Pleural effusion

Question 1

Imaging management for pleural effusion

Answer 1

• PA CXR
• USS guided aspiration
• Contrast CT to find cause - esp in exudative effusions

Question 2

How to manage pleural aspirate?

Answer 2

• USS guided
• 21G needle, 50ml syringe
• Send fluid for pH, LDH, protein, cytology and microbiology

Question 3

How to determine if exudate or transudate?

Answer 3

If protein level >30g/L = exudate
If <30g/L = transudate
If between 25-35g/L - apply Lights criteria

Question 4

Lights criteria for exudate

Answer 4

• Pleural fluid protein / serum fluid protein >0.5
• Pleural LDH / serum LDH >0.6
• Pleural LDH more than 2/3 upper limit of serum LDH

Question 5

What does low glucose in effusion suggest?

Answer 5

• Rheumatoid arthiritis
• Tuberculosis

Question 6

What does raised amylase suggest in effusion?

Answer 6

• Pancreatitis
• Oeseophageal perforation

Question 7

What does heavy blood staining suggest in effusion?

Answer 7

• Mesothelioma
• Tuberculosis
• PE

Question 8

Management of pleural effusion with infection

Answer 8

• If the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage
• If the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed

Question 9

Managment options for recurrent pleural effusions

Answer 9

• Recurrent aspiration
• Pleurodesis - using sterile talc, higher success rate - can do this via chest drain or thoracoscopsy
• Indwelling pleural catheter
• Drug management to relieve symptoms eg opiods for dyspnoea

Question 10

How is pleurodesis done with chest drain?

Answer 10

• Lung pleura is numbed using lidocaine solution into cavity
• Sterile talc is inserted up chest drain with saline - irritates pleura causing to stick together and remove any air space between them so fluid can no longer collect here

Question 11

Causes of transudate pleural effusion

Answer 11

• Heart failure
• Hypoalbuminaemia - liver disease, nephrotic syndrome, malabsorption
• Hypothyroidism
• Meig’s syndrome

Question 12

Cause of exudative effusions

Answer 12

• Infection - pneumonia, TB, subphrenic abscess
• Neoplasm - mesothelioma, metastases, lung cancer
• CT disease - SLE, RA
• Pancreatitis
• PE
• Dresslers syndrome
• Yellow nail syndrome

Question 13

Presenting symptoms of pleural effusion

Answer 13

• Dyspnoea
• Cough
• Chest pain?

Question 14

Examination findings for pleural effusion

Answer 14

• Dullness to percussion
• Reduced breath sounds
• Reduced chest expansion

Question 15

Classic presentation of empyema

Answer 15

• Not recovered with abx following pneumonia
• Swinging fever - up and down

Question 16

What to pleural effusions associated with RA often have?

Answer 16

Low glucose - <3.3