of the thoracic cavity.

• The visceral pleura tightly
envelopes both lungs completely, meeting the parietal pleura at the hilar root of the lungs.

Question 7

How does pleural effusion occur?

Answer 7

1-Usually result from excess
fluid production
2-decreased lymphatic absorption.

Question 8

What are the two factors that responsible for increasing the production fluid in patients with pleural effusion?

Answer 8

1.Increased hydrostatic pressure.( increased heart pressure)

2.Decreased osmotic pressure.( hypoalbuminemai)

3.Increased microvascular permeability/pressure any inflammatory disease can cause this )

Question 9

What is the normal amount fluid that pleural space contain?

Answer 9

10 to 20 mL

Question 10

What is the transudative effusion?

Answer 10

1- trnasudative effusion:
Result from an imbalance in oncotic and hydrostatic pressures.

Causes:
1.Congestive heart failure ( bilateral effusion)

2.Cirrhosis (hepatic hydrothorax) 3.Atelectasis

4.Hypoalbuminemia ( bilateral)

5.Nephrotic syndrome 6.Peritoneal dialysis 7.Urinothorax
8.Cerebrospinal fluid (CSF) leaks to the pleura (in the setting of ventriculopleural shunting or of trauma/surgery to the thoracic spine)

Question 11

Pleural effusion can be either, mention the two types?

Answer 11

1- Transudative effusion

2- Exudative effusion

Question 12

What is the exudative effusion?

Answer 12

Result mainly from inflammation and malignancies and
increased microvascular permeability.

1. Tuberculosis (Lymphocytes).
2. Pneumonia (parapneumonic effusion).
3. Malignant disease (malignant effusion)
4. Asbestos-related pleural effusion
5. Pulmonary infarction (Red blood cells).
6. Rheumatoid disease (Lymphocytes)
7. Systemic lupus erythematosus (Lymphocytes)
8. Acute pancreatitis (Higher amylase in pleural fluid than in serum)

Question 13

What is parapneumonic effusion?

Answer 13

If the patient has Pneumonia and then develops pleural effusion

Question 14

What are symptoms or presentation of pleural effusion?

Answer 14

1. Dyspnea:
   • Most common symptom associated with pleural effusion
   • In many patients, drainage of pleural fluid alleviates dyspnea despite
   • Note that dyspnea may be caused by the condition producing the pleural effusion, such as underlying
   intrinsic lung or heart disease or obstructing endobronchial lesions rather than by the effusion itself.
2. Cough:
   • Often mild and nonproductive. • More severe cough or the production of purulent or bloody sputum suggests an underlying pneumonia or
   endobronchial lesion.
3. Chest pain:
   • Raises the likelihood of an exudative etiology, such as pleural infection, mesothelioma(any malignant disease), or pulmonary infarction.
   • Pain may be mild or severe. It is typically described as sharp or stabbing and is exacerbated with deep
   inspiration.

Question 15

If a patient comes with pleural effusion symptoms + lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea, what is the mots likely diagnosis?

Answer 15

may all occur with congestive heart failure.

Question 16

If a patient comes with pleural effusion symptoms + night sweats, fever, hemoptysis and weight loss, what is the diagnosis?

Answer 16

TB

Question 17

What is the physical examination in pleural effusion patients ?

Answer 17

1-Typically, there are no clinical findings for effusions less than 300 mL.

2-Dullness to percussion.

3-Decreased tactile fremitus( in palpation).

4- Asymmetrical chest expansion, with diminished or delayed expansion on the side of the effusion.

5- Egophony ( on auscultation) (known as “E-to-A” changes). Decrease breath sound

Question 18

What do we find in chest x ray in pleural effusion pateints?

Answer 18

Right side pleural effusion
(blunting of the costophrenic angle)

Question 19

What is the investigation other than chest x ray of pleural effusion?

Answer 19

Point of care ultrasound ( PoCUS)

Question 20

What is the diagnostic investigation of pleural effusion?

Answer 20

Thoracentesis ( for light criteria)

Helps to distinguish pleural fluid transudates
from exudates.

Question 21

Do we need to do thoracentesis to every patients who has pleural effusion?

Answer 21

No.

• Should be performed for new and unexplained
pleural effusions or effusion that does not respond to therapy as expected when sufficient fluid is present.

Pleural effusions do not require thoracentesis if
they are too small to safely aspirate.

Question 22

What are the gross
characteristics of the fluid obtained during thoracentesis exudative pleural effusions ?

Answer 22

1. Frankly purulent fluid indicates an empyema.
2. A putrid odor suggests an anaerobic empyema.
3. A milky, opalescent fluid suggests a chylothorax, resulting most often from lymphatic obstruction by malignancy or thoracic duct injury by trauma or surgical procedure
4. Grossly bloody fluid may result from trauma, malignancy, traumatic tap, pulmonary
   infarction or asbestos-related effusion.
5. Black pleural fluid suggests a limited number of diseases, including infection ( fungal infection) with Aspergillus
   niger or Rizopus oryzae, malignant melanoma, non-small cell lung cancer

Question 23

What are the normal pleural fluid ?

Answer 23

Normal pleural fluid has the following characteristics:

• Clear ultrafiltrate of plasma that originates from the
parietal pleura

• PH of 7.60-7.64

• Protein content of less than 2% (1-2 g/dL)

• Fewer than 1000 white blood cells (WBCs) per cubic
millimeter

• Glucose content similar to that of plasma

• Lactate dehydrogenase (LDH) less than 50% of plasma

Question 24

What are the light’s criteria of pleural effusion types ?

Answer 24

Light’s Criteria are used to determine whether a pleural effusion is exudative or transudative.

Satisfying any ONE criterium means it is exudative:

1- Pleural Total Protein/Serum Total Protein ratio > 0.5.

2- Pleural lactate dehydrogenase/Serum lactate dehydrogenase ratio > 0.6.

Always send pleural fluid for protein, LDH, glucose, pH, gram stain and culture and cytoloy ( if suspected malignancy). Also serum LDH and protein

Question 25

What are the complication of thpracentesis?

Answer 25

.1- Puncture site, cutaneous or internal bleeding from laceration of an intercostal artery or spleen/liver puncture. 2- Pneumothorax. 3- Infection. 4-Reexpansion pulmonary edema (when removing more than 1.5 L at a time)

Question 26

What are contraindications to diagnostic thoracentesis include?

Answer 26

• Bleeding diathesis or systemic anticoagulation. • cutaneous disease over the proposed puncture site.

Question 27

How to manage pleural effusion?

Answer 27

1. Treat the underline condition (e.g. heart failure, pneumonia, PE or subphrenic abscess). 2. Therapeutic thoracentesis to palliate breathlessness. 3. Chest tube (indication: large effusion >50% of hemithorax, loculated effusion, complicated Parapneumonic effusion, empyema or sepsis from pleural source). 4. Pleurodesis (for recurrent effusion). 5. Indwelling tunneled pleural catheters (for recurrent effusion)

Question 28

Where is the site for chest tube?

Answer 28

4th - 5th intercostal space

Question 29

What is the Parapneumonic effusion and types?

Answer 29

Exudative plural effusion secondary to pneumonia. 1. Uncomplicated: • Effusion is clear. pH >7.2, LDH <1000, glucose <60 mg/dl. Gram stain and culture are negative. • Treatment with antibiotics. 2. Complicated: • Effusion is cloudy. pH <7.2, LDH >1000, glucose <60 mg/dl. Gram stain and culture are positive. • Effusion can be loculated. • Treatment with antibiotics (intravenous ceftriaxone + metronidazole) and chest tube drainage.

Question 30

What are the symtoms of empyema?

Answer 30

Symptoms include 1-severe pleuritic chest pain, 2-persisting or recurrent fever. ,3-dyspnea, 4- rigors and sweating, despite appropriate antibiotic treatment

Question 31

Empyema caused by?

Answer 31

always secondary to infection in a neighboring structure, usually the lung. Most commonly due to the bacterial pneumonias and tuberculosis.

Question 32

How to investigate a patient with empyema?

Answer 32

Chest X-ray, Ultrasound and CT chest. - Thoracentesis >> Fluid is thick and turbid pus. Pleural fluid glucose <60 mg/dL (or < 30 mg/dl), LDH >1000 IU/L, or a fluid pH <7.0 - 7.1. Gram stain and culture are positive.

Question 33

How to treat empyema?

Answer 33

Treatment should include: 1. Removal of all the pus from the pleural space by chest tube. 2. Antibiotics: - If the organism is identified, the appropriate antibiotic should be given for 2–4 weeks. - If not Identified, intravenous ceftriaxone + metronidazole for 2–4 weeks

Question 34

What distinguish hemothorax?

Answer 34

Hematocrit distinguish hemothorax from bloody exudate: 1. Hemothorax: Hematocrit in pleural fluid ≥ 50% of peripheral blood hematocrit. 2. Bloody exudative pleural effusion : Hematocrit in pleural fluid < 50% of peripheral blood hematocrit (caused by malignancy or pulmonary infarction)

Question 35

What is the treatment of hemothorax?

Answer 35

Chest tube to drain blood

Question 36

Pneumothorax can be ?

Answer 36

1. Primary spontaneous (risk factors): - Smoking. - Tall and thin stature. - presence of apical subpleural blebs. 2. Secondary spontaneous pneumothorax affects patients with pre-existing lung disease and is associated with higher mortality rates 3. Result from iatrogenic injury or trauma to the lung or chest wall. ( thoracocentisi) an example

Question 37

What type of pnemothorax is medical emergency?

Answer 37

Tension type ( likd a valve )

Question 38

What is the closed type pneumothorax?

Answer 38

communication between the airway and the pleural space seals off as the lung deflates and does not re-open

Question 39

What is the open type of pneumothorax?

Answer 39

communication fails to seal and air continues to pass freely between the bronchial tree and pleural space

Question 40

What is the tension type of pneumothorax?

Answer 40

communication between the airway and the pleural space acts as a one-way valve, allowing air to enter the pleural space during inspiration but not to escape on expiration (tension pneumothorax)

Question 41

Clincal features of pneumothorax?

Answer 41

• Sudden-onset unilateral pleuritic chest pain or breathlessness. • Decreased or absent breath sounds. • The combination of absent breath sounds and a resonant percussion note is diagnostic of pneumothorax. • In tension pneumothorax there is rapidly progressive breathlessness associated with a marked tachycardia, hypotension, cyanosis and tracheal displacement away from the side of the silent hemithorax

Question 42

Sudden onset chest pain or sudden onset dyspnea and and no breath sound on auscultation, what is the diagnosis?

Answer 42

Always pneumothrax until proven otherwise

Question 43

What do we see in chest x ray of pneumothrax?

Answer 43

Collapsed lung

Question 44

What are the signs and symptoms of tension pneumothorax?

Answer 44

In tension pneumothorax there is rapidly progressive breathlessness associated with a marked tachycardia, hypotension, cyanosis and tracheal displacement away from the side of the silent hemithorax

Question 45

How to mange pneumothorax?

Answer 45

Management: Chest tube +/- percutaneous needle aspiration. In tension pneumothorax, immediate percutaneous needle decompression prior to insertion of the chest tube

Question 46

Recurrent spomtaneuos pneumothorax is treated with?

Answer 46

Pleurodesis is recommended in all patients following a second pneumothorax Should prompt definitive treatment.