Download Pleural effusion

Pleural effusion
Riahi taghi,M.D.
Etiology
• Fluid formation: parietal pleura
• Fluid removal: parietal pleura (lymphatic)
• Also enter from visceral pleura and
diaphragm
Effusion finding
• Blunting of costophrenic angle in CXR
• Sub pulmonic effusion
• White lung
• Phantom tumor
• Sonography
• Chest CT scan
approach
• Transudate effusion (systemic factors)
•
heart failure, cirrhosis, nephrosis
• Exudative effusion (local factors)
•
pneumonia, malignancy, viral, PTE
Exudative effusion
• Pleural fluid protein / serum protein > 0.5
• Pleural fluid LDH / serum LDH > 0.6
• Pleural fluid LDH > 2/3 of upper limit for
serum
• Misdiagnos 25% of transudate as exudate
• Check albumin gradian
Heart failure
• Most common cause of transudate
effusion
• Thoracentesis if : not bilateral and
comparable, febrile, pleuretic chest pain
Hepatic hydrothorax
• 5% of patients with cirrhosis and ascitis
• Through small hole in the diaphragm
• Usually right sided
• Frequently large enough to produce
severe dyspnea
Parapnemonic effusion
• Bacterial pneumonia, lung abscess or
bronchiectasis
• Aerobic; acute illness
• Anaerobic; sub acute illness
• CXR, lat decubitus CXR, CT, sono
• If more than 10 mm, therapeutic
thoracenthesis should be performed
Complicated Para pneumonic
• Loculated pleural effusion
• Pleural fluid PH < 7.20
• Glucose < 60 mg/dl
• Positive gram stain or culture
• Gross pus
malignancy
• Malignant metastatic effusion are second
most common cause of exudative effusion
• Three most common cause; lung, breast
and lymphoma
• Dyspnea out of proportion to effusion
• Cytology and then thoracoscopy and if
unavailable pleural biopsy
• Most not curable with chemotheraoy
mesothelioma
• Most are related to asbestosis
• Present with dyspnea and chest pain
• Pleural effusion, thickening and shrunken
hemi thorax
• Thoracoscopy or open lung biopsy
Pulmonary embolism
• Effusion usually exudative but can be
transudate
• Diagnosis by perfusion scan, spiral CT, or
angiography
tuberculosis
• Hypersensitivity reaction to tubercule
protein
• Exudate small lymphocyte predominant
• TB marker in effusion; ADA > 45, IF
gamma > 140 , positive PCR for TB
• Culture of fluid, pleural biopsy or
thoracoscopy
Viral infection
• Sizable percentage of undiagnosed
exudative pleural effusion
• 20% remain undiagnosed
• No long term residua
AIDS
• Most common is kaposi sarcoma
• Para pneumonic effusion
• TB, cryptociccosis, primary effusion
lymphoma
chylothorax
• Most common cause is trauma
• Also from tumor in the mediastinum
• Milky fluid and TG level more than 110
mg/dl
• No obvious trauma on lymph angiogram
and mediastinal CT
• Pleuroperitoneal shunt
hemothorax
• Hemothorax more than 50% of peripheral
blood
• Trauma or rupture of vessel or tumor
• Thoracostomy
• Thoracotomy if hemorrhage exceed 200
ml/h
others
• Asbestosis
• Meigs SX
• Drug induced; eosinophilic
• Post CABG; Early is left sided, bloody and
eosinophilic
• Late post CABG; left, clear yellow,
lymphocytes