Pleural Effusion - School of Medicine€¦ · PPT file · Web viewIn this case would attempt diuresis first. Indications for thoracentesis. Pleural effusion of unknown etiology,

MARVIN CHANG, PGY2APRIL 2015

Pleural Effusion

Objectives

Know how to diagnose pleural effusions.Understand the indications for thoracentesis. Understand the main classification and

etiologies of pleural effusions.Know the common laboratory studies used to

analyze pleural fluid.

Clinical Presentation

History Dyspnea Pleuritic chest pain Cough Other symptoms related to underlying cause

Physical exam (Findings usually present for effusions > 300 mL ) Dullness to percussion, decreased tactile fremitus Asymmetric chest expansion Decreased breath sounds Egophony

Imaging Studies-Chest Radiographs

Lateral Decubitus – very sensitive,can detect effusions as small as 50 mLPA - usually around 250-500 mL

needed before visible

Imaging Studies

CT Scan Better characterization of underlying lung

parenchyma and certain processes that may be obscured on radiographs by large pleural effusions

Ultrasound Cheap and available at bedside Can help identify free vs. loculated effusions Thoracentesis is facilitated by ultrasound guidance

Case

82 year old male with a history of DM2, HTN, CAD and CHF who presents with dyspnea on exertion and cough over the past 3 days. His CHF was diagnosed 1 year ago, symptoms relatively well controlled with 20mg PO Lasix daily.

Labs notable for BNP of 1300 (baseline ~300) and CXR showed moderate bilateral pleural effusions. Temp 37.0, WBC 8.0

What is the next step in management? Is a thoracentesis indicated at this point?

Indications for thoracentesis

Pleural effusion of unknown etiology, with >10mm depth on lateral decubitus CXR or Ultrasound

Therapeutically for symptomatic reliefConcern for empyema Air fluid level in pleural space

Common Mechanisms for Pleural Effusion

hydrostatic pressure oncotic pressure vascular permeability lymphatic drainage negative pressure in pleural space

Case

A 37 year old female with a history of chronic alcohol use presents to the ER complaining of increased shortness of breath and abdominal pain. Chest x-ray shows large right sided pleural effusion

Thoracentesis is performed which reveals LDH of 120 (serum value 175), total protein 3.2 (serum protein 5.3) and markedly elevated pleural fluid amylase. Upper limit of normal serum LDH is 333.

Is this pleural effusion best classified as transudative or exudative. What is the most likely etiology?

Lights Criteria

Pleural effusion is exudative if one or more of the following: Ratio of pleural fluid protein level to serum protein

level > 0.5 Ratio of pleural fluid LDH level to serum LDH level >

0.6 Pleural fluid LDH level > 2/3 the upper limit of

normal for serum LDH level.98% sensitive and 83% specific for exudative

effusion using Lights criteria. Absence of all 3 criteria = transudative

Transudative vs Exudative

Transudative CHF ~36% Nephrotic syndrome Hypoalbuminemia Hepatic hydrothorax Atelectasis

Exudative Pneumonia ~ 22% Malignancy ~14% PE ~11% Inflammatory

(pancreatitis, ARDS, uremic pleurisy etc.) ~7%

Connective tissue disease

Pleural Fluid Evaluation – Cell count with diff

Pleural Fluid Evaluation

Other routine pleural fluid tests include LDH, protein, adenosine deaminase, cytology and glucose.

Optional tests include amylase, cholesterol, triglyceride, cultures, proBNP, tumor markers, and should be ordered based on clinical suspicion.

Algorithm for

evaluation

Summary

Pleural effusions are commonly encountered on wards

Thoracentesis is not immediately indicated if there is a obvious explanation for pleural effusion without atypical features

Pleural effusions are classified as transudative vs exudative.

CHF, pneumonia, malignancy and PE comprise the vast majority of causes for pleural effusions.

References

Heffer, Uptodate.com “diagnostic evaluation of a pleural effusion in adults: initial testing”

Light. Clinical practice: Pleural effusion. New England Journal of Med 2002; 346; 1971.

Porcel. Diagnostic approach to pleural effusion in adults. American family physician 2006 Apr 1;73(7):1211-1220.

Reubins, Medscape.com. “pleural effusions”radiopaedia.org