P.f. = pleural fluid Pleural Effusion
Definition Accumulation of fluid in the pleural cavity that impairs the expansion of the lungs Air in pleural space → ↓n
- Most common cause → CHF Age
Epidemiology - Parapneumonic effusion risk factors: old age, neonates, diabetes, - Primary → peak a
immunosuppression, alcoholism & dysphagia - Secondary → pea
- HIV+ → ↑↑↑ Kaposi Sarcoma, parapneumonic, Tb, lymphoma, P. carinii Sex → male > female
Transudative pleural effusion Spontaneous
- CHF - Primary (from pul
- Hepatic cirrhosis - Male ge
- Nephrotic syndrome - Young a
- Protein-losing enteropathy - Asthenic
- CKD → Na+ retention - Family h
Exudative pleural effusion - Smoking
- Infection - Homocy
- Parapneumonic effusion - #1 (S. pyogenes in CAP, S. aureus in HAP) - Secondary - com
Etiology & Types - Tb - COPD
- Pleural empyema - Tubercu
- Parasitic illness - Cystic fib
- Malignancies → lung ca, metastatic breast ca, lymphoma, mesothelioma, ovarian - Malignan
cancer - Pneumo
- Pulmonary embolism Traumatic
- Autoimmune disease (collagen vascular diseases - Vasculitis, SLE, RA, sarcoidosis) - Penetrating chest
- Trauma - Blunt trauma → r
- Pancreatitis - Iatrogenic pneum
- Hemothorax, chylothorax, pseudochylothorax catheter etc)
Transudative pleural effusion Spontaneous
- ↑ capillary hydrostatic pressure or ↓ capillary oncotic pressure → net fluid - Bullae or blebs fo
movement towards pleural space → fluid accumulation (↑bilateral) → ipsila
CHF → bilateral, ↑right lung if unilateral Traumatic
Exudative pleural effusion - Blunt trauma → a
- Insult → direct tissue damage or inflammation → ↑capillary permeability → - Lesion in chest w
fluid drainage into pleural space → fluid accumulation - Air shifts
Parapneumonic effusion - Cloudy or purulent → pH <7.2, ↑LDH, glucose <60, PMN Tension Pneumothorax
Pathophysiology Malignancy - malignant cells (pH<7.2, glucose <60, ↑LDH, Penetrating injury → valve
Chylothorax - Trauma, malignancy or congenital lymphatic abnormalities → ↓ air & tension accumulation
lymphatic drainage → lymphatic fluid accumulation - Collapse of ipsila
- ↑lipids (TAG > 110, TC < 200) → Cloudy & milky - Compression of
- Exudative, lymphocyte predominance - Contrala
Pseudochylothorax → RA, primary Tb → chronic pleural inflammation → cloudy & - Heart →
milky (TC > 200, TAG < 110) - Superior
Fluid causes restriction → ↓TLC, FRC & FVC - Trachea
- Hypoxemia, V/Q mismatch, ↓respiratory muscle function → respiratory distress, hem
<300 mL → often asymptomatic Range from asymptomatic
- Dyspnea - Pleuritic unilatera
Symptoms - Pleuritic chest pain - Dyspnea
- Dry, nonproductive cough (productive if parapneumonic) Tension pneumothorax
- Symptoms of underlying disease - ARDS
Clinical - Distended neck v
Features
- ↓RR - Tracheal deviatio
Signs - Major effusion → tracheal deviation - Respiratory distre
**If tachypneic, tachycardic & pleuritic chest pain → consider pulmonary embolism - Tachycardia
→ may be exudate or transudate (tends to be a small effusion) - Subcutaneous em
Inspection Asymmetric expansion & unilateral lagging
Palpation ↓ tactile fremitus
Lung
Examination
Auscultation ↓ lung sounds, pleural friction rub
Percussion Dull tone (mate)
First line → chest x-ray - lateral decubitus view (detects as little as 50 mL) Gold standard diagnosis
- Blunting of costophrenic angle, ↑radiopacity, contralateral tracheal deviation - ↓ lung markings
→ meniscus sign - Abrupt change in
Testing Diagnostic thoracentesis → for an etiologic dx → check Light's Criteria, serum - Deep sulcus sign
protein, lipid panel, and LDH. - Indications: - Hemidiaphragm e
- Any new unilateral effusion > 1cm on x-ray in an undx px - Findings of under
- History of malignancy + >1 cm Other imaging technique
- Pneumonia + parapneumonic effusion >5 cm ***Tension pneumothorax
- HF + atypical findings
Lymphocytosis in p.f. → malignancy or tb (chronic condition) Spontaneous pneumotho
Eosinophilia (>10%) → pneumo & hemothorax, asbestosis, Churg-Strauss, mycosis
ADA > 40 → Tb
Definition Accumulation of fluid in the pleural cavity that impairs the expansion of the lungs Air in pleural space → ↓n
- Most common cause → CHF Age
Epidemiology - Parapneumonic effusion risk factors: old age, neonates, diabetes, - Primary → peak a
immunosuppression, alcoholism & dysphagia - Secondary → pea
- HIV+ → ↑↑↑ Kaposi Sarcoma, parapneumonic, Tb, lymphoma, P. carinii Sex → male > female
Transudative pleural effusion Spontaneous
- CHF - Primary (from pul
- Hepatic cirrhosis - Male ge
- Nephrotic syndrome - Young a
- Protein-losing enteropathy - Asthenic
- CKD → Na+ retention - Family h
Exudative pleural effusion - Smoking
- Infection - Homocy
- Parapneumonic effusion - #1 (S. pyogenes in CAP, S. aureus in HAP) - Secondary - com
Etiology & Types - Tb - COPD
- Pleural empyema - Tubercu
- Parasitic illness - Cystic fib
- Malignancies → lung ca, metastatic breast ca, lymphoma, mesothelioma, ovarian - Malignan
cancer - Pneumo
- Pulmonary embolism Traumatic
- Autoimmune disease (collagen vascular diseases - Vasculitis, SLE, RA, sarcoidosis) - Penetrating chest
- Trauma - Blunt trauma → r
- Pancreatitis - Iatrogenic pneum
- Hemothorax, chylothorax, pseudochylothorax catheter etc)
Transudative pleural effusion Spontaneous
- ↑ capillary hydrostatic pressure or ↓ capillary oncotic pressure → net fluid - Bullae or blebs fo
movement towards pleural space → fluid accumulation (↑bilateral) → ipsila
CHF → bilateral, ↑right lung if unilateral Traumatic
Exudative pleural effusion - Blunt trauma → a
- Insult → direct tissue damage or inflammation → ↑capillary permeability → - Lesion in chest w
fluid drainage into pleural space → fluid accumulation - Air shifts
Parapneumonic effusion - Cloudy or purulent → pH <7.2, ↑LDH, glucose <60, PMN Tension Pneumothorax
Pathophysiology Malignancy - malignant cells (pH<7.2, glucose <60, ↑LDH, Penetrating injury → valve
Chylothorax - Trauma, malignancy or congenital lymphatic abnormalities → ↓ air & tension accumulation
lymphatic drainage → lymphatic fluid accumulation - Collapse of ipsila
- ↑lipids (TAG > 110, TC < 200) → Cloudy & milky - Compression of
- Exudative, lymphocyte predominance - Contrala
Pseudochylothorax → RA, primary Tb → chronic pleural inflammation → cloudy & - Heart →
milky (TC > 200, TAG < 110) - Superior
Fluid causes restriction → ↓TLC, FRC & FVC - Trachea
- Hypoxemia, V/Q mismatch, ↓respiratory muscle function → respiratory distress, hem
<300 mL → often asymptomatic Range from asymptomatic
- Dyspnea - Pleuritic unilatera
Symptoms - Pleuritic chest pain - Dyspnea
- Dry, nonproductive cough (productive if parapneumonic) Tension pneumothorax
- Symptoms of underlying disease - ARDS
Clinical - Distended neck v
Features
- ↓RR - Tracheal deviatio
Signs - Major effusion → tracheal deviation - Respiratory distre
**If tachypneic, tachycardic & pleuritic chest pain → consider pulmonary embolism - Tachycardia
→ may be exudate or transudate (tends to be a small effusion) - Subcutaneous em
Inspection Asymmetric expansion & unilateral lagging
Palpation ↓ tactile fremitus
Lung
Examination
Auscultation ↓ lung sounds, pleural friction rub
Percussion Dull tone (mate)
First line → chest x-ray - lateral decubitus view (detects as little as 50 mL) Gold standard diagnosis
- Blunting of costophrenic angle, ↑radiopacity, contralateral tracheal deviation - ↓ lung markings
→ meniscus sign - Abrupt change in
Testing Diagnostic thoracentesis → for an etiologic dx → check Light's Criteria, serum - Deep sulcus sign
protein, lipid panel, and LDH. - Indications: - Hemidiaphragm e
- Any new unilateral effusion > 1cm on x-ray in an undx px - Findings of under
- History of malignancy + >1 cm Other imaging technique
- Pneumonia + parapneumonic effusion >5 cm ***Tension pneumothorax
- HF + atypical findings
Lymphocytosis in p.f. → malignancy or tb (chronic condition) Spontaneous pneumotho
Eosinophilia (>10%) → pneumo & hemothorax, asbestosis, Churg-Strauss, mycosis
ADA > 40 → Tb
