Pleural effusion: Difference between revisions

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==Background==
==Background==
*Exudative
*Exudative
**Active fluid secretion or leakage w/ high protein content
**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
**PA view requires 200-250cc of fluid; Lateral requires 50-75cc of fluid
**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 w/ suspected side down will show free-flowing pleural fluid
***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 cx bottle at the bedside)
*Gram stain and culture (place 10cc into blood culture bottle at the bedside)
*Cell count
*Cell count
**RBC >100K: trauma, malignancy, PNA, or pulmonary infarction
**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 temp for up to 1hr w/o affecting results
**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)


==Work-Up==
==Management==
[[Thoracentesis]]
*Dyspnea at rest:
 
**Therapeutic [[thoracentesis]] with max drainage 1-1.5L to avoid reexpansion pulmonary edema
==Differential Diagnosis==
[[File:Pleural effusion.png|thumb]]
===Common===
*Transudative
**[[CHF]]
*Exudative
**Cancer
**[[PNA]] (parapneumonic effusion)
***Occurs in 40% of pts hospitalized w/ PNA
**[[PE]]
***Occurs in 30% of pts w/ PE
 
===Less Common===
*Transudative
**[[Nephrotic Syndrome]]
**Cirrhosis
***Both via hypoalbuminemia and transdiaphragmatic leakage of ascites
**[[PE]]
*Exudative
**Viral, fungal, or parasitic infection
**SLE, RA
**Uremia
**[[Pancreatitis]]
**Amiodarone
 
==Treatment==
*Dyspnea at rest
**Therapeutic thoracentesis w/ max drainage 1-1.5L to avoid reexpansion pulmonary edema
*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 w/ large-bore thoracostomy tube
**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 abx tx
***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 w/in 2-3d
**[[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]


==Source==
==References==
Tintinalli
<references/>


[[Category:Pulm]]
[[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

Pleural effusion.png

Common

  • Transudative
  • Exudative
    • Cancer
    • Pneumonia (parapneumonic effusion)
      • Occurs in 40% of patients hospitalized with pneumonia
    • PE
      • Occurs in 30% of patients with PE

Less Common

Non-infectious Effusions

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

Thoracentesis

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
  • CHF
    • Diuretic therapy resolves >75% of effusions within 2-3d

Disposition

See Also

External Links

References