Pleural effusion: Difference between revisions
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| − | == |
+ | ==Etiology== |
| − | * |
+ | *Increased influx from pleural vessels and decreased efflux via lymphatic system of pleural fluid |
| − | == |
+ | ==Differential Diagnosis== |
| − | * |
+ | *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 |
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| + | **[[Nephrotic syndrome]] |
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| − | ** Cirrhosis |
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| + | **[[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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| − | ** |
+ | **Inflammatory disorders |
| + | **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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| + | ==Clinical Manifestations== |
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| − | == Fluid Analysis == |
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| + | *History of CHF, cirrhosis, CKD, TB, malignancy |
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| − | * '''Light's Criteria''' |
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| + | *Decreased lung sounds with dullness on percussion |
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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 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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| − | **** ULN usually ~220, so LD > 148 |
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| − | * Modified Light's Criteria |
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| − | ** Protein >29 |
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| − | ** LDH >0.45 times serum LDH |
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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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| − | * pH |
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| − | ** Normal: 7.60-7.64 |
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| − | ** Exudate: 7.30-7.45 |
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| − | ** Transudate: 7.40-7.55 |
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| − | ** <7.2 |
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| − | *** Malignancy |
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| − | *** Empyema (low glucose) |
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| − | *** TB |
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| − | *** Rheumatoid arthritis (especially if really low glucose) |
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| − | * Glucose <3.3 |
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| − | ** Malignancy |
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| − | ** Empyema |
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| − | ** TB |
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| − | ** Rheumatoid arthritis (especially when <1.6) |
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| + | ==Investigations== |
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| − | == Clinical Manifestations == |
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| + | *Labs: pleural fluid and serum protein and LDH |
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| − | * History of CHF, cirrhosis, CKD, TB, malignancy |
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| + | *Imaging |
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| − | * Decreased lung sounds with dullness on percussion |
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| + | **CXR is first-line imaging |
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| + | ***Blunting suggests at least 200mL of effusion |
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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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| + | **Bedside ultrasound is best for internal medicine |
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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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| + | *Diagnostic thoracentesis |
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| + | **Risks |
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| + | ***Pneumothorax <5% |
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| + | ***Hemothorax 1% |
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| + | ****Avoid if INR >3 or platelets <25 |
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| + | ***Re expansion pulmonary edema <1% |
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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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| + | ===Fluid Analysis=== |
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| − | == Investigations == |
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| + | *'''Light's Criteria''' |
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| − | * Labs |
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| + | **Exudate is exudative if at least one of: |
||
| − | ** Pleural fluid and serum protein and LDH |
||
| + | ***Pleural fluid to serum protein ratio > 0.5 |
||
| − | * Imaging |
||
| + | ***Pleural fluid to serum lactate dehydrogenase (LD) ratio > 0.6 |
||
| − | ** CXR is first-line imaging |
||
| + | ***Pleural fluid LD level > 2/3 of upper limit of normal |
||
| − | *** Blunting suggests at least 200mL of effusion |
||
| + | ****ULN usually ~220, so LD > 148 |
||
| − | *** Lateral more sensitive (50mL) |
||
| + | *Modified Light's Criteria |
||
| − | *** Lateral decubitus is also helpful to rule out loculations |
||
| + | **Protein >29 |
||
| − | ** Bedside ultrasound is best for internal medicine |
||
| + | **LDH >0.45 times serum LDH |
||
| − | *** More sensitive than CXR (3-5mL) |
||
| + | **Pleural cholesterol >1.165 mmol/L |
||
| − | *** Better than CT for assessing the pleura |
||
| + | *Also albumin gradient and BNP can help differentiate |
||
| − | * Thoracentesis |
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| + | *pH |
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| − | ** Risks |
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| + | **Normal: 7.60-7.64 |
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| − | *** Pneumothorax <5% |
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| + | **Exudate: 7.30-7.45 |
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| − | *** Hemothorax 1% |
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| + | **Transudate: 7.40-7.55 |
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| − | **** Avoid if INR >3 or platelets <25 |
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| + | **<7.2 |
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| − | *** Re expansion pulmonary edema <1% |
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| + | ***Malignancy |
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| − | **** Avoid taking more than 1-2L |
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| + | ***Empyema (low glucose) |
||
| − | ** Diagnostic requires 50mL (5-10 for microbiology, 2-5 for biochemistry, 20-40 for cytology) |
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| + | ***TB |
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| + | ***Rheumatoid arthritis (especially if really low glucose) |
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| + | *Glucose <3.3 |
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| + | **Malignancy |
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| + | **Empyema |
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| + | **TB |
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| + | **Rheumatoid arthritis (especially when <1.6) |
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[[Category:Respirology]] |
[[Category:Respirology]] |
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Latest revision as of 13:34, 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
- CXR is first-line imaging
- 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)
- Risks
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
- Exudate is exudative if at least one of:
- 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)
