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Flashcards in Pleural Effusions -GOya Deck (28):
1

Which pleura produces fluid? Which reabsorbs fluid?

Parietal produces pleural fluid and receives blood supply from systemic capillaries

visceral pleura is supplied by bronchial circulation and reabsorbs the pleural fluid

2

How does the parietal pleura communicate with the pleural space?

Stomas

3

Which pleura has nerve innervation?

Parietal ONLY

visceral does not have pain fibers

4

What is the leading cause of pleural effusion in the united states? What kind of effusion is this?

CHF

Transudate

5

What is the difference between transudative and exudative effusion? Which is an inflammatory response?

Transudative Effusion:
-Abnormalities in the Starling law
-Fluid will accumulate until pleural fluid formation is equal to absorption
-ex: heart failure

Exudative Effusion:
-Increase permeability of pleural space to proteins with impaired lymphatic flow
*inflammatory*
-ex: parapneumonic, malignancy

6

What are some symptoms of pleural effusion?

pleural chest pain

inflammation of the diaphragm --> ipsilateral shoulder pain

nonproductive cough

dyspnea

7

What are some PE findings associated with Pleural effusions?

Dullness to percussion

Decrease tactile fremitus

Decrease breath sounds

Pleural friction rub

8

What chest x-ray findings would you expect in pleural effusion?

Effusions appear as a homogeneous density through which lung markings maybe seen

Upper margins of fluid forms a meniscus at the lateral chest wall

200 cc needed to blunt costophrenic angle

9

What is a chest ultrasound good for?

Localizing pleural fluid

provide the best spot for biopsy or thoracentesis

10

What is a chest CT helpful in determining?

distinguishing lung abscess from empyema

11

How can you determine exudative vs transudative effusion?

thoracentesis
(should be performed in all newly diagnosed pleural effusions)

35-50 cc needed for analysis

exudative meets at least one of the criteria:

-Pleural fluid protein/serum protein ratio > 0.5

-Pleural fluid LDH/serum LDH ratio > 0.6

-Pleural fluid LDH > 2/3 upper limit for serum LDH

12

In our patient thoracentesis is performed which reveals the following information:
•Cell count-RBC 150,000; WBC 980 with 20% neutrophils, 55% lymphocytes, 10% mesothelial cells & 15% eosinophils
•Total protein 4.5 mg/dl
•LDH 1200U/L, Glucose 45 mg/d, pH 7.2
•Pleural fluid gram stain is negative, cultures & cytology pending

Is the pleural fluid exudate or a transudate?

exudative

13

What can whitish pleural fluid be due to? Brown fluid? Black pleural fluid?

Whitish: chyle, cholesterol, empyema

brown: ameobic liver abscess

black =aspergillus

14

If the pleural fluid LDH is > 1000 (IU/L), what should be suspected ?

empyema

TB pleurisy

15

What does pleural fluid with low glucose levels typically have? What can cause this?

normally also has low pH and high LDH

causes:
-parapneumonic effusion (empyema)
-malignant pleural effusion
-TB

16

What can elevated pleural fluid amylase indicate?

-Acute pancreatitis
-Pancreatic pseudocyst (amylase levels >100,000U)
-Esophageal rupture-50% mortality if not repaired in 24 hrs
-Malignant disease
-Rupture ectopic pregnancy

17

What does a high lymphocyte count (>50%) in the pleural effusion suggest?

TB

TB effusion may occur in the absence of CXR evidence of active TB

18

What does a high WBC count suggest?

empyema/ infection

19

What can a bloody pleural effusion indicate?

Trauma

Pulmonary Embolus

Malignancy

Asbestos Pleural Effusion

20

What diagnostic test is 92% diagnostic for malignancy and 100% for TB? What are some side effects of this test?

thoracoscopy

SE:
pneumothorax, hemothorax, site pain, transient fever, empyema, subcutaneuous emphysema

21

What is the standard of care for affections Pleural effusion?

Pleurodesis

22

What kind of pleural effusion will be seen in CHF?

normally bilateral, transudative effusion

23

What are the characteristics of liver cirrhosis leading to pleural effusion?

normally on the right side

fluid moves from peritoneal to pleural cavity by diaphragm defects

transudate effusion

24

What is the difference between parapneumonic effusion and empyema?

Complicated parapneumonic effusion:
-pH < 7.20
-LDH > 3x upper limit for serum levels
-Glucose < 60 mg/dl

Empyema: (in addition to the symptoms above)
-Positive gram stain/culture
-Frank pus

25

When should an empyema or parapneumonic effusion be drained?

-Fluid layer > 1cm on decubitus films

-Loculated fluid on imaging( need thoracoscopy with breakdown of adhesions)

-Effusion > 50% of hemithorax

-Persistent signs of infection/SOB after treatment

26

What primary tumors are the most common to metastasize to the pleura? What are these carcinomatous effusions like?

lung, breast, stomach & ovary

normally involve the mediastinum, moderate to massive in size, frequently hemorrhagic and always exudative

27

What are some characteristics of a rheumatoid effusion?

found in men with rheumatoid nodules and high serum rheumatoid factors

effusions may not produce symptoms

low glucose and pH

exudative

28

What are the characteristics of chylothorax? What are the causes?

milky pleural fluid

> triglycerides > 110

> cholesterol

chylomicroms

from: lymphoma and trauma to the thoracic duct