Pleural effusion: Difference between revisions

Latest revision as of 17:34, 30 July 2020

Etiology

Increased influx from pleural vessels and decreased efflux via lymphatic system of pleural fluid

Differential Diagnosis

Transudative
- Heart failure, unless post-diuresis
- Cirrhosis
- Nephrotic syndrome
- Peritoneal dialysis
- Atelectasis
Exudative
- Infection, including parapneumonic effusion
- Malignancy
- Connective tissue disorders
- Inflammatory disorders
- Movement of fluid from abdomen to pleural space
- CABG
- Pulmonary embolism
Medication (check Pneumotox online)
Asbestosis

Clinical Manifestations

History of CHF, cirrhosis, CKD, TB, malignancy
Decreased lung sounds with dullness on percussion

Investigations

Labs: pleural fluid and serum protein and LDH
Imaging
- CXR is first-line imaging
  - Blunting suggests at least 200mL of effusion
  - Lateral more sensitive (50mL)
  - Lateral decubitus is also helpful to rule out loculations
- Bedside ultrasound is best for internal medicine
  - More sensitive than CXR (3-5mL)
  - Better than CT for assessing the pleura
Diagnostic thoracentesis
- Risks
  - Pneumothorax <5%
  - Hemothorax 1%
    - Avoid if INR >3 or platelets <25
  - Re expansion pulmonary edema <1%
    - Avoid taking more than 1-2L
- Diagnostic requires 50mL (5-10 for microbiology, 2-5 for biochemistry, 20-40 for cytology)

Fluid Analysis

Light's Criteria
- Exudate is exudative if at least one of:
  - Pleural fluid to serum protein ratio > 0.5
  - Pleural fluid to serum lactate dehydrogenase (LD) ratio > 0.6
  - Pleural fluid LD level > 2/3 of upper limit of normal
    - ULN usually ~220, so LD > 148
Modified Light's Criteria
- Protein >29
- LDH >0.45 times serum LDH
- Pleural cholesterol >1.165 mmol/L
Also albumin gradient and BNP can help differentiate
pH
- Normal: 7.60-7.64
- Exudate: 7.30-7.45
- Transudate: 7.40-7.55
- <7.2
  - Malignancy
  - Empyema (low glucose)
  - TB
  - Rheumatoid arthritis (especially if really low glucose)
Glucose <3.3
- Malignancy
- Empyema
- TB
- Rheumatoid arthritis (especially when <1.6)

@@ Line 1: / Line 1: @@
-== Etiology ==
+==Etiology==
-* Increased influx from pleural vessels and decreased efflux via lymphatic system of pleural fluid
+*Increased influx from pleural vessels and decreased efflux via lymphatic system of pleural fluid
-== Differential Diagnosis ==
+==Differential Diagnosis==
-* Transudative
+*Transudative
+**[[Heart failure]], unless post-diuresis
-** Congestive heart failure
+**[[Cirrhosis]]
-*** Unless post-diuresis
+**[[Nephrotic syndrome]]
-** Cirrhosis
+**[[Peritoneal dialysis]]
-** Nephrotic syndrome
+**[[Atelectasis]]
-** Peritoneal dialysis
+*Exudative
-** Atelectasis
+**Infection, including [[parapneumonic effusion]]
-* Exudative
+**[[Malignancy]]
-** Infection, including [[parapneumonic effusion]]
+**[[Connective tissue disorder|Connective tissue disorders]]
-** Malignancy
-** Connective tissue disorders
+**Inflammatory disorders
+**Movement of fluid from abdomen to pleural space
-** Inflammatory disorders
+**[[CABG]]
-** Movement of fluid from abdomen to pleural space
+**[[Pulmonary embolism]]
-** CABG
+*Medication (check [https://www.pneumotox.com/pattern/view/31/V.a/pleural-effusion Pneumotox online])
-** Pulmonary embolism
+**[[Methotrexate]]
-* Medication (check Pneumotox online)
+**[[Amiodarone]]
-** Methotrexate
+**[[Nitrofurantoin]]
-** Amiodarone
+**[[Phenytoin]]
-** Nitrofurantoin
+**[[Beta-blocker|Beta-blockers]]
-** Phenytoin
+*[[Asbestosis]]
-** Beta-blockers
-* Asbestosis
+==Clinical Manifestations==
-== Fluid Analysis ==
+*History of CHF, cirrhosis, CKD, TB, malignancy
-* '''Light's Criteria'''
+*Decreased lung sounds with dullness on percussion
-** Exudate is exudative if at least one of:
-*** Pleural fluid to serum protein ratio &gt; 0.5
-*** Pleural fluid to serum lactate dehydrogenase (LD) ratio &gt; 0.6
-*** Pleural fluid LD level &gt; 2/3 of upper limit of normal
-**** ULN usually ~220, so LD &gt; 148
-* Modified Light's Criteria
-** Protein &gt;29
-** LDH &gt;0.45 times serum LDH
-** Pleural cholesterol &gt;1.165 mmol/L
-* Also albumin gradient and BNP can help differentiate
-* pH
-** Normal: 7.60-7.64
-** Exudate: 7.30-7.45
-** Transudate: 7.40-7.55
-** &lt;7.2
-*** Malignancy
-*** Empyema (low glucose)
-*** TB
-*** Rheumatoid arthritis (especially if really low glucose)
-* Glucose &lt;3.3
-** Malignancy
-** Empyema
-** TB
-** Rheumatoid arthritis (especially when &lt;1.6)
+==Investigations==
-== Clinical Presentation ==
+*Labs: pleural fluid and serum protein and LDH
-* History of CHF, cirrhosis, CKD, TB, malignancy
+*Imaging
-* Decreased lung sounds with dullness on percussion
+**CXR is first-line imaging
+***Blunting suggests at least 200mL of effusion
+***Lateral more sensitive (50mL)
+***Lateral decubitus is also helpful to rule out loculations
+**Bedside ultrasound is best for internal medicine
+***More sensitive than CXR (3-5mL)
+***Better than CT for assessing the pleura
+*Diagnostic thoracentesis
+**Risks
+***Pneumothorax &lt;5%
+***Hemothorax 1%
+****Avoid if INR &gt;3 or platelets &lt;25
+***Re expansion pulmonary edema &lt;1%
+****Avoid taking more than 1-2L
+**Diagnostic requires 50mL (5-10 for microbiology, 2-5 for biochemistry, 20-40 for cytology)
+===Fluid Analysis===
-== Investigations ==
+*'''Light's Criteria'''
-* Labs
+**Exudate is exudative if at least one of:
-** Pleural fluid and serum protein and LDH
+***Pleural fluid to serum protein ratio &gt; 0.5
-* Imaging
+***Pleural fluid to serum lactate dehydrogenase (LD) ratio &gt; 0.6
-** CXR is first-line imaging
+***Pleural fluid LD level &gt; 2/3 of upper limit of normal
-*** Blunting suggests at least 200mL of effusion
+****ULN usually ~220, so LD &gt; 148
-*** Lateral more sensitive (50mL)
+*Modified Light's Criteria
-*** Lateral decubitus is also helpful to rule out loculations
+**Protein &gt;29
-** Bedside ultrasound is best for internal medicine
+**LDH &gt;0.45 times serum LDH
-*** More sensitive than CXR (3-5mL)
+**Pleural cholesterol &gt;1.165 mmol/L
-*** Better than CT for assessing the pleura
+*Also albumin gradient and BNP can help differentiate
-* Thoracentesis
+*pH
-** Risks
+**Normal: 7.60-7.64
-*** Pneumothorax &lt;5%
+**Exudate: 7.30-7.45
-*** Hemothorax 1%
+**Transudate: 7.40-7.55
-**** Avoid if INR &gt;3 or platelets &lt;25
+**&lt;7.2
-*** Re expansion pulmonary edema &lt;1%
+***Malignancy
-**** Avoid taking more than 1-2L
+***Empyema (low glucose)
-** Diagnostic requires 50mL (5-10 for microbiology, 2-5 for biochemistry, 20-40 for cytology)
+***TB
+***Rheumatoid arthritis (especially if really low glucose)
+*Glucose &lt;3.3
+**Malignancy
+**Empyema
+**TB
+**Rheumatoid arthritis (especially when &lt;1.6)
 [[Category:Respirology]]