Pleural effusion: Difference between revisions

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

Revision as of 13:33, 30 July 2020

Etiology

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

Differential Diagnosis

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)

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
  • 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)
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