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CR - Pul Path (ii) Pleural Effusion (Hx (depends on underlying cause…
CR - Pul Path (ii) Pleural Effusion
Accumulation of fluid in pleural space (between visceral + parietal pleura)
when formation rate > removal rate by lymphatics
normally a small amount of fluid in pleural space: pale yellow, eases friction + permits movement
empyema if fluid in infection
usually bilat
2 types
transudate
low specific gravity (few cells, little protein)
occurs due to alterations in systemic factors influencing pleural movement
causes
nephrotic syndrome (increased protein lost via kidneys, hypoalbuminaemia, decreased colloid/serum oncotic osmotic pressure)
left heart failure (increased visceral pleural capill pressure)
right heart failure (increased parietal pleural capill pressure)
fluid overload
liver cirrhosis (decreased protein synthesis - decreased oncotic pressure)
peritoneal dialysis
Meig's syndrome
triad of pleural effusion, ascites + fibroma (benign ovarian tumour)
effusion resolves after fibroma resected
myxoedema (hypothyroidism)
exudate
high specific gravity (lots of cells + protein)
causes
infection (pneumonia, TB, esp abscess)
malignancy
PE
pleuritis
connective tissue disorders (SLE, RA), acute rheumatic fever
Hx
depends on underlying cause
ascites in liver damage
elevated JVP + peripheral oedema in heart failure
unilateral leg swelling in PE arising from DVT
dyspnoea
pleuritic chest pain
cough
haemoptysis
weightloss
ask about trauma, malignancy, surgery
decreased breath sounds @ site of effusion, with bronchial breath sounds directly above
dull on percussion
absent/reduced tactile fremitis
Management
CXR
sometimes CT-thorax
bloods
thoracocentesis
aspirate fluid via needle in pleural space
indicted if effusion persists > 3 days
@ bedside
normally site located by percussion but may require radiological guidance in small (located)
gross appearance of fluid can be helpful
bloody = cancer
cloudy = WBCs
malodorous = empyema
use fluid to measure ratio of pleural fluid protein:serum protein
fluid may contain glucose, LDH, amylase, inflamm cells (neutrophils suggest empyema), malignant cells - do cytology, culture + sensitivity