Pleural effusion

• What is a pleural effusion?


  Accumulation of fluid in the pleural cavity

  Can be transudative or exudative
• What are transudative pleural effusions due to?


  Decreased oncotic pressure (decreased protein or albumin)

  Connective tissue autoimmune disorders can also cause transudative effusions
• What are exudative effusions due to?


  Infection/inflammation

  Increased permeability -> due to endothelial damage
• What is a unilateral effusion a worry for?


  Malignancy (often later in progression)
• What is Meig's Syndrome?


  Ovarian mass that presents with pleural effusion
• What are the signs & symptoms of pleural effusion?


  Can be asymptomatic

  SOB

  Chest pain

  Cough (non-productive)

  Symptoms of underlying disease

  Tachypnoea

  Low O2 sats

  Decreased breath sounds

  Dullness on percussion ('stony dullness')

  Reduced tactile vocal fremitus

  Reduced chest expansion (large effusion)

  Tracheal deviation (very large effusion)

  Peripheral stigmata
• What are the RFs of pleural effusion?

  CHF

  Pneumonia

  Malignancy

  Recent CABG

  PE

  Recent MI

  Occupational lung disease

  RA

  SLE

  Renal failure
• What are the Inx for pleural effusion?


  Obs

  Full Hx & examination

  ECG

  Urine dip

  Bloods (FBC, U&E, LFTs, CRP, LDH, amylase (for pancreatitis), TFTs, Coag (prior to thoracentesis), ABG)

  CXR

  CT thorax

  USS

  Echo

  Thoracentesis (diagnostic)

  Pleural biopsy
• What is shown in this image?

  Large pleural effusion

  
• How can you tell if a pleural effusion in transudative or exudative?


  Thoracentesis

  Fluid sent for pH, protein, lactate dehydrogenase (LDH), cytology & microbiology

  • Transudative = protein < 25g/L
  • Exudative = protein > 35g/L

  If protein level is 25-35g/L, use Light's criteria

  • Exudative likely if meet 1 of the criteria...
  • Pleural fluid protein divided by serum protein >0.5
  • Pleural fluid LDH divided by serum LDH >0.6
  • Pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
• What are the DDx of pleural effusion?


  Pleural thickening

  Pulmonary collapse & consolidation

  Elevated hemidiaphragm

  Pleural tumours/extrapleural fat

  COVID-19
• What is the treatment of pleural effusion?


  Treat underlying cause

  Drain fluid

  Follow up

  If persistent -> repeat drain & reconsider diagnosis

  If recurrent -> pleurodesis (usually talc -> sticks pleural space shut), intrapleural catheter