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Pleural Effusions 

ATHI S – RESPIRATORY AT

SLIDES EDITED BY: YOSHUA SELVADURAI AND VIVIAN LIN FOR NPMT

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Outline

  • Definition
  • Differential Diagnoses
  • Investigations
  • Management 

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Definition

  • Build-up of fluid within the pleural cavity
  • Usually produce 200mL of pleural fluid a day – drained by lymphatic system 

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Differential Diagnoses

  • Can be split into high protein (exudative) and low protein (transudative) using Light's criteria
  • Needs to fit one of the criteria to be exudative 

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Differential Diagnoses Cont.

  • Transudative causes (low protein) - occurs due to alterations in Starling Forces
    • Congestive heart failure
    • Hypoalbuminaemic causes
      • Cirrhosis
      • Nephrotic syndrome
    • Constrictive pericarditis
    • Peritoneal dialysis
    • Nephrotic syndrome

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Starling Forces

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Differential Diagnoses Cont. 

  • Exudative causes
    • Malignancy
    • Parapneumonic effusions and other examples of infected pleura including empyema
    • Tuberculosis
    • Pulmonary embolism
    • Autoimmune pleuritis – rheumatoid arthritis, SLE
    • Benign asbestos effusion
    • Pancreatitis
    • Dressler syndrome – pleural effusion post myocardial infarction
    • Drugs
    • Fungal infections

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Investigations - CXR

Large right sided effusion – meniscus sign

Large right sided effusion – meniscus sign

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Investigations – CXR Cont.

PA Film

Lateral film

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Investigations – Pleural US

Simple anechoic effusion

Complex pleural effusion

Probe side

Deep side

Liver

Parietal pleura

Fibrinous bands

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Investigations – Pleural Fluid

  • Fluid can be obtained from an ICC or pleural aspirate – should be performed US guided 

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Investigations – Pleural Fluid pH

British Thoracic Society Guidelines

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Management

  • Management is very much dependent on the cause
  • Transudative pleural effusions
    • Usually caused by alterations to Starling forces
    • Fluid can be drained, but if underlying cause not managed will simply reaccumulate 
    • Need to treat underlying cause to rebalance Starling forces
      • Heart failure – excess fluid = diurese
      • Cirrhosis – low protein = treat cirrhosis and increase protein uptake
      • Nephrotic syndrome – low protein = treat nephrotic syndrome and increase protein uptake 

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Management cont.

  • Exudative causes
    • Malignancy
      • 1st instance, pleural drain and drain to dry. Send for cytology to confirm diagnosis. Send for flow cytometry as well for lymphoma subsets.
      • If recurs, need to start thinking about longer term solutions
        • Pleurodesis – Use talc powder to irritate the visceral and parietal pleura, cause inflammation and thus stick the 2 layers of the pleura together
        • Intrapleural catheter – long term catheter stays in the pleural cavity and is accessed by nurses every few days to drain fluid

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Management cont.

  • Pleural infection
    • Drain inserted to remove the collection and aim to achieve source control
    • Effusion may be difficult to drain due to formation of pockets with fibrin
    • Fibrinolysis can be considered
      • TPA and dornase alpha administered intrapleural to break down fibrin clots and allow for drainage of the pleural fluid 
    • If fails, would need cardiothoracics consult for consideration of VATS

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