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30 Cards in this Set

  • Front
  • Back
What is a pleural effusion?
Plain and simply, a pleural effusion is a state of excess fluid in the pleural space.
What are the two broad types of pleural effusions and what is the difference between them?
Pleural effusions are classified as either transudative or exudative.

Recall that ALL pleural effusions result from either excess fluid production or impaired fluid reabsorption.

Transudative pleural effusions arise when systemic factors affecting the formation or absorption of fluid from the pleural cavity are altered.

Exudative pleural effusions arise when local factors affecting the formation or absorption of fluid from the pleural space are altered.
What is an empyema?
An empyema is a grossly purulent pleural effusion.
What is hepatic hydrothorax? Describe the pathophysiology leading to this condition.
A hepatic hydrothorax is a pleural effusion resulting from cirrhosis with ascites.

The predominant mechanism is the direct movement of peritoneal fluid through small openings in the diaphragm into the pleural space.

The effusion is usually right-sided and frequently is large enough to produce severe dyspnea.
What is the term for a pleural effusion caused by liver failure?
Hepatic hydrothorax
Where does the visceral pleura receive its blood supply from?
Bronchial circulation, drains via pulmonary veins
Where does the parietal pleura receive its blood supply from?
Chest wall arteries, drains via IVC
How does lymphatic drainage of the pleural space occur?
Via stomata, which are 2 t0 6 micrometer openings in the parietal pleura
What are the two ways a pleural effusion can develop?
Increase in pleural fluid production or decrease in drainage (or both)
What are the 6 mechanisms by which excess pleural fluid can accumulate?
1) Increased hydrostatic pressure in the circulatory system

2) Decreased intravascular oncotic pressure

3) Decreased lymphatic drainage

4) Increased vascular permeability

5) Transit of peritoneal fluid

6) Decreased hydrostatic pressure in the pleural space
Which type of pleural effusion (transudative or exudative) is high in protein?
Exudative
What are the two principle pathophysiologic mechanisms leading to transudative pleural effusion?
Increased hydrostatic pressure in the circulatory system or decreased intravascular oncotic pressure
Name 5 causes of transudative pleural effusion.
CHF, pulmonary embolism, liver cirrhosis, peritoneal dialysis, nephrotic syndrome
What are the two principle pathophysiologic mechanisms leading to an exudative pleural effusion?
Increased vascular permeability or blockage of lymphatic drainage
Name 5 causes of exudative pleural effusion.
Infection (parapneumonic, emyema)

Malignancy

Pancreatitis

Trauma

Pulmonary embolism
Name 3 findings of physical exam suggestive of pleural effusion.
Diminished breath sounds, decreased tactile fremitus, dullness to percussion
Name 3 imaging modalities used to investigate a possible pleural effusion.
Plain X-ray, CT, ultrasound
What finding a plain-film chest X-ray suggests pleural effusion?
Blunting of the costophrenic angle
What diagnostic test is the cornerstone of investigating a pleural effusion?
Pleural fluid analysis
When analyzing pleural fluid, what diagnostic criteria are used to separate transudates from exudates?
Light’s Criteria
What are Light’s Criteria?
An effusion is exudative if one or more of the following are present:

1) Ratio of pleural fluid proten level to serum protein level >0.5

2) Ratio of pleural fluid LDH to serum LDH >0.6

3) Pleural fluid LDH more than two-thirds the upper limit for normal serum LDH
What is LDH?
Lactate dehydrogenase
You draw pleural fluid out and it appears bloody. Name four potential causes of this effusion.
TB, PE, malignancy, trauma
How do you diagnose a hemothorax?
Pleural fluid hematocrit >50 of the peripheral hematocrit
What tests might you run on the pleural fluid if malignancy is suspected?
Cytology/flow cytometry
What is the first step in the management of pleural effusion?
ABCs

Is the patient in respiratory distress? Respiratory failure? Urgent thoracentesis may be required, bearing in mind that the respiratory distress may be caused by the underlying etiology of the effusion (e.g. PE, pneumonia) and not the effusion itself.

If not, you can move on to determining the etiology of the pleural effusion.
What is the treatment for asymptomatic transudative pleural effusion?
Conservative management (treat underlying cause, e.g. diuresis for CHF)
What important fact must you bear in mind when treating symptomatic transudative pleural effusion with thoracentesis?
Unless the underlying cause is addressed the effusion is likely to quickly recur
What is the treatment for empyema?
Drainage with CHEST TUBE, ABX
Name three indications for prompt drainage of a pleural effusion with a chest tube.
1) Frank blood in the pleural space

2) Pus in the pleural space

3) pH < 7.20