Evaluation Pleural Effusions C.L.I.P.S. Patients with effusions from heart failure DO NOT need a Thoracentesis How Common Affects 1.5 million people each year-U.S. Causes Heart failure-transudate Pneumonia-exudate Cancer-exudate PE can be either transudate or exudate How do they usually present (history)? Asymptomatic, dyspnea, cough, pleuritic chest pain Differentiate cardiac (heart failure, pericarditis) from pulmonary (pneumonia, PE, malignancy)and GI (Cirrhosis, pancreatitis) Physical exam findings Auscultation-decreased breath sounds Percussion-dullness Palpation-decreased tactile fremitus Radiology CXR-Need 50 ml to see meniscus on lateral, 200 ml to see on AP Get lateral decub (both right and left) can be helpful USN- Anechoic fluid collection above the diaphragm Loss of mirroring (lung usually looks like liver in normal) Extension of the spine sign above diaphragm

No need for CXR after procedure unless pt has increasing SOB. Pleural Effusions C.L.I.P.S. Thoracentesis Indications-DX- unexplained effusion, empyema Tx- relieve dyspnea, improve oxygenation Contraindications-uncooperative pt, skin infection at site, ruptured diaphragm. OK to perform if platelets above 25k, INR below 3, bleeding risk 0.4% Consider US guided Never take more than 1.5 L Never use Evacuated container Stop procedure if aspirate air, increasing dyspnea, chest pain or cough. Laboratory CBC with diff Protein, Alb LDH, Glucose Culture and Gram stain- Inoculate culture bottles at bedside. Lights criteria of exudate ratio of pleural fluid protein to serum protein > 0.5 ratio of pleural fluid LDH to serum LDH > 0.6 pleural fluid LDH level > 2/3 upper limit of normal for serum LDH Transudates Increase hydrostatic pressure of decreased osmotic pressure-CHF Nephrotic syndrome, cirrhosis Exudates Increased capillary permeability, impaired fluid resorption- Empyema, Ca, viral/bacterial infections. Bloody less than 1% of pt HCT- no worries. 1-20% PE, cancer or trauma No need for CXR after procedure unless pt has increasing SOB.