Pleural effusion: Difference between revisions
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==Background== | ==Background== | ||
*Exudative | *Exudative | ||
**Active fluid secretion or leakage | **Active fluid secretion or leakage with high protein content | ||
*Transudative | *Transudative | ||
**Imbalance between hydrostatic (e.g. CHF) and oncotic (e.g. nephrotic syndrome) | **Imbalance between hydrostatic (e.g. CHF) and oncotic (e.g. nephrotic syndrome) | ||
**Fluid has low protein content | **Fluid has low protein content | ||
==Diagnosis== | ==Clinical Features== | ||
*[[SOB]] | |||
*Decreased breath sounds | |||
*Frequently found on CXR | |||
==Differential Diagnosis== | |||
[[File:Pleural effusion.png|thumb]] | |||
===Common=== | |||
*Transudative | |||
**[[CHF]] | |||
*Exudative | |||
**Cancer | |||
**[[Pneumonia]] (parapneumonic effusion) | |||
***Occurs in 40% of patients hospitalized with pneumonia | |||
**[[PE]] | |||
***Occurs in 30% of patients with PE | |||
===Less Common=== | |||
*Transudative | |||
**[[Nephrotic Syndrome]] | |||
**[[Cirrhosis]] | |||
***Both via hypoalbuminemia and transdiaphragmatic leakage of ascites | |||
**[[PE]] | |||
*Exudative | |||
**[[Viral syndrome|Viral]], [[fungal infections|fungal]], or [[parasitic infection]] | |||
**[[SLE]], [[RA]] | |||
**[[Uremia]] | |||
**[[Pancreatitis]] | |||
**[[Amiodarone pulmonary toxicity|Amiodarone]] | |||
==Non-infectious Effusions== | |||
*Left sided > R | |||
**[[Aortic dissection]] | |||
**[[Boerhaave syndrome]] | |||
*Right sided > L | |||
**[[CHF]] | |||
**[[Pancreatitis]] | |||
**[[Hepatitis]] | |||
==Evaluation== | |||
===Detection=== | ===Detection=== | ||
*CXR | *[[CXR]] | ||
**Earliest sign is blunting of costophrenic angle | **Earliest sign is blunting of costophrenic angle | ||
** | **Lateral decubitus with affected side down requires 50-75 cc of fluid for visualization | ||
**Supine view may only show a generalized hazy appearance of affected hemithorax | ***PA view requires 200-250 cc of fluid | ||
***Supine view may only show a generalized hazy appearance of affected hemithorax | |||
**Subpulmonic effusion | **Subpulmonic effusion | ||
***Fluid collects in isolation between lung base and diaphragm | ***Fluid collects in isolation between lung base and diaphragm | ||
***May not cause blunting of costophrnic angle or meniscus appearance | ***May not cause blunting of costophrnic angle or meniscus appearance | ||
***Suspect if "hemidiaphragm" (actually fluid) is elevated and flattened | ***Suspect if "hemidiaphragm" (actually fluid) is elevated and flattened | ||
***Lateral decubitus | ***Lateral decubitus with suspected side down will show free-flowing pleural fluid | ||
*CT | *CT | ||
*US | *[[Lung ultrasound|US]] | ||
===Work-Up=== | |||
[[Thoracentesis]] | |||
===Exudative versus Transudative (Light's Criteria)=== | ===Exudative versus Transudative (Light's Criteria)=== | ||
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===Exudative Work-up=== | ===Exudative Work-up=== | ||
*Gram stain and culture (place 10cc into blood | *Gram stain and culture (place 10cc into blood culture bottle at the bedside) | ||
*Cell count | *Cell count | ||
**RBC >100K: trauma, malignancy, | **RBC >100K: trauma, malignancy, pneumonia, or pulmonary infarction | ||
**Neutrophil predominance (>50%): parapneumonic, pulmonary embolism, pancreatitis | **Neutrophil predominance (>50%): parapneumonic, pulmonary embolism, pancreatitis | ||
**Lymphocytic predominance (>50%): malignancy, TB, PE, viral pleuritis | **Lymphocytic predominance (>50%): malignancy, TB, PE, viral pleuritis | ||
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**Low glucose (<60) seen in parapneumonic, empyema, malignant, TB, and RA | **Low glucose (<60) seen in parapneumonic, empyema, malignant, TB, and RA | ||
*ABG (pH) | *ABG (pH) | ||
**May be left at room | **May be left at room temperature for up to 1hr with out affecting results | ||
**Normal pleural fluid pH = 7.64; | **Normal pleural fluid pH = 7.64; | ||
**In parapneumonic effusions, <7.10 predicts development of empyema or persistence and indicates need for thoracostomy tube drainage | **In parapneumonic effusions, <7.10 predicts development of empyema or persistence and indicates need for thoracostomy tube drainage | ||
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*Cytology (requires 50cc) | *Cytology (requires 50cc) | ||
== | ==Management== | ||
*Dyspnea at rest: | |||
**Therapeutic [[thoracentesis]] with max drainage 1-1.5L to avoid reexpansion pulmonary edema | |||
*Dyspnea at rest | |||
**Therapeutic thoracentesis | |||
*Patient positioning (lateral decubitus) for unilateral pleural effusions | *Patient positioning (lateral decubitus) for unilateral pleural effusions | ||
**Most of the time, "Good lung to Ground" to improve V/Q mismatch | **Most of the time, "Good lung to Ground" to improve V/Q mismatch | ||
**Exceptions in which "bad" lung should be "down": | **Exceptions in which "bad" lung should be "down": | ||
***Massive hemoptysis | ***Massive [[hemoptysis]] | ||
***Severe/large pleural effusions | ***Severe/large pleural effusions | ||
***Large pulmonary abscesses | ***Large pulmonary abscesses | ||
*[[Empyema]] | *[[Empyema]] | ||
**Drain | **Drain with large-bore thoracostomy tube | ||
*Parapneumonic Effusion | *Parapneumonic Effusion: | ||
**Consider thoracostomy tube drainage if: | **Consider [[thoracostomy]] tube drainage if: | ||
***Comorbid disease | ***Comorbid disease | ||
***Failure to respond to | ***Failure to respond to antibiotic treatment | ||
***Anaerobic organisms | ***Anaerobic organisms | ||
***Pleural fluid pH <7.10 | ***Pleural fluid pH <7.10 | ||
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***Loculated effusion | ***Loculated effusion | ||
*[[CHF]] | *[[CHF]] | ||
**Diuretic therapy resolves >75% of effusions | **[[Diuretic]] therapy resolves >75% of effusions within 2-3d | ||
==Disposition== | |||
==See Also== | ==See Also== | ||
[[Thoracentesis]] | *[[Thoracentesis]] | ||
==External Links== | |||
*[http://ddxof.com/pleural-effusion/ DDxOf: Differential Diagnosis of Pleural Effusion] | |||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Pulmonary]] |
Revision as of 14:22, 13 October 2019
Background
- Exudative
- Active fluid secretion or leakage with high protein content
- Transudative
- Imbalance between hydrostatic (e.g. CHF) and oncotic (e.g. nephrotic syndrome)
- Fluid has low protein content
Clinical Features
- SOB
- Decreased breath sounds
- Frequently found on CXR
Differential Diagnosis
Common
- Transudative
- Exudative
Less Common
- Transudative
- Nephrotic Syndrome
- Cirrhosis
- Both via hypoalbuminemia and transdiaphragmatic leakage of ascites
- PE
- Exudative
Non-infectious Effusions
- Left sided > R
- Right sided > L
Evaluation
Detection
- CXR
- Earliest sign is blunting of costophrenic angle
- Lateral decubitus with affected side down requires 50-75 cc of fluid for visualization
- PA view requires 200-250 cc of fluid
- Supine view may only show a generalized hazy appearance of affected hemithorax
- Subpulmonic effusion
- Fluid collects in isolation between lung base and diaphragm
- May not cause blunting of costophrnic angle or meniscus appearance
- Suspect if "hemidiaphragm" (actually fluid) is elevated and flattened
- Lateral decubitus with suspected side down will show free-flowing pleural fluid
- CT
- US
Work-Up
Exudative versus Transudative (Light's Criteria)
- If one of the following is present the fluid is virtually always an exudate
- If none is present the fluid is virtually always a transudate
- Pleural fluid/serum protein ratio >0.5
- Pleural fluid/serum LDH ratio >0.6
- Pleural fluid LDH > two thirds of upper limit for serum LDH
Exudative Work-up
- Gram stain and culture (place 10cc into blood culture bottle at the bedside)
- Cell count
- RBC >100K: trauma, malignancy, pneumonia, or pulmonary infarction
- Neutrophil predominance (>50%): parapneumonic, pulmonary embolism, pancreatitis
- Lymphocytic predominance (>50%): malignancy, TB, PE, viral pleuritis
- Glucose
- Low glucose (<60) seen in parapneumonic, empyema, malignant, TB, and RA
- ABG (pH)
- May be left at room temperature for up to 1hr with out affecting results
- Normal pleural fluid pH = 7.64;
- In parapneumonic effusions, <7.10 predicts development of empyema or persistence and indicates need for thoracostomy tube drainage
- Amylase: >100 in pleural effusions due to pancreatitis or esophageal rupture
- TB (adenosine deaminase)
- India ink
- Cytology (requires 50cc)
Management
- Dyspnea at rest:
- Therapeutic thoracentesis with max drainage 1-1.5L to avoid reexpansion pulmonary edema
- Patient positioning (lateral decubitus) for unilateral pleural effusions
- Most of the time, "Good lung to Ground" to improve V/Q mismatch
- Exceptions in which "bad" lung should be "down":
- Massive hemoptysis
- Severe/large pleural effusions
- Large pulmonary abscesses
- Empyema
- Drain with large-bore thoracostomy tube
- Parapneumonic Effusion:
- Consider thoracostomy tube drainage if:
- Comorbid disease
- Failure to respond to antibiotic treatment
- Anaerobic organisms
- Pleural fluid pH <7.10
- Effusion involving >50% of thorax or air-fluid level on CXR
- Loculated effusion
- Consider thoracostomy tube drainage if:
- CHF
- Diuretic therapy resolves >75% of effusions within 2-3d