Pleural Effusion Overview
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Questions and Answers

What defines pleural effusion in terms of fluid accumulation?

10 mL of fluid in the pleural space.

Differentiate between transudative and exudative pleural effusions based on their causes.

Transudates are due to systemic influences, while exudates result from local influences.

List two common causes of transudative pleural effusions.

Left ventricular heart failure and cirrhosis.

What is the approximate volume of pleural fluid normally secreted by the parietal pleura daily?

<p>Approximately 2.5 L.</p> Signup and view all the answers

Identify a common cause of exudative pleural effusion.

<p>Bacterial pneumonia.</p> Signup and view all the answers

What clinical feature may suggest the presence of pleural inflammation?

<p>Pleuritic chest pain.</p> Signup and view all the answers

What might a physical examination reveal in a patient with pleural effusion?

<p>Reduced chest expansion and stony dull percussion note.</p> Signup and view all the answers

What can a ‘friction rub’ during auscultation indicate?

<p>Pleural inflammation.</p> Signup and view all the answers

In which population are the commonest causes of pleural effusion predominantly cardiac-related?

<p>In the UK and US.</p> Signup and view all the answers

Name a specific type of pleural effusion that results primarily from blood accumulation.

<p>Hemothorax.</p> Signup and view all the answers

What is the significance of sequential blunting of costophrenic angles observed on CXR in relation to pleural effusion?

<p>It indicates the increasing size of pleural effusions as they progress.</p> Signup and view all the answers

How much pleural fluid can a PA CXR typically detect compared to a lateral CXR?

<p>A PA CXR can usually detect effusions of 200mL or more, while a lateral CXR can detect as little as 50mL.</p> Signup and view all the answers

What is the classical CXR appearance indicative of pleural effusion?

<p>It shows basal opacity obscuring the hemidiaphragm with a concave upper border.</p> Signup and view all the answers

Why is ultrasound preferred over CXR for detecting pleural fluid?

<p>Ultrasound has a much higher sensitivity and can accurately localize pleural fluid, distinguishing it from other issues.</p> Signup and view all the answers

What CT findings might suggest malignant pleural disease?

<p>Nodular, mediastinal, or circumferential pleural thickening and parietal pleural thickening greater than 1cm.</p> Signup and view all the answers

What essential information should be noted after performing a thoracentesis?

<p>The appearance of the pleural fluid should be documented.</p> Signup and view all the answers

Which tests should be conducted on pleural fluid samples following a diagnostic thoracentesis?

<p>Samples should be sent for glucose, protein, lactate dehydrogenase (LDH), cytology, Gram stain, and microbiology culture.</p> Signup and view all the answers

What is the main differentiator used to classify pleural effusions as transudate or exudate?

<p>The measurement of pleural fluid protein relative to serum protein levels.</p> Signup and view all the answers

What indicates an effusion is exudative according to Light's criteria?

<p>An effusion is exudative if it meets at least one of Light's criteria concerning pleural fluid and serum protein levels.</p> Signup and view all the answers

In suspected pleural infection, what additional tests should be conducted on pleural fluid?

<p>Perform a blood culture, AFB stain, and tuberculosis culture.</p> Signup and view all the answers

What ratios can indicate an exudative pleural effusion in relation to serum protein and LDH?

<p>A pleural fluid protein/serum protein ratio &gt;0.5 and pleural fluid LDH/serum LDH ratio &gt;0.6 indicate exudative pleural effusion.</p> Signup and view all the answers

What is the minimum LDH level in pleural fluid to be classified as exudative?

<p>Pleural fluid LDH must be greater than two-thirds the upper limit of normal serum LDH.</p> Signup and view all the answers

Describe the progression of a simple parapneumonic effusion to empyema.

<p>A simple parapneumonic effusion can progress to a complicated parapneumonic effusion and eventually lead to empyema.</p> Signup and view all the answers

What is a primary empyema and how does it occur?

<p>Primary empyema occurs when pleural infection develops without a preceding pneumonic illness.</p> Signup and view all the answers

List some clinical features that prompt consideration of pleural infection in pneumonia patients.

<p>Features include slow-to-respond pneumonia, failure of CRP to decrease &gt;50% in the first 3 days, and pleural effusion with fever.</p> Signup and view all the answers

What risk factors increase the likelihood of developing empyema?

<p>Risk factors include diabetes, alcohol abuse, gastro-oesophageal reflux, and IV drug use.</p> Signup and view all the answers

How does anaerobic empyema typically present clinically?

<p>Anaerobic empyema often presents with weight loss and without fever, and may not be acute.</p> Signup and view all the answers

What clinical variables are associated with developing pleural infection in pneumonia patients?

<p>Variables include albumin &gt;100 mg/L, platelet count &gt;400 × 10^9/L, and sodium levels.</p> Signup and view all the answers

What is the role of pleural tissue biopsy in diagnosis?

<p>Pleural tissue biopsy is used for histology and culture to confirm the presence of infection.</p> Signup and view all the answers

In what scenarios should pleural effusion be considered in pneumonia patients?

<p>Pleural effusion should be considered in patients with pneumonia who have fever, non-specific symptoms, or slow clinical improvement.</p> Signup and view all the answers

What specific ratio of pleural fluid protein to serum protein indicates an exudative pleural effusion?

<blockquote> <p>0.5</p> </blockquote> Signup and view all the answers

What is the significance of a pleural fluid LDH to serum LDH ratio greater than 0.6?

<p>It indicates an exudative pleural effusion.</p> Signup and view all the answers

Define a complicated parapneumonic effusion.

<p>It is an effusion that occurs as a complication of pneumonia, often requiring drainage.</p> Signup and view all the answers

In what context may primary empyema occur?

<p>In the absence of a preceding pneumonic illness.</p> Signup and view all the answers

What clinical feature may suggest a slow response to treatment in pneumonia patients?

<p>Failure of CRP to fall ≥50% in the first 3 days.</p> Signup and view all the answers

What typical symptoms might indicate anaerobic empyema?

<p>Weight loss often without fever.</p> Signup and view all the answers

Identify two risk factors for developing empyema.

<p>Diabetes and alcohol abuse.</p> Signup and view all the answers

What type of biopsy is performed for histology and culture in cases of pleural infection?

<p>Pleural tissue biopsy.</p> Signup and view all the answers

What is the role of image-guided biopsies in managing pleural effusions?

<p>To obtain pleural tissue for histological examination.</p> Signup and view all the answers

What is the significance of identifying nodular or circumferential pleural thickening on a prior CT scan?

<p>It can indicate malignant pleural disease.</p> Signup and view all the answers

How does the sensitivity of ultrasound compare to that of CXR in detecting pleural fluid?

<p>Ultrasound has a much higher sensitivity than CXR for detecting pleural fluid.</p> Signup and view all the answers

What role does MRI play in the evaluation of pleural disease?

<p>MRI's role is unclear but may help distinguish benign from malignant pleural disease.</p> Signup and view all the answers

What is the significance of measuring the appearance of pleural fluid after a thoracentesis?

<p>It provides diagnostic clues about the underlying cause of the pleural effusion.</p> Signup and view all the answers

In the context of pleural fluid analysis, what does a protein level of 30g/L suggest?

<p>It suggests the pleural effusion is likely an exudate.</p> Signup and view all the answers

Which additional tests should be conducted on pleural fluid in suspected cases of infection?

<p>Gram stain, microscopy, culture, and blood cultures should be sent for analysis.</p> Signup and view all the answers

What metastatic evidence might CT scans provide regarding pleural disease?

<p>CT scans can reveal mediastinal or parietal pleural thickening indicative of malignancy.</p> Signup and view all the answers

What is the diagnostic significance of analyzing lactate dehydrogenase (LDH) levels in pleural fluid?

<p>LDH levels help differentiate between transudative and exudative effusions.</p> Signup and view all the answers

How is Light's criteria applied when analyzing borderline pleural protein levels?

<p>Light's criteria is used to classify the effusion as exudative if it meets at least one specific criterion.</p> Signup and view all the answers

What findings would be indicative of a complicated parapneumonic effusion on imaging?

<p>Basal opacity obscuring the hemidiaphragm and possibly loculated fluid accumulation.</p> Signup and view all the answers

What is the normal volume of fluid in the pleural space, and what constitutes a pleural effusion?

<p>The normal volume of fluid in the pleural space is approximately 10 mL, while a pleural effusion is defined as an accumulation of fluid greater than 10 mL.</p> Signup and view all the answers

Explain the mechanism by which the pleural membranes secrete and reabsorb fluid.

<p>The parietal pleura secretes fluid into the pleural space and the visceral pleura reabsorbs it, maintaining a balance in pleural fluid composition.</p> Signup and view all the answers

Identify one significant clinical sign that may indicate pleural effusion during a physical examination.

<p>A stony dull percussion note can indicate the presence of pleural effusion on examination.</p> Signup and view all the answers

What specific type of pleural effusion involves a collection of chyle, and how does it occur?

<p>Chylothorax refers to the collection of chyle in the pleural space, often resulting from damage to the thoracic duct.</p> Signup and view all the answers

What underlying conditions are commonly associated with transudative pleural effusions?

<p>Transudative pleural effusions are commonly associated with left ventricular heart failure, cirrhosis, and nephrotic syndrome.</p> Signup and view all the answers

What clinical features might be present in a patient with pleural effusion?

<p>Patients with pleural effusion may experience breathlessness, dry cough, pleuritic chest pain, and chest heaviness.</p> Signup and view all the answers

Describe the relationship between fluid accumulation in the pleural space and complications in pneumonia patients.

<p>Fluid accumulation in the pleural space, such as in parapneumonic effusions, can lead to complications like empyema if infectious processes deepen.</p> Signup and view all the answers

What is the primary difference between transudative and exudative pleural effusions?

<p>Transudative effusions are caused by systemic factors affecting fluid dynamics, while exudative effusions are due to local factors causing increased permeability.</p> Signup and view all the answers

List a common cause of exudative pleural effusion and explain its significance.

<p>Bacterial pneumonia is a common cause of exudative pleural effusion, indicating possible infection requiring aggressive treatment.</p> Signup and view all the answers

How might breath sounds be affected in a patient with pleural effusion?

<p>In a patient with pleural effusion, breath sounds may be quiet or diminished over the affected area due to fluid interference.</p> Signup and view all the answers

Study Notes

Pleural Effusion

  • Pleural effusion is the accumulation of more than 10mL of fluid in the pleural space, the space between the lung and chest wall.
  • The pleural membrane lining the lung is called visceral pleura, while the parietal pleura covers the remaining chest wall structures.
  • There are two main types of pleural effusions: transudates and exudates.
  • Transudates are caused by systemic influences on fluid formation or resorption, while exudates are caused by local influences.
  • Common causes of transudative effusions include left ventricular heart failure, cirrhosis, and nephrotic syndrome.
  • Common causes of exudative effusions include bacterial pneumonia, malignancy, viral infection, and pulmonary embolism.
  • Commonest causes in the UK and US are cardiac failure, pneumonia, malignancy, and pulmonary embolism (PE).
  • Symptoms may include breathlessness, dry cough, pleuritic chest pain, and pain referred to the shoulder or abdomen.
  • Examination may reveal reduced chest expansion, reduced tactile vocal fremitus, stony dull percussion note, quiet breath sounds, and possibly a friction rub.
  • A pleural effusion >10 mL is considered an effusion.

Imaging

  • CXR: Sequential blunting of costophrenic angles indicates effusion.
  • PA CXR detects effusions of 200mL or more, while lateral CXR is more sensitive and can detect as little as 50mL.
  • Classical CXR appearance is basal opacity blocking hemidiaphragm, with a concave upper border.
  • Ultrasound: Has higher sensitivity than CXR in detecting and localizing pleural fluid. Useful to differentiate between pleural fluid and masses/thickening. Can guide thoracentesis procedures.
  • CT: Used in differentiating between benign and malignant diseases; nodular, mediastinal, or circumferential pleural thickening >1cm is highly suggestive of malignancy.
  • MRI: Potentially useful, though less clear, to distinguish benign from malignant pleural diseases.

Thoracentesis

  • Thoracentesis is a pleural tap or pleural fluid aspiration and can be diagnostic or therapeutic, depending on the volume of fluid removed.
  • Following thoracentesis, the pleural fluid is examined.
  • Biochemistry testing for glucose, protein, lactate dehydrogenase (LDH), and specific gravity is performed.
  • Cytology examination is done for malignant cells.
  • Microbiology testing (Gram stain and microscopy, culture) and pleural infection testing (e.g., culture for AFB, tB) are performed.
  • pH, cholesterol, triglycerides, chylomicrons, haematocrit, adenosine deaminase, and amylase are assessed, if clinically relevant; these are useful for determining cause.

Exudates vs. Transudates

  • Apply Light's criteria to classify effusion.
  • One of these must be met for exudative effusion:
    • Pleural fluid protein/serum protein ratio >0.5
    • Pleural fluid LDH/serum LDH ratio >0.6
    • Pleural fluid LDH > two-thirds the upper limit of normal serum LDH levels

Pleural Effusion with Pneumonia

  • Parapneumonic effusions are pleural effusions secondary to pneumonia.
  • They occur in up to 57% of patients with pneumonia.
  • Initially, they may be sterile (simple parapneumonic effusion), but can progress to a complicated parapneumonic effusion and even empyema.
  • Empyema is a pus-filled pleural cavity.
  • Clinical features to consider include slow response to pneumonia treatment, presence of fever, high risk groups with non-specific symptoms like weight loss, and anaerobic empyema.

Empyema

  • Pleural infection can occur in the absence of pneumonia ("primary empyema").
  • Risk factors for empyema include diabetes, alcohol abuse, gastroesophageal reflux, and IV drug abuse.
  • Clinical variables linked to pleural infection with pneumonia include albumin <30g/L, CRP >100mg/L, platelets >400 × 109/L, sodium <130mmol/L, IVDU, and chronic alcohol abuse; these can increase suspicion of infection.
  • Common bacterial causes include Streptococcus milleri group, anaerobes, Streptococcus pneumoniae, and Staphylococcus aureus. Hospital-acquired infections commonly involve MRSA and Enterobacteriaceae.
  • Pleural infection often involves mixed organisms.

Pleural Tissue Biopsy (Histology and TB Culture)

  • Sometimes, image-directed or thoracoscopic pleural tissue biopsy is needed for histological analysis and TB (tuberculosis) culture to help with diagnosis. This can be done to further analyze the cause especially in problematic cases.

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Description

This quiz covers pleural effusions, including their definition, types, and common causes. Learn about transudative and exudative effusions and the associated symptoms. Test your knowledge on the factors influencing fluid accumulation in the pleural space.

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