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Pleural Effusion and Pleural Disease

Pleural effusion is where there's a collection of fluid in the pleural cavity. It can be classed into 2 types:

  • Transudative - more likely to be bilateral, with less protein (< 35g/L) and LDH

  • Exudative - more likely to be unilateral, with a lot more protein (> 35g/L) and LDH


N.B. If the protein content is equivocal (25-35 g/L), the Light's criteria can be applied to work out if it's an exudative effusion or not.


Pleurisy is the inflammation of the pleura, which impairs its lubricating function, leading to a sharp pleuritic chest pain.


Types

Transudative effusion - Imbalance of the pressure changes that govern fluid shifts, which results in fluid moving across into the pleural space. This can be due to:

  • Increased capillary hydrostatic pressure (water forced out of vessels) e.g. Congestive HF

  • Increased capillary oncotic pressure (water isn’t reabsorbed into vessels) e.g. Cirrhosis, Nephrotic Syndrome, CKD, GI malabsorption/malnutrition (These all cause Hypoalbuminaemia)


Exudative effusion - Increased vessel permeability, which results in proteins leaking out of tissues and into the pleural space. This can be caused by:

  • Infection e.g. Pneumonia, TB

  • Cancer

  • Inflammatory conditions e.g. RA, SLE

  • Pulmonary infarct e.g. after PE

  • Trauma

  • Other rarer causes:

    • Hypothyroidism

    • Meig’s syndrome (Triad of Ascites, Pleural effusion, and Benign ovarian tumour)

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“Diagram showing a build up of fluid in the lining of the lungs (pleural effusion)” © Cancer Research UK (Licensed under CC BY-SA 4.0) https://creativecommons.org/licenses/by/4.0/


Presentation

Patients will present with SOB and Chest pain.


O/E:

  • Stony dull percussion

  • Reduced breath sounds

  • Reduced chest expansion

  • Tracheal deviation away from the affected side (if large enough)


Investigations

  • CXR

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“Medical X Rays” © Nevit Dilmen (Licensed under CC-BY 3.0) https://creativecommons.org/licenses/by/3.0/


Management

  • Conservative if small

  • Aspiration or Chest drain

  • Treat underlying cause


Complications

Main complication here is an Empyema (infected pleural effusion). It should be suspected in a patient with improving pneumonia but a new/ongoing fever. Pleural tap should be done and the fluid analysed, which will show pus, low pH, low glucose, and high LDH.




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