4 Pleural EffusionPleural effusion is an abnormal accumulation of fluid in the pleural space. The 5 major types of pleural effusion are:Transudate,Exudate,Empyema,Hemorrhagic pleural effusion or hemothorax andChylous or chyliform effusion.
5 Causes of Pleural Effusion Other causes of pleural effusion: nephrotic syndrome, TB, collagen vascular disease, urinothorax, SVC syndrome, Meigs syndrome, rheumatoid arthritis, pancreatitis, yellow-nail syndrome, drugsLight. NEJM 2002; 346:1971Annual incidence in the US
11 Indications for Thoracentesis Likely indicated in most patients> 1 cm layering on lateral decubitusNo need for thoracentesis for patient with obvious cause may not need further study (CHF with bilateral effusions. However:In heart failure: febrile/pleuritic pain, unilateral, no cardiomegaly, no response to diuresis
12 Pleural fluid analysis Bloody:Hct <1% not significant1-20%= CA, PE, Trauma>50% serum Hct = hemothoraxCloudytrig level >110mg/dl = chylothoraxPutrid odorstain and culture = infection?
13 Light’s Criteria Pleural fluid is exudate if one or more: Pleural LDH/Serum LDH > 0.6* -OR-Pleural protein/Serum protein > OR-Pleural LDH > 2/3 upper limit of normal (serum)Usually > 200 IUAbsence of ALL: transudateSensitivity 99%, Specificity 98%
14 Pleural Fluid TestsPORCEL et al. AFP 2006; 73: 1212
15 Pleural Fluid TestsPORCEL et al. AFP 2006; 73: 1212
16 Pleural Fluid TestsPORCEL et al. AFP 2006; 73: 1212
17 Pleural Fluid TestsPORCEL et al. AFP 2006; 73: 1212
23 UNDIAGNOSED PLEURAL EFFUSIONS 15-20% of effusionsCareful review of history, PE, meds, risk factorsConsider occult abdominal processConsider PE
24 UNDIAGNOSED PLEURAL EFFUSIONS Cont’d Risk factors for TB or malignant effusionWeight loss > 4.5 kg (10 pounds)Fever > 38 CPositive PPDLarge effusion (> 1/2 hemithorax)< 95% lymphs in pleural fluidIf ANY factor present, evaluate for TB, CA
25 UNDIAGNOSED PLEURAL EFFUSIONS Cont’d PPDIf (+) and lymphocytic effusion, initiate TB treatmentIf (-), repeat in 6-8 wksHowever, if effusion < 5% mesothelial cells, consider TB treatmentIf (-), not anergic, > 5% mesothelial cells, wait for repeat PPD in 6-8 wksIf repeat PPD (-), not anergic and cultures negative, observe
27 BEYOND THORACENTESIS Pleural Biopsy Thoracoscopy Most helpful in evaluating for TBLimited utility for CA (40-50% positive)Repeat cytology x 3Sarcoid, fungal: might be helpfulThoracoscopyMost helpful in evaluating for malignancy
28 Approach to Pleural Effusion PORCEL et al. AFP 2006; 73: 1212
29 Approach to Pleural Effusion PORCEL et al. AFP 2006; 73: 1212
30 Approach to Pleural Effusion PORCEL et al. AFP 2006; 73: 1212
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