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Pleural Effusion

Title               

Ñ    Pleural Effusion

Definition

Ñ    Accumulation of fluid

Ñ    In the pleural space

Pathogenesis

Causes

Mural Factors

Ñ    Secondary deposits

Ñ    Tuberculosis

Ñ    Lymphoma

Ñ    Mesothelioma

External Factors

Ñ    Pneumonia

Ñ    Pulmonary embolism

Ñ    Bronchial carcinoma

Ñ    Subphrenic abscess

Ñ    Trauma

Systemic Factors

LMS

Ñ    Rheumatoid arthritis

Ñ    Systemic lupus erythematosus

CVS

Ñ    Cardiac failure

Ñ    Dressler’s syndrome

KUS

Ñ    Nephrotic syndrome

GIT

Ñ    Cirrhosis of the liver

Ñ    Pancreatitis

E&M

Ñ    Hypothyroidism

IS

Ñ    Yellow nail syndrome

RAG

Ñ    Meig’s syndrome

HS

Ñ    Lymphoma

Pathophysiology

Pleural effusions may be:

Ñ    Transudates

Ñ    Exudates

Transudate

Ñ    Transudates occur in relation to increased hydrostatic pressure in capillaries or decreased colloid osmotic pressure.

Ñ    Hence, most likely to occur in relation to failure of organs or organ systems:

Heart failure, liver failure, nephrotic syndrome

Exudate

Ñ    Exudation is due to damage to the mesothelial lining of the pleura caused by inflammation or tumour

Clinical Features

History

E&M

Ñ    Fever

RS

Ñ    Cough

Ñ    Breathlessness

Ñ    Pleuritic chest pain

Ñ    Haemoptysis

Past Illnesses

Ñ    History of underlying illness

Examination

RS

500 ml of fluid should be present for the effusion to be detectable clinically

Ñ    Respiratory movement:

·          Decreased:

On affected side

Ñ    Mediastinal shift:

To opposite side

Ñ    Vocal fremitus:

·          Decreased:

On affected side

Ñ    Percussion note:

·          Stony dull:

On affected side

Ñ    Breath sounds:

·          Decreased:

On affected side

Ñ    Vocal resonance

·          Decreased:

On affected side

Ñ    Aegophony:

At upper level of effusion

Investigations

Fluids

Pleural Fluid

Physical Appearance

Ñ    Clear yellow:

Non-diagnostic

Ñ    Turbid yellow:

Empyema

Parapneumonic effusion

Ñ    Bloody:

Malignancy,

Pulmonary embolism

Trauma

Haematology

Ñ    Neutrophils:

Parapneumonic effusion

Pulmonary embolism

Ñ    Lymphocytes:

Malignancy

Tuberculosis

Rheumatoid

SLE

Sarcoid

Biochemistry

Ñ    Protein < 30 g/L, lactic acid dehydrogenase < 200 IU/L:

Transudate

Ñ    Protein >30g/L, lactic acid dehydrogenase >200 IU/L:

Exudate

Ñ    Glucose < 3.3 mmol/L:

Empyema

Tuberculosis

Malignancy

Rheumatoid

SLE

Ñ    pH < 7.2:

Empyema

Tuberculosis

Malignancy

Rheumatoid disease

SLE

Ñ    Lactic acid dehydrogenase increased:

Empyema,

Tuberculosis

Malignancy

Rheumatoid disease

SLE

Ñ    Amylase increased:

Pancreatitis

Bacterial pneumonia

Oesophageal rupture

Cancer

Immunology

Ñ    Rheumatoid factor:

Rheumatoid disease

Ñ    Antinuclear factor:

SLE

Ñ    Complement levels:

·          Decreased:

Rheumatoid disease

SLE

Malignancy

Infection

Microbiology

Ñ    Microscopy and culture:

Bacterial infection

Ñ    Ziehl-Nielsen, auramine stain, TB culture:

Tuberculosis

Cytology

Ñ    Mesothelial cells:

Pulmonary embolism

Ñ    Abnormal mesothelial cells:

Mesothelioma

Ñ    Malignant cells:

Carcinoma

Imaging

Chest X-ray

Ñ    Blunting of costophrenic angle:

Earliest sign

300 mls of fluid at least

Ñ    Dense homogenous shadow:

Occupying part of or the whole of the hemithorax

CT Scan

Ñ    May show underlying cause

Endoscopy

Bronchoscopy

Ñ    Bronchial cancer

Thoracoscopy

Ñ    Targeted pleural biopsy

Tissue Diagnosis

Pleural Biopsy

Ñ    If diagnosis not clear on other investigations

Management

Cure

Ñ    Treat underlying cause

Control

Surgery

Ñ    Drain effusion:

Aspiration

Intercostal drainage tube

Ñ    Pleurodesis:

Tetracycline, bleomcyin, talc

Ñ    Formal surgery for persistent collection and increasing pleural thickness

Prognosis

Ñ    Depends on underlying condition

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