PANCE Blueprint Pulmonary (12%)

Pleural effusion (ReelDx)

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Pleural Effusion

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. This is seen on CXR.

Pathologic accumulation of fluid in the pleural space: often association with pneumonia

Transudate vs. Exudate:

  • Transudate = Think “transient” fluid due to hydrostatic pressure (Cirrhosis, CHG, Nephrotic Syndrome).  The most common causes of transudative effusions are heart failure, cirrhosis with ascites, and hypoalbuminemia (usually due to the nephrotic syndrome).
  • Exudative: Fluid due to infection, malignancy, immune.  The most common causes of exudative effusions are pneumonia, cancer, pulmonary embolism, and TB.

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 
    1. Pleural fluid protein/serum protein ratio > 0.5
    2. Pleural fluid LDH/serum LDH ratio greater than 0.6
    3. Pleural fluid LDH > two-thirds the upper limits of the laboratory normal serum LDH

“It's all about that LDH"

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

  • Lateral decubitus x-rays, chest CT, or ultrasonography should be done if it is unclear whether an x-ray density represents fluid or parenchymal infiltrates or whether suspected fluid is loculated or free-flowing

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

  • Isolated left sided pleural effusion is likely exudative
  • Right sided think transudative

Thoracocentesis: Effusions that are chronic or recurrent and causing symptoms can be treated with pleurodesis or by intermittent drainage with an indwelling catheter

Large left sided pleural effusion

Large left sided pleural effusion

IM_MED_Lightscriteria_V1.3_ Light's Criteria is a diagnostic tool used to determine of the cause of a pulmonary effusion; transudate versus exudate. This relies on a comparison of the chemistries in the pleural fluid to those in the blood. According to Light's criteria, a pleural effusion is likely exudative if at least one of the following exists: The ratio of pleural fluid protein to serum protein is greater than 0.5, the ratio of pleural fluid LDH and serum LDH is greater than 0.6, or the pleural fluid LDH is greater than 0.6 or 2⁄3 times the normal upper limit for serum.

Light's Criteria Picmonic

Question 1
On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause?
A
asthma
Hint:
Asthma is characterized by decreased tactile fremitus, but would have resonant to hyperresonant percussion, not dullness.
B
consolidation
Hint:
Consolidation from pneumonia is characterized by dullness to percussion, but would have an increased, not decreased, tactile fremitus.
C
pneumothorax
Hint:
A pneumothorax is characterized by decreased to absent tactile fremitus, but would have a hyperresonant percussion note, not dullness.
D
pleural effusion
Question 1 Explanation: 
A decreased tactile fremitus and dullness to percussion would be found in a pleural effusion.
Question 2
Which of the following conditions will produce a transudative pleural effusion?
A
Kaposi's sarcoma
Hint:
Kaposi's sarcoma, pneumonia, or mesothelioma will produce a transudative pleural effusion.
B
Pneumonia
Hint:
See A for explanation.
C
Cirrhosis
D
Mesothelioma
Hint:
See A for explanation.
Question 2 Explanation: 
Transudative pleural effusions result from alteration in the formation of pleural fluid, the absorption of pleural fluid, or both, by systemic factors. Local factors affecting pleural fluid absorption and/or formation produce
Question 3
A 42 year-old male is brought to the emergency department with a stab wound to his right lateral chest wall. On physical examination, the patient is stable with decreased breath sounds on the right with dullness to percussion. An upright chest x-ray reveals the presence of a moderate pleural effusion. Subsequent diagnostic thoracentesis contains bloody aspirate. Which of the following is the next most appropriate intervention?
A
Thoracotomy
Hint:
A thoracotomy is indicated in a small percentage of patients that do not respond to IV administration of fluids and evacuation of the hemothorax via tube thoracostomy. (u) B. Needle aspiration as treatment for a hemothorax is not recommended as it fails to adequately drain the bloody fluid.
B
Needle aspiration
Hint:
Needle aspiration as treatment for a hemothorax is not recommended as it fails to adequately drain the bloody fluid.
C
Close observation
Hint:
Close observation is only indicated for small effusions in a patient that remains hemodynamically stable.
D
Tube thoracostomy
Question 3 Explanation: 
This patient has a hemothorax. Drainage of a hemothorax is best obtained through insertion of a chest tube (tube thoracostomy).
Question 4
A 60 year-old female with a 30 pack year smoking history complains of new onset shortness of breath. On physical examination, dullness is noted on percussion with dimished breath sounds over her left base. Chest x-ray shows a new left pleural effusion. Which of the following is the next step in the management of this patient?
A
Repeat chest x-ray in two months
Hint:
See B for explanation.
B
Perform diagnostic thoracentesis
C
Order MRI of the chest
Hint:
See B for explanation.
D
Treat with antibiotic
Hint:
See B for explanation.
Question 4 Explanation: 
Diagnostic thoracentesis should be performed whenever there is a new pleural effusion and no clinically apparent cause.
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