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https://upload.medbullets.com/topic/117039/images/pleural effusion.jpg
https://upload.medbullets.com/topic/117039/images/pleural_effusion.jpg
Snapshot
  • A 55-year-old male with congestive heart failure, coronary artery disease, and hypertension presents to your urgent care with shortness of breath. He is on vacation and lost his medications during his travel. He reports that his shortness of breath has been getting worse over the past few days, especially when he is walking. His exam is notable for decreased lung sounds bilaterally with overlying dullness to percussion and bilateral 1+ pitting edema to the knees. A chest radiograph was performed, which showed blunting of the costophrenic angles.
Introduction
  • Clinical definition
    • pathologic accumulation of fluid in the pleural space (5 - 10 cc physiologically)
  • Epidemiology
    • incidence
      • the most common cause in the United States
        • congestive heart failure, pneumonia, and malignancy
      • the most common cause in the world
        • tuberculosis
  • Etiology
    • any abnormal balance between fluid entering and/or exiting pleural space
  • Pathogenesis
    • characteristics of the fluid suggest the pathogenesis
      • transudative
        • ↑ hydrostatic pressure or ↓ capillary oncotic pressure
      • exudative
        • ↑ capillary permeability
  • Prognosis
    • depends on etiology and baseline pulmonary function
Presentation
  • Symptoms
    • asymptomatic
    • dyspnea and/or dyspnea on exertion
    • cough
  • Physical examination
    • ↓ breath sounds
    • ↓ tactile fremitus
      • versus consolidation, which ↑ breath sounds
  • Special presentation
    • hepatic hydrothorax
      • intra-abdominal fluid enters via diaphragmatic defects
Imaging
  • Chest radiography 
    • upright show blunting of the costophrenic angles 
    • lateral decubitus shows layering if free flowing 
Studies
  • Thoracentesis 
    • diagnostic gold standard
    • indicated for new effusions
  • Fluid studies 
    • Gram stain and culture
    • cell count with differential
    • cytology
    • Light criteria  

Light Criteria for Pleural Fluid Analysis

Transudative Exudative
Fluid LDH
  • ≤ 2/3 upper limit of normal serum
  • > 2/3 upper limit of normal serum
Fluid LDH/Serum LDH
  • ≤ 0.6
  • > 0.6
Fluid total protein/serum total protein
  • ≤ 0.5
  • > 0.5
Diagnosis
  • Must meet all criteria to diagnose a transudate
  • Meet any single criterion to diagnose exudate

 
Differential Diagnosis
  • Pyothorax
  • Hemothorax
  • Chylothorax
Treatment
  • Management approach
    • if high suspicion of congestive heart failure, diurese
    • if new effusion, perform diagnostic and therapeutic thoracentesis
    • concurrent treatment of the underlying disease 
  • Interventional 
    • therapeutic thoracentesis
    • thoracostomy or thoracotomy
      • indication
        • loculated effusions
    • pleurodesis and decortication
      • indication
        • indwelling catheter for recurrent effusion 
Complications
  • Empyema
  • Loculation
  • Pneumothorax from thoracentesis
 

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(M1.PL.17.4799) A 54-year-old woman 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, pleural fluid: 3.8 g/dL
Proteins, serum (total): 7.0 g/dL

Which of the following conditions is most strongly associated with these findings?
Tested Concept

QID: 109189
FIGURES:
1

Pulmonary embolism

25%

(63/257)

2

Cirrhosis

19%

(50/257)

3

Nephrotic syndrome

6%

(16/257)

4

Protein losing enteropathy

11%

(29/257)

5

Congestive heart failure

34%

(88/257)

M 2 B

Select Answer to see Preferred Response

(M1.PL.14.79) 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? Tested Concept

QID: 106902
FIGURES:
1

Fluid LDH:serum LDH ratio of 0.5:1

8%

(4/51)

2

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

10%

(5/51)

3

Fluid protein:serum protein ratio of 0.6:1

45%

(23/51)

4

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

10%

(5/51)

5

A gram stain is needed in order to evaluate this question

12%

(6/51)

M 2 E

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