PLEURAL  EFFUSION

 

Etiology:

  1. Transudate - CHF, PE, Cirrhosis, CRF
     
  2. Exudate - PE, Pneumonia, TB, Empyema, CA, Collagen-vascular ( SLE, RA), Trauma  (chylo/hemothorax), Chemical (Boorhave's, Pancreatitis).

S  &  S :

  1. Dyspnea, tachypnea, dullness on percussion, decreased breath sounds

DX:

  1. CXray. Pleural effusion can be demonstrated on PA view. To differentiate pleural effusion  from other possible causes of  opacification, and to determine that the fluid is not loculated, a lateral decubitus film is useful. Lateral decubitus Cxray should show layering of  > 10 mm  to be safe.
     
  2. Thoracentesis. Best site is the 6th intercostal space at the  midscapular line, but percussion to ascertain dullness must always be performed prior to procedure.
     
  3. DO  NOT drain more then 1500cc of fluid. Both hypotension and pulmonary edema can occur secondary to fluid shifts. PTX is another complication to look out for, and  a f/u CXR should always be done. Also, hypoxia may occur (secondary to an acute change in VQ due to improved perfusion of previously unsupplied area).
     
  4. Following are the tests requested: LDH, Proteins, glucose, pH, Cytology, Gram stain, culture. Other tests are ordered if one has any indication such as AFB, Amylase (pancreatitis, Boorhave's),  Cholesterol (if aspirate is milky 2ry to chylothorax).
     
    • Tube #1:  Lytes - LDH, glucose, protein, amylase, TG
    • Tube #2:  CBC - cell count
    • Tube #3:  Cultures - Gram stain, C&S, AFB
       
  5. To determine if the effusion is:
     

    exudate

    transudate

    a) Effusion/LDH

    >200IU/dl

    <200 IU/dl

    b) Eff/serum LDH

    >0.6

    <0.6

    c) Eff/serum protein

    >0.5

    <0.5
  6. Other helpful tests are:
     
    • Glucose - this is low (as compared to serum) in CA, Pneumonia, Collagen-vascular  (especially RA).
       
    • pH - most transudates have pH > 7.4, while most exudate's pH is  < 7.3. The pH of  < 7.1 is suggestive of Empyema. Other pathologies that may have pH < 7.1 are RA and Boorhave's. The pH must be done with ABG syringe and placed on ice.

Treatment:

  1. The goal of  treatment of pleural effusions in the ER should be aimed to relieve dyspnea  and provide comfort to the pt by  draining pleural  fluid .  If effusion is big enough to compress and shift the trachea, thoracentesis should be done to improve ventilation. Starting  pt on antbx that could cover  G (+), G (-) and anaerobes, such as  ticarcillin clavulanate (Timentin) 3.1 g q4-6 hr, is probably the only  treatment aimed at correcting the underlying  problem that the ER healthcare provider can offer to the pt in the ED. Chest tube, although indicated as treatment of choice for empyema, in addition to antbx, is not necessary in the ER. Chest tube is  obviously indicated for chylothorax, hemothorax, ruptured esophagus (e.g.  Boorhave's).

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