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Snapshot
  • A 56-year-old woman presents to the emergency department due to worsening shortness of breath and cough. Her symptoms began yesterday after receiving peritoneal dialysis. She denies any productive cough, fevers, or chills. Medical history is significant for end-stage renal disease secondary to poorly controlled diabetes mellitus, requiring peritoneal dialysis. Physical exam is notable for a woman with increased work of breathing and decreased breath sounds over the right lower lobe. A chest radiograph is performed, which demonstrates an extensive right pleural effusion.
Introduction
  • Definition
    • excessive fluid in the pleural space
  • Pathogenesis
    • anatomy
      • pleural fluid accumulation results when the formation of the pleural fluid exceeds its absorption
        • pleural fluid enters the pleural space via 
          • capillaries within the parietal pleural
          • interstitial spaces of the lung
          • peritoneal cavity through holes in the diaphragm
        • pleural fluid is removed from the pleural space via
          • lymphatics in the parietal pleura
      • disruption in any of these processes leads to the development of a pleural effusion
    • effusions can be divided into transudative and exudative effusions
      • transudative
        • due to increased capillary pressure (e.g., congestive heart failure) or decreased plasma oncotic pressure (e.g., hypoalbuminemia)
          • note, transudative pleural effusions result from alterations in systemic factors that affect the formation and absorption of pleural fluid
      • exudative
        • due to increased permeability of the pleural surfaces or impaired lymphatic reabsorption
          • note, exudative pleural effusions result from alterations in local factors that affect the formation and absorption of pleural fluid
  • Etiology
    • transudative effusion
      • left-sided heart failure
      • cirrhosis
      • nephrotic syndrome
      • peritoneal dialysis
      • atelectasis
    • exudative effusion 
      • bacterial pneumonia
      • malignancy
      • viral infection
      • pulmonary embolism
      • tuberculosis 
      • collagen vascular disorder
  • Prognosis
    • depends on the cause of the pleural effusion
Presentation
  • Symptoms 
    • asymptomatic
    • dyspnea on exertion
    • peripheral edema
  • Physical exam
    • dullness to percussion
    • decreased breath sounds on the effusion
    • decreased tactile fremitus
Imaging
  • Radiography of the chest
    • indication
      • to determine the presence of a pleural effusion
Studies
  • Distinguishing transudative and exudative fluid requires the measuring of pleural and serum fluid levels 
    • lactate dehydrogenase (LDH)
    • protein levels
  • Thoracentesis with ultrasound guidance
    • indication
      • to collect pleural fluid in order to determine its etiology
      • confirms the presence of pleural fluid
  • Light criteria 
    • criteria used to differentiate transudative and exudative effusions
      • protein (pleural)/protein (serum) > 0.5
      • LDH (pleura)/LDH (serum) > 0.6
      • LDH > 2/3rds the upper limit of normal serum LDH
    • based on the Light criteria, a pleural effusion is said to be exudative if any of the above is met
Treatment
  • Depends on the underlying cause
    • e.g., if there is an exudative effusion secondary to a bacterial pneumonia, treat with antibiotics
  • Procedural
    • therapeutic thoracentesis
      • indication
        • in cases where the pleural effusion is massive and its affecting the patient's breathing
    • tube thoracostomy  
      • indication
        • in complicated parapneumonic effusions or empyema 
Complications
  • Parapneumonic effusion
  • Empyema
 
 

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(M2.PL.17.4799) A 69-year-old female comes to the emergency department complaining of chest pain and difficulty breathing. She reports that she had a heart attack a few weeks ago that was treated with cardiac catheterization. At that time she had chest pain, but reports that this chest pain is different. A review of systems is significant for headaches, a productive cough with frothy sputum, and paresthesias in her fingertips. The patient’s temperature is 99°F (37.2°C), blood pressure is 130/78 mmHg, pulse is 78/min, and respirations are 20/min with an oxygen saturation of 96% O2 on room air. A chest radiograph is obtained, as shown in Figure A. Which of the following would you expect to find upon physical exam? Tested Concept

QID: 109320
FIGURES:
1

Crepitus

23%

(10/44)

2

Decreased tactile fremitus

36%

(16/44)

3

Increased pectoriloquy

9%

(4/44)

4

Increased tympanic percussion

7%

(3/44)

5

Kussmaul breathing

14%

(6/44)

M 6 C

Select Answer to see Preferred Response

(M2.PL.17.4799) A 67-year-old male comes into the ED complaining of dyspnea and a heavy feeling in his chest. He reports that over the past month he has become more easily “winded" to the point that he now sleeps in his living room because he can’t make it up the stairs. A review of systems is notable for headaches and fatigue. On physical exam you note decreased breath sounds and a dullness to percussion on the right. A chest radiograph is obtained, which shows a right-sided pleural effusion. Thoracocentesis is performed and the fluid is analyzed, with results shown below:

Volume: 30 cc of fluid
Pleural fluid protein: 5.8 g/dL
Serum protein ratio: 7.0 g/dL
Lactate dehydrogenase (LDH): 258 U/L

Which of the following conditions may have led to the findings in this patient’s pleural cavity?
Tested Concept

QID: 109321
1

Congestive heart failure

7%

(2/29)

2

Hypoalbuminemia

0%

(0/29)

3

Liver cirrhosis

7%

(2/29)

4

Lymphoma

83%

(24/29)

5

Nephrotic syndrome

3%

(1/29)

M 6 C

Select Answer to see Preferred Response

Topic COMMENTS (5)
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