1. 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

2. 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.