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Pleural Effusions

Pleural Effusions. Definition. Increased amount of fluid within the pleural cavity Stedman’s Medical Dictionary Accumulation of fluid between the layers of the membrane that lines the lungs and the chest cavity Medline Plus. Epidemiology. United States 1 million cases annually

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Pleural Effusions

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  1. Pleural Effusions

  2. Definition • Increased amount of fluid within the pleural cavity • Stedman’s Medical Dictionary • Accumulation of fluid between the layers of the membrane that lines the lungs and the chest cavity • Medline Plus

  3. Epidemiology • United States • 1 million cases annually • Internationally • 320/100,000 in industrialized countries

  4. Pathophysiology • Normal: 1 mL of pleural fluid • Balance between hydrostatic/oncotic forces and lymphatic drainage • Abnormal: Pleural effusion • Disruption of balance

  5. Clinical History • Dyspnea • Chest pain

  6. Physical Exam • Decreased breath sounds • Dullness to percussion • Decreased tactile fremitus • Egophony • Pleural friction rub

  7. Types • Hydrothorax • Hemothorax • Chylothorax • Pyothorax or Empyema

  8. Classification • Transudate • Ultrafiltrate of plasma • Small group of etiologies • Exudate • Produced by host of inflammatory conditions • Large group of etiologies

  9. Workup: Thoracentesis • Light’s criteria: Transudate vs. Exudate • Pleural fluid protein / serum protein > 0.5 • Pleural fluid LDH / serum LDH > 0.6 • Pleural fluid LDH > 2/3 ULN serum LDH

  10. Workup: Thoracentesis • Other criteria: Transudate vs. Exudate • Pleural fluid LDH > 0.45 ULN serum LDH • Pleural fluid cholesterol > 45 mg/dL • Pleural fluid protein > 2.9 g/dL

  11. Workup: Laboratory • LDH > 1000 IU/L • Empyema, Malignancy, Rheumatoid • Glucose < 30 mg/dL • Empyema, Rheumatoid • Glucose between 30 – 50 mg/dL • Lupus, Malignancy, TB

  12. Workup: Laboratory • Lymphocytes > 85% • Chylothorax, Lymphoma, Rheumatoid, TB • Lymphocytes between 50 – 70% • Malignancy • Mesothelial cells > 5% • TB unlikely • ADA > 43 U/mL • Supports TB

  13. Workup: Imaging • Upright Chest X-Ray • Blunting of costophrenic angles • Supine Chest X-Ray • Increased density over lower lung fields • Lateral decubitus Chest X-Ray • Layering

  14. Workup: Imaging

  15. Workup: Imaging

  16. Workup: Imaging • Ultrasound • Aids in identification of loculated effusions • Aids in differentiation of fluid from fibrosis • Aids in identification of thoracentesis site • Available at bedside

  17. Workup: Imaging • CT Scan • Aids in differentiation of • Lung consolidation vs. Pleural effusion • Cystic vs. Solid lesions • Peripheral lung abscess vs. Loculated emypema • Aids in identification of • Necrotic areas • Pleural thickening, nodules, masses • Extent of tumor

  18. Work up: Imaging

  19. Treatment • Treat underlying etiology • Therapeutic thoracentesis

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