Pleural Effusion

Question 1

Normal amount of fluid in a pleural space?

Answer 1

5-25 ml

Question 2

What is the pleural space?

Answer 2

a potential space/serous membrane between the thin visceral and parietal pleura

Question 3

Normal movement of pleural fluid

Answer 3

Made by parietal pleura, absorbed by visceral pleura

Should eb virtually fluid free

Question 4

Three basic ways to get a fluid into the pleural space

Answer 4

Increased drainage of fluid in
Increades production by cells in the space
Decreased drainage from the space

Question 5

Defects that could alter the fluid homeostasis of the pleural cavity, causing effusion (8)

Answer 5

Increased Capillary hydro. pressure (CHF)
Increased capillary permeability (Pneumonia)
Increased intrapleural pressure (atelectasis)
Decreased plasma oncotic pressure (hypoalbuminemia)
Decreased pleural mem. permeab. (malignancy)
Increased lymphatic obstruction (malignancy)
Diaphragmatic Defect (hepatic hydrothorax)
Thoracic Duct Rupture (Chylothorax)

Question 6

ID the fluid found in….

Hydrothorax, Hemothorax, Chylothorac, Empyema

Answer 6

Hydro - Serous
Hemo - Blood
Chylo – Milk-like (lymphatics)
Empyema - Pus

Question 7

Causes of transudative pleural effusion?

Answer 7

CHF, Cirrhosis, Nephrotic Syndrome, Constrictive pericarditis, peritoneal dialysis

Question 8

Causes of exudative pleural effusion?

Answer 8

PARAPNEUMONIC + TB
Connective Tissue Disorders
Malignancy
Pancreatitis
Subphrenic Abscess
Dengue
Radiation Pleuritis

Question 9

Causes of chylous pleural effusion?

Answer 9

Congenital
Post-traumatic
Post-malignancy

Question 10

Causes of hemothorax

Answer 10

Blunt trauma

Malignancy

Question 11

Top 4 most common causes of pleural effusion

Answer 11

CHF
Pneumonia
Cancer
PE

Question 12

Physical exam findings associated with pleural effusion?

Answer 12

Dullness to percussion
Decreased tactile fremitus
Asymmetric expansion
Decreased breath sounds
Egophony

Question 13

How to diagnose pleural effusion?

Answer 13

CXR (Lateral decubitus most sensitive)
Pleural fluid analysis
Chest US
CT scan (fluid, abscess, or tumor)

Question 14

Fluid in Xray is seen as…

Answer 14

Dense, White Shadow with a concave upper edge

Question 15

How do heart/mediastinum move in response to atelectasis? effusion?

Answer 15

TOWARD ATELECTASIS

AWAY FROM HEMOTHORAX

Question 16

Indications for thoracentesis?

Answer 16

Unilateral effusion, asymmetric bilateral
Evidence of pleurisy/fever
No response to diuresis in 2-3 days
Effusion out of proportion to clinical setting

Question 17

How is thoracentesis performed?

Answer 17

Needly passd through upper border of lower rib to remove 50-100 mL fluid for analysis.

Question 18

According to Light’s Criteria, how is a fluid labeled as Transudate?

Answer 18

Pleural fluid protein: Serum Protein ration under 0.5
Pleural LDH:serum LDH under 0.6
Pleural fluid LDH is less than 2/3 of serum level (or under 200)

Question 19

According to Light’s Criteria, how is a fluid labeled as Exudate?

Answer 19

Failure to meet any of the three criteria for transudate

Question 20

Pleural glucose levels below 3.3 mmol/L (or 1/2 serum glu) indicate…

Answer 20

RA Pleurisy, Empyema, Malignancy, Esophageal Rupture

Lupus, TB

Question 21

Low pH fluid indicates…

Answer 21

RA Pleurisy, Malignancy, Empyema, Esophageal Rupture

Urinothorax

Question 22

Significant elevation of lactate (over 90) strongly increased your index of suspicion for…

Answer 22

bacterial/TB pleural infections

Question 23

Elevated amylase levels (above 1.5-2) indicate the presence of…

Answer 23

pancreatitis
esophageal rupture
malignant effusion

Question 24

Elevated Adenosine deminase (over 43) indicates…

Answer 24

TB

Question 25

Elevated IFN-g (over 140 pg/ml) indicates...

Answer 25

TB

Question 26

Elevated eosinophil values (over 10%) may indicate...

Answer 26

Pneumothorax, Hemothorax, Parasitic/Fungal Infection

Question 27

Markedly increased numbers of mesothelial cells in bloody/eosinophilic effusions indicate...

Answer 27

PE

Question 28

Lung cancer most prone to cause effusion

Answer 28

Adenocarcinoma

Question 29

Most common cancer to cause effusion in young adults

Answer 29

Lymphoma

Question 30

What is a chylothorax ad what might cause itq

Answer 30

An acute effusion with a normal pleural surface with TG above 110. Its caused by trauma or malignancy.

Question 31

What is a pseudochylothorax and what might cause it?

Answer 31

Chronic effusion with a thickened pleura. Cholesterol over 200. Can be caused by any chronic effusion (over 6 months) Typically associated with TB or RA

Question 32

Labs for pleural effusion patient that gets a chest tube (5 features)

Answer 32

``` Complicated Fluid is cloudy, pH under 7.2, glucose under 40, LDH over 1000 PMN over 25,000 ```

Question 33

Causes of chest tube decision

Answer 33

EMPYEMA Complicated parapneumonic effusion Hemothorax Malignant efusion

Question 34

Three stages of Empyema

Answer 34

Exudative (1-3 days) Fibrinopurulant (4-14) Organizational (14+)