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Questions and Answers
What is a pleural effusion?
What is a pleural effusion?
- An excess quantity of fluid in the pleural space. (correct)
- Destruction of lung tissue.
- A blockage of the airway.
- An inflammation of the pleura.
What primarily influences the accumulation of pleural fluid?
What primarily influences the accumulation of pleural fluid?
- Decrease in chest wall elasticity.
- Increased formation and reduced absorption of fluid. (correct)
- Decreased lung capacity for air intake.
- Increased atmospheric pressure on the lungs.
What method has replaced lateral decubitus x-ray for evaluating suspected pleural effusions?
What method has replaced lateral decubitus x-ray for evaluating suspected pleural effusions?
- Fluoroscopic imaging.
- Computed tomography (CT) scan.
- Magnetic resonance imaging (MRI).
- Chest ultrasound. (correct)
Through which structure is pleural fluid primarily absorbed under normal conditions?
Through which structure is pleural fluid primarily absorbed under normal conditions?
What two factors can lead to the development of pleural effusion?
What two factors can lead to the development of pleural effusion?
Which of the following is a characteristic of a transudative pleural effusion?
Which of the following is a characteristic of a transudative pleural effusion?
What is the primary role of the thin layer of fluid in the pleural space?
What is the primary role of the thin layer of fluid in the pleural space?
Where can pleural fluid enter into the pleural space from aside from the capillaries?
Where can pleural fluid enter into the pleural space from aside from the capillaries?
What is the LDH level in pleural fluid that suggests it is exudative when compared to serum?
What is the LDH level in pleural fluid that suggests it is exudative when compared to serum?
What can be ignored if the gradient between serum and pleural fluid protein levels is greater than 31 g/L?
What can be ignored if the gradient between serum and pleural fluid protein levels is greater than 31 g/L?
When is it likely for transudates to be misidentified as exudates?
When is it likely for transudates to be misidentified as exudates?
What is the suggested pleural fluid protein/serum protein ratio to indicate an exudative effusion?
What is the suggested pleural fluid protein/serum protein ratio to indicate an exudative effusion?
If a patient is suspected of having a transudative effusion, what should be done if exudative criteria are met?
If a patient is suspected of having a transudative effusion, what should be done if exudative criteria are met?
Which criterion is NOT part of the exudative criteria for pleural fluid analysis?
Which criterion is NOT part of the exudative criteria for pleural fluid analysis?
What problem arises if the exudative criteria are applied incorrectly?
What problem arises if the exudative criteria are applied incorrectly?
What is the expected condition of patients with a gradient greater than 31 g/L?
What is the expected condition of patients with a gradient greater than 31 g/L?
What tests are indicated for a patient with an exudative pleural effusion?
What tests are indicated for a patient with an exudative pleural effusion?
In heart failure patients, when is a diagnostic thoracentesis required?
In heart failure patients, when is a diagnostic thoracentesis required?
What indicates that a pleural effusion is likely due to congestive heart failure?
What indicates that a pleural effusion is likely due to congestive heart failure?
What is the most common cause of exudative pleural effusion in the United States?
What is the most common cause of exudative pleural effusion in the United States?
Why does hepatic hydrothorax predominately occur on the right side?
Why does hepatic hydrothorax predominately occur on the right side?
What symptoms do patients with aerobic bacterial pneumonia and pleural effusion typically present with?
What symptoms do patients with aerobic bacterial pneumonia and pleural effusion typically present with?
What complication may arise if pleural effusions persist despite heart failure therapy?
What complication may arise if pleural effusions persist despite heart failure therapy?
What is the predominant mechanism causing pleural effusions in patients with cirrhosis?
What is the predominant mechanism causing pleural effusions in patients with cirrhosis?
What is a leading cause of transudative pleural effusions in the United States?
What is a leading cause of transudative pleural effusions in the United States?
Which of the following conditions is NOT a leading cause of exudative pleural effusions?
Which of the following conditions is NOT a leading cause of exudative pleural effusions?
What is the primary reason for distinguishing between transudative and exudative pleural effusions?
What is the primary reason for distinguishing between transudative and exudative pleural effusions?
Which of the following criteria is used to classify exudative pleural effusions?
Which of the following criteria is used to classify exudative pleural effusions?
Which condition is typically associated with high protein levels in pleural fluid?
Which condition is typically associated with high protein levels in pleural fluid?
What type of pleural effusion would likely require additional diagnostic testing?
What type of pleural effusion would likely require additional diagnostic testing?
Which of the following factors is NOT typically altered in transudative pleural effusions?
Which of the following factors is NOT typically altered in transudative pleural effusions?
What is one of the leading causes of exudative pleural effusions?
What is one of the leading causes of exudative pleural effusions?
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Study Notes
Pleural Effusion Overview
- The pleural space is between the lung and chest wall and contains a thin layer of fluid for lubrication.
- An excess of fluid in this space is termed pleural effusion.
Etiology of Pleural Effusion
- Accumulation occurs when fluid formation surpasses absorption by lymphatics.
- Fluid enters the pleural space via capillaries in the parietal pleura and interstitial lung spaces.
- The lymphatics can absorb 20 times more fluid than is normally formed.
- Pleural effusions can result from increased fluid formation or decreased fluid removal.
Diagnostic Approach
- Chest imaging (preferably ultrasound) is essential for diagnosing pleural effusions.
- Classification into transudative or exudative effusions is crucial for further diagnostic steps.
Transudative Pleural Effusions
- Caused by systemic factors affecting fluid dynamics.
- Leading causes include left ventricular failure and cirrhosis.
Exudative Pleural Effusions
- Occur due to local factors altering fluid dynamics.
- Major causes include bacterial pneumonia, malignancy, viral infections, and pulmonary embolism.
- Requires additional diagnostic procedures to identify underlying local disease.
Differentiation Criteria
- Distinguish between transudative and exudative effusions based on:
- Pleural fluid protein/serum protein >0.5
- Pleural fluid LDH/serum LDH >0.6
- Pleural fluid LDH over two-thirds of the serum upper limit.
- Misidentification occurs in ~25% of cases using these criteria.
- If suspected transudate shows exudative criteria, measure serum-pleural fluid protein gradient:
- A gradient >31 g/L (3.1 g/dL) indicates a transudate.
Further Testing for Exudative Effusions
- If exudative fluid is confirmed, analyze:
- Appearance of the fluid
- Glucose level
- Differential cell count
- Microbiologic studies
- Cytology
Common Causes of Pleural Effusions
-
Heart Failure:
- Most frequent cause; linked to left ventricular failure.
- Effusion often occurs when interstitial lung fluid overwhelms lymphatic removal.
- Thoracentesis is advised if effusions are asymmetric or if the patient shows fever or pleuritic pain.
- NT-proBNP level >1500 pg/mL suggests effusion from heart failure.
-
Hepatic Hydrothorax:
- Occurs in ~5% of cirrhosis patients with ascites.
- Primarily right-sided, fluid moves through diaphragm openings, potentially causing severe dyspnea.
-
Parapneumonic Effusion:
- Associated with bacterial pneumonia, lung abscess, or bronchiectasis.
- Most common exudative effusion in the U.S.
- Empyema refers to purulent effusion. Presenting symptoms include fever, chest pain, and increased sputum production.
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