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Respiratory > Pleural effusion > Flashcards

Pleural effusion Flashcards

1
Q

What is a pleural effusion?

A

Collection of fluid in the pleural cavity

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2
Q

What are the different types of pleural effusions?

A

Exudate = > 3g/dL of protein

Transudate = < 3g/dL of protein

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3
Q

What is Light’s criteria?

A

pleural fluid protein / serum protein = > 0.5

pleural fluid LDH / serum LDH = > 0.4

pleural fluid LDH is > 2/3 the upper limit of the lab normal value for serum LDH

Exudate = one or more of the criteria above met

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4
Q

What are the common causes of transudates?

A

‘the failures’

  • heart failure
  • liver failure (cirrhosis)
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5
Q

What are the less common causes of transudates?

A
  • hypoalbuminaemia
  • nephrotic syndrome
  • peritoneal dialysis
  • hypothyroidism
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6
Q

What are the rare causes of transudates?

A

Meigs’ syndrome (benign ovarian tumour, ascites, pleural effusion?

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7
Q

What are the common causes of exudates?

A
  • infection (parapneumonic, TB)
  • malignancy
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8
Q

What are the less common causes of exudates?

A
  • pulmonary infarction
  • autoimmune diseases (e.g., rheumatoid arthritis)
  • pancreatitis
  • post-MI (Dressler’s syndrome)
  • post coronary artery bypass grafting (CABG)
  • asbestos
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9
Q

What are the rare causes of exudates?

A
  • yellow nail syndrome
  • drugs (e.g., methotrexate, amiodarone, nitrofurantoin, phenytoin)
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10
Q

What are other causes of fluids in the pleural cavity?

A

Haemothorax

Empyema

Chylothorax - chyle in the pleural space due to disruption of the thoracic duct (due to a neoplasm, trauma or infection/inflammation)

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11
Q

What are the clinical features of a pleural effusion?

A

SOB

Percussion dullness over the effusion

Reduced breath sounds

Trachea deviation/mediastinal shift away from effusion if it is big

Pleuritic chest pain

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12
Q

Apart from SOB, cough and pleuritic chest pain, what are the other important areas to cover in the Hx?

A

Symptoms suggestive of lung cancer:
- haemoptysis
- weight loss

Symptoms suggestive of heart failure:
- orthopnoea
- paroxysmal nocturnal dyspnoea
- leg swelling

Symptoms suggestive of infection:
- productive cough
- fever

Social history
- smoking history (lung cancer risk)
- asbestos exposure (mesothelioma)

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13
Q

What lab Ix would you do for a pleural effusion?

A

FBC/CRP/blood culture : look for infection

ABG : if oxygenation is affected

D-dimer : if PE is suspected

LFTs, U&Es, albumin, coagulation profile : look for liver and renal disease

Amylase : if pancreatitis is suspected

TFTs : if hypothyroidism is suspected

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14
Q

What should be done with the pleural fluid?

A

Note appearance : purulent = infection, blood = malignancy/PE/trauma

Send for:
- biochemistry
*protein
*LDH
*glucose
- microbiology (gram stain and culture)
- cytology

If fluid not purulent use blood gas machine to analyse pH

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15
Q

If the pleural fluid protein is 25-35g/L, how would you distinguish transudative from exudative pleural effusions?

A

Light’s criteria

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16
Q

What does a pleural fluid pH < 7.3 indicate?

A

Malignancy

Pleural infection

Rheumatoid arthritis

TB

Oesophageal rupture

17
Q

Which pH indicates that drainage is needed in parapneumonic effusions?

A

< 7.2

18
Q

What is the medical Mx of pleural effusions?

A

Smaller pleural effusion = could observe

Diuretic in HF

Antibiotics in infection

Pleural fluid aspiration/chest drain insertion under USS for symptomatic patients with larger pleural effusions

19
Q

If the pleural fluid reaccumulates despite medical Mx, what can be done?

A

Long-term indwelling chest drain

Pleurodesis - by chest drain or medical thoracoscopy

20
Q

What is the surgical Mx of pleural effusions?

A

Video assisted thoracic surgery (VATS) by a thoracic surgeon

21
Q

What are the complications of pleural effusions?

A

Increasing resp compromise

In parapneumonic effusions = empyema and sepsis

Pneumothorax - can be due to pleural procedures done during Dx and Mx

Patients with malignancy or pneumonia have poorer prognosis if pleural effusion develops

22
Q

How do chest drains work?

A

Creates a one-way mechanism - lets air/fluid out of pleural space but prevents air/fluid entering pleural space

Accomplished via an underwater seal

Distal end of drainage tube is submerged in 2cm of H2O

Flexible plastic tube inserted through chest wall in between pleural space between 5th and 6th intercostal space in mid-axillary line

23
Q

How do you know a chest drain is working?

A

Swinging = movement of fluid up and down the tube

Bubbling = air bubbles inside fluid contained in chest-drain bottle

24
Q

If the chest drain is swinging but not bubbling what does this indicate?

A

Chest drain should be removed - no longer needed

25
Q

What is an empyema?

A

Pus in the pleural space

26
Q

When should you suspect an empyema?

A

If a patient with a resolving pneumonia develops a recurrent fever

27
Q

What are the characteristics of a aspirated pleural fluid that is suspected to be an empyema?

A

Typically yellow + turbid

pH < 7.2

Reduced glucose

Increased LDH

28
Q

How should an empyema be managed?

A

Drain using a chest drain inserted under radiological guidance

Intrapleural alteplase and dornase alfa can help with empyema

29
Q

How should you do a diagnostic aspiration/chest drain insertion in a pleural effusion?

A

Percuss the upper border of the pleural effusion and choose a site 1 or 2 intercostal spaces below it (don’t go too low or you’ll be in the abdomen!).

Infiltrate down to the pleura with 5–10mL of 1% lidocaine.

Attach a 21G needle to a syringe and insert it just above the upper border of an appropriate rib (avoids neurovascular bundle).

Draw off 10–30mL of pleural fluid and send it to the lab for clinical chemistry (protein, glucose, pH, LDH, amylase), bacteriology (microscopy and culture, auramine stain, TB culture), cytology, and, if indicated, immunology (rheumatoid factor, ANA, complement).

For draining, fluid is best removed slowly (i.e., 0.5-1.5L/24h)

30
Q

Sources

A

https://zerotofinals.com/medicine/respiratory/pleuraleffusion/

https://geekymedics.com/pleural-effusion/

https://www.physio-pedia.com/Chest_Drains

https://www.guysandstthomas.nhs.uk/health-information/chest-drain

Empyema + how to do diagnostic aspiration/chest drain info = pg 170, 193 Oxford Handbook of Clinical Medicine 10th Edition

Respiratory (10 decks)

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