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https://upload.medbullets.com/topic/117039/images/pleural_effusion.jpg
Introduction
  • Pathologic accumulation of fluid in the pleural space  often parapneumonic (in association with pneumonia) 
    • if infected, known as an empyema
  • Effusions classified by pathogenesis 
    • transudative
      • occur secondary to ↑ pulmonary capillary pressure or ↓ capillary oncotic pressure
    • exudative
      • occur secondary to increased pleural vascular permeability
Presentation
  • Symptoms
    • often asymptomatic
    • may present with dyspnea
    • pleuritic chest pain
    • cough
  • Physical examination
    • decreased breath sounds
    • dullness to percussion
    • decreased tactile fremitus
      • versus consolidation, which produces increased tactile fremitus
Evaluation
  • CXR
    • shows blunting of the costophrenic angles
    • layering on decubitus film if free flowing
  • Thoracentesis
    • diagnostic gold standard
    • indicated for new effusions
  • Fluid Studies 
    • Light's criteria: exudative if any 1 of 3 present  
      • ratio of fluid protein to serum protein > 0.5
      • ratio of fluid LDH to serum LDH > 0.6
      • fluid LDH > 2/3 upper limit of normal for serum
    • Other common studies to help identify etiology and guide treatment
      • glucose
      • pH
      • amylase
      • triglycerides
      • Gram stain, culture
Treatment
  • Transudates
    • directed at underlying cause
  • Exudates
    • Drainage if concern for complicated parapneumonic effusions or empyema
    • Indwelling pleural catheter or pleurodesis for recurrent malignant effusions
 

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Questions (3)

(M1.PL.4799) A 54-year-old female presents to the emergency department complaining of shortness of breath. She does not speak English and her medical history is unknown. Her temperature is 100.1°F (37.8°C), blood pressure is 130/85 mmHg, pulse is 105/min, and respirations are 24/min. Physical examination reveals bilateral rales and dullness to percussion at the lung bases that is worse on the left. Hepatosplenomegaly is noted. A chest radiograph is shown in Figure A. A thoracentesis and hematologic analysis are performed, with the following results:

Pleural lactate dehydrogenase: 54 U/L
Serum lactate dehydrogenase: 82 U/L
Proteins, serum (total): 7.0 g/dL
Proteins, pleural fluid: 3.8 g/dL

Which of the following conditions is most strongly associated with these findings?
Review Topic

QID: 109189
FIGURES:
1

Pulmonary embolism

25%

(51/202)

2

Cirrhosis

19%

(39/202)

3

Nephrotic syndrome

6%

(13/202)

4

Protein losing enteropathy

11%

(22/202)

5

Congestive heart failure

35%

(70/202)

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PREFERRED RESPONSE 1
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(M1.PL.79) A 78-year-old woman with a past medical history of heavy alcohol and tobacco use, esophageal cancer and chronic pancreatitis presents to the emergency room with shortness of breath. Her blood pressure is 165/94, heart rate is 118 beats per minute, respiratory rate is 31 breaths per minute, and SpO2 is 78% on room air. A chest X-ray is shown below (Figure A). She then undergoes a thoracentesis for evaluation of the left-sided pleural effusion. Which of the following results is consistent with a pleural effusion secondary to an esophageal perforation? Review Topic

QID: 106902
FIGURES:
1

Fluid LDH:serum LDH ratio of 0.5:1

0%

(0/4)

2

Fluid LDH of 50 IU/L (normal <300)

0%

(0/4)

3

Fluid protein:serum protein ratio of 0.6:1

25%

(1/4)

4

Fluid protein of 10 g/L (normal <25)

25%

(1/4)

5

A gram stain is needed in order to evaluate this question

25%

(1/4)

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