PANCE Blueprint Pulmonary (9%)

68 y/o female with 6 months of bilateral chest pain and difficulty breathing

Patient presents as → a 58-year-old female who returns to the hospital with chest pain and difficulty breathing several weeks after being discharged following a myocardial infarction requiring immediate cardiac catheterization. She has been coughing up frothy sputum for the past three days. The patient complains of a sharp pain that worsens during inspiration. Physical exam reveals decreased tactile fremitus, dullness to percussion, and diminished breath sounds on the left side. Chest X-ray demonstrates blunting of the left costophrenic angle, meniscus sign, obliteration of the left hemidiaphragm, and mediastinal shift.

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A pleural effusion is a pathologic accumulation of fluid in the pleural space (often associated with pneumonia)

• Presents with decreased breath sounds + decreased tactile fremitus and dullness to percussion

Dullness to percussion—In pleural effusions, percussion over the affected area is dull. This is because fluid in the pleural space absorbs the sound waves during percussion, resulting in a dull sound instead of the normal resonant sound heard over air-filled lung tissue.

Decreased tactile fremitus—Tactile fremitus refers to the palpable vibration of the chest wall that results from the transmission of sound vibrations through the lung tissue to the chest wall

• Pleural effusion presents with decreased tactile fremitus because the presence of fluid in the pleural space dampens the transmission of sound vibrations from the lung to the chest wall

Light's criteria: If at least one of the following three criteria is present, the fluid is defined as an exudate

Basically, ↑ Protein and ↑ LDH = Exudative

• Pleural fluid protein/serum protein ratio > 0.5
• Pleural fluid LDH/serum LDH ratio greater than 0.6
• The pleural fluid LDH is greater than two-thirds the upper limit of normal for serum LDH

“It's all about that LDH"

Evaluation requires imaging (usually chest x-ray) to confirm the presence of fluid and pleural fluid analysis to help determine the cause

• lateral decubitus chest X-ray and upright films
  • A large free pleural effusion appears as a dependent opacity with lateral upward sloping of a meniscus-shaped contour at the junction of the lung and the diaphragm (meniscus sign). The diaphragmatic contour is partially or completely obliterated, depending on the amount of the fluid (silhouette sign)
• Chest CT or ultrasonography should be done if it is unclear whether an x-ray density represents fluid or parenchymal infiltrates or whether the suspected fluid is loculated or free-flowing
• Thoracentesis is performed for diagnostic and therapeutic purposes, with analysis of pleural fluid (e.g., protein, LDH, cell count, pH, glucose) to differentiate between transudative and exudative effusions

Physical exam: decreased tactile fremitus and dullness to percussion would be found in a pleural effusion

• In pleural effusions, vocal fremitus is decreased
• In pleural effusions, breath sounds are decreased
• Isolated left-sided pleural effusion is likely exudative
• Right-sided think transudative

Pleural effusion seen on lateral decubitus chest x-ray. Arrow A shows fluid layering in the right pleural cavity. The B arrow shows the normal width of the lung in the cavity.

Treatment is with thoracocentesis

• Small transudative pleural effusions resulting from heart failure may be treated with diuretics and sodium restriction
• Effusions that are chronic or recurrent and causing symptoms can be treated with pleurodesis (pleural space is artificially obliterated) or by intermittent drainage with an indwelling catheter