Pleural Effusions Flashcards
Thoracentesis
- Insert needle b/t ribs into pleural space to sample pleural effusions
- Done in all patients that CHF is NOT the obvious cause
- Risk: pneumothorax or hemothorax
- Contraindicated if increased risk of bleeding or only 1 lung
Definition of exudate
- Meets at least one of Light’s criteria
1. Pleural protein to serum protein ratio>0.5
2. pleural LDH to serum LDH ratio>0.6
3. Pleural LDH > 2/3 upper limit of normal for serum LDH - Caused by many things: pneumonia, malignancy, and PE most common
Define transudate
- Doesn’t meet ANY of light’s criteria
- Usually due to increased pulmonary capillary pressure due to heart failure
- Also caused by deceased plasma oncotic pressure
- Hypoalbuminemia from cirrhosis
- Nephrotic syndrome
Pleuritic chest pain
- Sharp stabbing pain
- Worsened w/ inspiration or cough
Loculated
- Fluid collected agains chest wall and doesn’t move
- Doesn’t layer w/ gravity or position change
- Most common in intesne pleural inflammation
- Pneumonia, TB, hemothorax
Empyema
- Due to pneumonia
- Also called parapneumonic
- Similar to abscess
- Requires drainage
- Characteristics: acidic pH, low glucose, high LDL, visible pus
Tube Thoracostamy
-Placing tube in chest wall b/t ribs to drain empyema, blood or air
Sclerosant
- Chemical that cause inflammatory reaction in pleural space
- Obliterates pleural space so no fluid can return
- Antibiotics or powders
Role of pH in effusions
- pH <7.2 suggests complicated effusion/empyema
- also seen in malignancy or TB
Glucose levels in effusion
- Normally same as serum
- Low is associated w/ same conditions as low pH
- glucose of 0 only seen in empyema or rheumatoid arthritis
Effusion with >10% eosinophils
- pneumothorax
- hemothorax
- Benign asbestos effusion
Effusions with >50% lymphocytes
- Malignancy
- TB
- PE
- Post-CABG
Effusion with >90% lymphocytes
-TB or lymphoma
Effusion with >50% neutrophils
- parapneumonic effusion
- PE
- Intrabdominal disease
- Very rarely TB or cancer
Scarcity of mesothelial cells in effusion
- Normally present in pleural fluid as cells are exfoliated
- Paucity indicates:
- TB
- Empyema
- Chronic cancer
- Due to intense inflammation limiting shedding
Effusion with Adenosine Deaminase (ADA) >40U/L
- TB 90%
- Empyema 60%
- Parapneumonic 30%
- Malignancy 5%
- RA
Interferon and effusions
-Identifies TB effusion
Amylase increase and Effusions
-Increased due to malignancy, pancreatic disease, or esophageal rupture
Cholesterol levels in effusion
> 45-60 mg/dL suggests exudate
NT-pro BNP levels
> 1500 mg/dL suggests heart failure
Pathophysiology or Effusion
- Increased fluid formation
- Increased capillary pressure from heart failure
- Decreased capillary oncotic pressure from liver failure, nephrotic syndrome or malnutrition
- Ascites from cirrhosis can move up to pleura (hepatic hydrothorax)
- Transudative - Fluid removal limited by obstruction
- Damage to capillaries
- Infection from pneumonia or TB
- Malignancy
- Trauma
- Systemic disease such as lupus
Effusion presentation
- Decreased breath sounds
- Decreased tactile fremitus
- Decreased voice transmission
- In large effusions, trachea may deviate from affected side
- CXR shows costophrenic angle blunting
- Lat. decubitus position shows free fluid
