Download Pleural effusion

Resident Version
Pleural Effusion Module
created by Dr. Farzana Harji
Objectives:
By the end of this module, you should be able to:
1. Identify top three most common causes of pleural effusion
2. Recognize indications for thoracentesis
3. Understand the diagnostic approach to pleural effusion and be able to
differentiate transudative versus exudative pleural effusion.
4. Understand the significance of fluid pH, glucose level, gross appearance of
fluid, gram stain and culture.
References:
Light, RW. Pleural effusions. Medical clinics of North America Nov 1977;
Vol. 61, No. 6, 1339-1352.
2. Light, RW. Pleural effusion. N Engl J Med June 20, 2002; Vol. 346, No. 25,
1971-1977.
3. Uptodate: Diagnostic evaluation of a pleural effusion in adults.
4. Light, RW. Pleural diseases, 3rd ed, Williams Wilkins, Baltimore, 1995.
1.
Pleural effusion

Top three most common causes of pleural effusion in the United States are
congestive heart failure, pneumonia, and cancer.
FIRST STEP: History and examination
Exam findings:
Chest exam typically reveals dullness to percussion, the absence of fremitus, and
diminished breath sounds or their absence.
-Distended neck veins, and S3 gallop, or peripheral edema suggests congestive
heart failure.
-Right ventricular heave or thrombophlebitis suggests pulmonary embolus.
-Presence of lymphadenopathy or hepatosplenomegaly suggests neoplastic
disease or liver disease.
-Ascites may suggest hepatic cause.
Imaging studies sometimes necessary to verify pleural effusion:
-Lateral decubitus chest x-ray
-Ultrasound
-CT scan (for lung parenchyma or mediastinum)
Indications for thoracentesis:
Presence of a clinically significant pleural effusion (more than 2cm thick on ultrasound or
lateral films) with no known cause (not worked up previously). Thoracentesis is
performed for diagnosis or therapeutic reasons.
SECOND STEP: Differentiate Exudates versus Transudates
____________________________________
Leading causes of transudative pleural effusions: chf, cirrhosis, nephrosis, and PE
Leading causes of exudative pleural effusions: pneumonia, cancer, and PE
THIRD STEP: Additional Tests and Interpretation:
1.
Low glucose level (<60 mg/dL): complicated parapneumonic effusion,
malignancy, or rheumatoid pleuritis (not SLE) or tuberculous pleural effusion
2.
Pleural fluid pH: useful prognostic factor
<7.2 pleural fluid pH (arterial pH >7.35): strongly suggests that fluid will not resolve
spontaneously in parapneumonic effusions and will most likely need a chest tube. Low
pH can also occur in malignancy, rheumatoid pleuritis and tuberculous effusion
3.
Smears and cultures
-Usually just need aerobic and anaerobic cultures and gram stain
-If chronic febrile illness or fever of unknown origin then include fungal culture
-If >50% lymphocytes, then include AFB smear and culture
4.
Amylase: elevated in pancreatic disease, or esophageal rupture, 10% with
malignancy
5.
Appearance of Pleural Fluid
Interpretation
1. Bloody
<1% of peripheral hematocrit
1-20%
>50%
 nonsignificant
 cancer, PE and trauma
 hemothorax
2. White/milky/opaque
chylothorax, chyliform; pyothorax
3. Putrid odor
probably infection due to anaerobic bacteria
6.
Total and differential cell count and their values:
A. Neutrophils (limited value): (>50% of cells) parapneumonic, pancreatitis, PE,
malignancy, TB
B. Lymphocytes (good value): (>50% of cells) cancer or tuberculous pleuritis
C. Eosinophils (limited value): (>10%) most common cause is trauma resulting in either
blood (hemothrax) or air (pneumothorax), or viral pleuritis, or resolving parapneumonic
effusion. Unusual causes reactions to drugs or exposures (asbestos)
D. Mesothelial cells: commonly found up to 12 or more can be normal; uncommon in
tuberculous effusions; presence of numerous mesothelial cells nearly excludes a
diagnosis of tuberculosis
7.
Cytologic Exam Efficiency when cancer involving the pleura:
Metastatic adenocarcinoma
70% sensitive
Mesothelioma
10% sensitive
Squamous-cell carcinoma
20% sensitive
Lymphoma
25-50% sensitive
Sarcoma
25% sensitive
8.
Lipid analysis: if fluid is milky or opaque
-Chylous pleural effusion arises when the thoracic duct is severed or obstructed. High
TG, low cholesterol.
-Chyliform pleural effusion has been present for a long time and cholesterol accumulates.
High cholesterol, normal TG.
Case:
HPI: 75 yom w/ 50 pack year smoking history, and MI x2, who presents with increasing
shortness of breath. He has had increasing shortness of breath over last 2 weeks, and low grade
fever, sweats, cough, and orthopnea x4 days. No sick contacts, no recent chest pain, no
hemoptysis. Productive cough w/ white sputum.
PMH:
1.
2.
3.
4.
5.
6.
7.
8.
MI x2, first 5 years ago, most recent 1 year ago
DM, HgB A1c 8.3
Obese
Chronic bronchitis
Osteoarthritis
HTN
Past heavy alcohol abuse
Hyperlipidemia
Medications:
1. Lisinopril 10mg
2. Metformin 1000mg bid
3. Metoprolol 75mg bid
4. Albuterol/Atrovent MDI
5. ASA 81mg qd
6. Tylenol prn
7. Atorvastatin 80mg qd
8. Lasix 40mg po qd
Allergies: none
FH: father died in MVA, mother died of cancer “unknown”, one brother w/ diabetes, one sister
w/ HTN.
SH: lives in Albuquerque w/ wife. Denies recent alcohol in past month, denies illicit drug use.
ROS: denies n/v/d, admits to decreased appetite x 2 weeks, weight fluctuates – sometimes pants
are tight, sometimes they are loose. Denies melena/hematuria. Has occasional LEE – resolves
when legs elevated.
PE: T 100.3 BP 150/85 HR 82 RR 28 O2Sat 86% RA  94% 2L
Gen: A&Ox3, mild respiratory discomfort,
HEENT: mild temporal wasting, otherwise normal
CV: rrr, no m/r/g, JVP 13cm, no carotid bruits
Lungs: diminished BS lower 2/3 of L lung, lower ½ of R lung, no egophony, decreased tactile
fremitus bilaterally lower regions, + dullness to percussion over same area, normal chest
excursion bilaterally
Abd: Obese, NABS, s/nt, mild hepatomegaly, no splenomegaly
Ext: 1+ edema BLE, brownish discoloration of skin on BLE, + varicose veins, 2+ pulses
throughout, warm
Skin: few telangiectasias over upper chest and shoulders, no rashes
Labs:
CBC: WBC 10.0, Hbg 14, Hct 40, Plts 120
Chem 10: Na 131, K 3.7, Cl 105, CO2 18, BUN 37, Cr 1.6, Glucose 225
Ca 7.1, Mg 2.1, Po4 2.1
LFT’s: TP 7.0, Alb 2.5, AST 49, ALT 45, Alk Phos 190, T Bili 1.5, D Bili .8, I Bili .7
Imaging: pCXR – Bilateral pleural effusions L>R, mild cardiomegaly, prominent pulmonary
vasculature, consolidation vs. atelectasis in LLL, clinical correlation recommended.
1. Discuss possible etiologies of this patient’s pleural effusion.
2. Discuss whether thoracentesis is appropriate for this patient.
3. What pleural fluid results do you expect from this patient depending on etiology of
pleural effusion.
Review Questions:
1.
A 43 year-old male nurse presents to your office for evaluation. For the past 2
months, he has experienced intermittent fever, night sweats, and a 20-lb weight
loss. He denies having any cough or sputum production. The patient states that
about 3 months ago, he tested positive on purified protein derivative (PPD)
screening. He denies any drug abuse, nor does he report any HIV risk factors. The
patient states that he was prescribed isoniazid, but he chose not to follow this
regimen. His chest x-ray is remarkable only for a moderate left pleural effusion.
Which of the following statements regarding tuberculous pleuritis is true?
A. Pleural effusion is more often a manifestation of reactivation tuberculosis
than of primary tuberculosis.
B. Without therapy, this patient’s pleural effusion will likely persist for many
years.
C. In most cases of this illness, pleural fluid cell differential will reveal
greater than 85% neutrophils.
D. Acid-fast bacilli are rarely seen in pleural liquid, and cultures are positive
in only 20% to 40% of patients.
2. A 55-year-old man visits your office with a complaint of fatigue and increasing
dyspnea on exertion. He has been experiencing these symptoms for 2 weeks. He
denies having fever, chills, cough, or weight loss, and he has no significant
cardiac history. He denies having been in contact with anyone who was ill. He
recently quit smoking, after having smoked cigarettes for 35 years. He does have
a history of alcoholism and chronic pancreatitis; the pancreatitis has been well
controlled with analgesics and pancreatic enzyme replacement therapy. His
serum chemistries and complete blood count are unremarkable. A chest x-ray
reveals a large left pleural effusion. A diagnostic thoracentesis is performed.
Which of the following statements regarding laboratory studies of pleural fluid is
true?
a. An elevated pleural fluid amylase level is uncommon in patients with a
malignant pleural effusion
b. Pleural fluid eosinophilia is diagnostic of a pulmonary parasitic infection.
c. A pleural liquid hematocrit that exceeds half of the simultaneous
peripheral blood hematocrit indicates frank bleeding into the pleural space
and is diagnostic of a hemothorax.
d. A pleural effusion with a pH of 5.8 is suggestive of empyema
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to
Dr. Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment
below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient
curriculum in general:
6) Please circle one:
Attending
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