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Pleural Effusion (Examination (Chest (Auscultation (↓ AE, ↓ VR), Tracheal…
Pleural Effusion
Examination
Causes
Transudate
Modified Starling’s Forces
Protein <25
Usually bilateral
Causes
CCF
Renal failure
↓ albumin
Hypothyroidism
Meig’s syn.
Exudate
↑ Capillary Permeability Protein >35
Often unilateral
Causes
Infection: pneumonia, TB
Ca: primary or secondary
Inflammation: RA, SLE
Infarction: PE
Trauma
Peripheral Inspection
Paraphernalia
Chest drain
Evidence of Specific Cause
Cancer: clubbing, cachexia, LNs
Pneumonia: febrile
CCF: ↑JVP, S3, ascites, ankle oedema
CLD: clubbing, leukonychia, spiders, gynaecomastia
CTD: rheumatoid hands, malar rash
Chest
Tracheal shift: away from lesion
↓ expansion unilaterally
PN: stony dull
Auscultation
↓ AE
↓ VR
Significant Negatives
Absence of
Fever
Clubbing
↑ JVP and peripheral oedema
Features of CTD
Differential of Dull Lung Base
Consolidation: bronchial breathing + crackles
Collapse: ↑ VR
Viva
Hx
Cause
Fever, sputum
Smoking, wt. loss, haemoptysis
Previous MI, orthopnoea, PND
Hepatitis
Symptoms: SOB, pleurisy
Ix
Blood
FBC: ↓Hb
U+E: ↑ Cr
LFTs: ↓ albumin
TFT: ↑TSH
ESR: ↑ in CTD
Ca: ↑ in Ca
Sputum: MC+S, cytology
Imaging
CXR
Dependent homogenous opacification w/ meniscus
Unilateral or bilateral
Cardiomegaly
Coin lesions
Hilar LNs
Apical TB
US: may guide pleurocentesis
Volumetric CT
Diagnostic Pleurocentesis
Percuss upper border and go 1-2 spaces below
Infiltrate down to pleura w/ lignocaine + aspirate w/ 21G
needle
Send for
Chemistry: protein, LDH, pH, glucose, amylase
Bacteriology: MCS, auramine stain, TB culture
Cytology
Immunology: RF, ANA, complement
Light’s Criteria for Dx of an Exudative Effusion
Effusion : serum protein ratio >0.5
Effusion : serum LDH ratio >0.6
Effusion LDH is 0.6 x ULN
Empyema: turbid fluid, ↓ glucose and pH <7.2
Pleural Biopsy
If pleural fluid is inconclusive
CT-guided w/ Abrams needle
Mx
Rx underlying cause
May use drainage if symptomatic (≤2L/24h)
Repeated aspiration or ICD
Pleurodesis w/ talc if recurrent malignant effusion
Persistent effusions may require surgery