Pleural effusion

Question 1

Pleural effusion

Answer 1

This patient has been breathless for 2 weeks. Examine his respiratory system to elucidate the cause.

Question 2

Clinical signs

Answer 2

• Inspection: Asymmetrically reduced expansion
• Trachea or mediastinum displaced away from side of effusion
• Palpation: Absent tactile vocal fremitus
• Percussion: Stony dull percussion note
• Auscultation: Reduced breath sounds and bronchial breathing above (aegophony)

Question 3

Signs that may indicate the cause

Answer 3

• Cancer: clubbing; lymphadenopathy; mastectomy (breast cancer being a very common cause of pleural effusion)
• Congestive cardiac failure: raised JVP; peripheral oedema
• Chronic liver disease: leuconychia, spider naevi gynaecomastia
• Chronic renal failure: arteriovenous fistula
• Connective tissue disease: rheumatoid hands; butterfly rash of SLE

Question 4

Causes of a dull lung base

Answer 4

• Consolidation: bronchial breathing and crackles
• Collapse: tracheal deviation towards the side of collapse and reduced breath sounds
• Previous lobectomy = reduced lung volume
• Pleural thickening: signs are similar to a pleural effusion but with normal tactile vocal fremitus; may have three scars suggestive of previous VATS pleuradesis
• Raised hemidiaphragm ± hepatomegaly

Question 5

Causes of pleural effusion

Answer 5

• Transudate (protein<30g/L)
  Congestive cardiac failure
  Chronic renal failure
  Chronic liver failure
• Exudate (protein >30 g/L)
  Neoplasm: 1° or 2°
  Infection
  Infarction
  Inflammation: RA and SLE

Question 6

Pleural aspiration (exudate)

Answer 6

• Protein: effusion albumin/plasma albumin >0.5 (Light’s criteria)
• LDH: effusion LDH/plasma LDH >0.6
• Empyema: an exudate with a low glucose and pH <7.2 is suggestive

Question 7

Empyema

Answer 7

• Definition: A collection of pus within the pleural space
• Most frequent organisms: anaerobes, staphylococci and Gram‐negative organisms
• Associated with bronchial obstruction, e.g. carcinoma, with recurrent aspiration; poor dentition; alcohol dependence

Question 8

Treatment

Answer 8

• Pleural drainage and IV antibiotics intrapleural DNAse plus TPA (MIST 2 Trial)
• Surgical decortication