Flashcards in Pleural Effusions -GOya Deck (28):
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
How does the parietal pleura communicate with the pleural space?
Which pleura has nerve innervation?
visceral does not have pain fibers
What is the leading cause of pleural effusion in the united states? What kind of effusion is this?
What is the difference between transudative and exudative effusion? Which is an inflammatory response?
-Abnormalities in the Starling law
-Fluid will accumulate until pleural fluid formation is equal to absorption
-ex: heart failure
-Increase permeability of pleural space to proteins with impaired lymphatic flow
-ex: parapneumonic, malignancy
What are some symptoms of pleural effusion?
pleural chest pain
inflammation of the diaphragm --> ipsilateral shoulder pain
What are some PE findings associated with Pleural effusions?
Dullness to percussion
Decrease tactile fremitus
Decrease breath sounds
Pleural friction rub
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
What is a chest ultrasound good for?
Localizing pleural fluid
provide the best spot for biopsy or thoracentesis
What is a chest CT helpful in determining?
distinguishing lung abscess from empyema
How can you determine exudative vs transudative effusion?
(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
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?
What can whitish pleural fluid be due to? Brown fluid? Black pleural fluid?
Whitish: chyle, cholesterol, empyema
brown: ameobic liver abscess
If the pleural fluid LDH is > 1000 (IU/L), what should be suspected ?
What does pleural fluid with low glucose levels typically have? What can cause this?
normally also has low pH and high LDH
-parapneumonic effusion (empyema)
-malignant pleural effusion
What can elevated pleural fluid amylase indicate?
-Pancreatic pseudocyst (amylase levels >100,000U)
-Esophageal rupture-50% mortality if not repaired in 24 hrs
-Rupture ectopic pregnancy
What does a high lymphocyte count (>50%) in the pleural effusion suggest?
TB effusion may occur in the absence of CXR evidence of active TB
What does a high WBC count suggest?
What can a bloody pleural effusion indicate?
Asbestos Pleural Effusion
What diagnostic test is 92% diagnostic for malignancy and 100% for TB? What are some side effects of this test?
pneumothorax, hemothorax, site pain, transient fever, empyema, subcutaneuous emphysema
What is the standard of care for affections Pleural effusion?
What kind of pleural effusion will be seen in CHF?
normally bilateral, transudative effusion
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
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
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
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
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