Pleural Effusion (OSCE Guide)

7/03/2020

Pleural Effusion (OSCE Guide)

Pleural Effusion is one of the commonest (if not the commonest), respiratory short cases you would get at the undergraduate level. The clinical findings are usually prominent and well defined in patients with Pleural effusions.

Reduced chest expansion, reduced vocal fremitus, stony dull to percussion, absent breath sounds and bronchial breathing above the effusion is very classical of a pleural effusion.

Always try to figure the out possible aetiology for the pleural effusion. Unilateral large effusions are usually caused by underlying malignancies (Lung CA, Breast CA, Lymphoma) or maybe even Dengue hemorrhagic fever.

Bilateral mild effusions are usually caused by organ failures (Cardiac failure, Liver failure, Renal failure) & hypoalbuminaemia. Rheumatological diseases can also cause pleural effusions.

PLEURAL EFFUSION – EXAMINATION

Pleural effusion is a pretty straightforward diagnosis with the characteristic clinical findings you would get in your chest examination. But finding the aetiology for the effusion should be done in your General Examination.

So, after completing your chest examination, you may come back to your General Examination in order to make sure you did not miss anything which would be suggestive of the primary pathology causing the pleural effusion.

GENERAL EXAMINATION

  • Respiratory Distress – In large effusions
  • Cachexia – Malignant effusion, Hypoalbuminemic effusion, TB effusion
  • Running Fever – Suggestive of Synpneumonic effusion
  • Sputum Cup – Bloodstained in Malignant, Tuberculous effusions
  • Ankle Oedema – Organ (Liver, Heart, Kidney) failure & Hypoalbunaemia
  • Malignancy – Distended neck veins, Horner’s Syndrome, Small Muscle Wasting of hand, Finger Clubbing, Tar staining, Lymphadenopathy (cervical, axillary, supraclavicular, epitrochlear)
  • Rheumatological Disease – Rheumatic nodules, Deforming arthritis, Rash
  • CLCD – Gynaecomastia, Spider naevi, Parotid swelling, Jaundice
  • Heart Failure – Elevated pulsatile JVP

RESPIRATORY EXAMINATION PROPER

INSPECTION
  • Tachypnoea, Decreased movements in affected site, Look for aspiration marks, Radiotherapy marks.
PALPATION
  • Reduced chest expansion, Reduced vocal fremitus, Trachea is deviated to the opposite side (in large effusions), may be central if the effusion is associated with Lung collapse.
PERCUSSION
  • Stony Dull (Percuss for the upper margin of the effusion).
AUSCULTATION
  • Reduced or absent breath sounds with decreased vocal resonance, Bronchial breathing can be heard above the effusion.

EXTENDED EXAMINATION

  • Hepatomegaly & Splenomegaly – If Lymphoma is likely.
  • Apex beat & 3rd heart sound – If heart failure is likely.

PLEURAL EFFUSION – CASE PRESENTATION

This average build middle-aged patient is breathless at rest. There is no finger clubbing or tar staining. There is cervical, axillary lymphadenopathy and the epitrochlear node is palpable indicative of generalized lymphadenopathy. There are no features suggestive of CLCD or Rheumatological disease and there is no ankle oedema.

There are no surgical scars, aspiration marks or radiotherapy marks. There is reduced chest expansion on the right side. The vocal fremitus and the vocal resonance on the right lower zone are reduced where the percussion note is stony dull up to the mid zone. Trachea is slightly deviated to the left side. Breath sounds are markedly diminished over the right lower zone and Bronchial breathing is heard in the right upper zone.

So, my clinical findings are compatible with a Right side moderate pleural effusion, possibly due to underlying malignancy. Lymphoma is more likely than a Lung malignancy and I would like to examine for hepatosplenomegaly.


FREQUENTLY ASKED QUESTIONS

1. What are the causes of dullness at the base of the lungs other than pleural effusion?

1. Lung Collapse 2. Lung Consolidation (Pneumonia, Pulmonary Infarction) 3. Pleural Thickening 4. Lower Lobectomy 5. Raised Hemidiaphragm

2. How do you rule out raised hemidiaphragm from other causes?

Using Tidal Percussion.

3. How do you differentiate each of the other four cases from a pleural effusion?

1. Pleural Effusion – stony dull, absent breath sounds, trachea may be deviated to the opposite side (in large effusions). 2. Lung Collapse – dull, absent breath sounds, trachea deviated to the same side 3. Lung Consolidation – increased vocal resonance, trachea not deviated, bronchial breathing, crepitations 4. Pleural Thickening – breath sounds heard, trachea not deviated. 5. Lobectomy – surgical scar, absent breath sounds

4. What are the two types of pleural effusions?

1. Exudate Effusion. 2. Transudate Effusion.

5. How would you differentiate those two types?

Analyzing pleural fluid protein level. When proteins < 30 g/L – “Transudate”. When proteins > 30 g/L – “Exudate”.

6. What are the causes of transudative effusions?

1. Cardiac Failure 2. Liver Failure 3. Renal Failure 4. Hypothyroidism 5. Nephrotic Syndrome (Hypoalbuminemia)

7. What are the causes of exudative effusions?

1. Neoplasia – Bronchial CA, Mesothelioma, Lung Secondaries, Lymphoma 2. Connective tissue disorders – SLE, RA 3. Infections – Pneumonia, Tuberculosis 4. Drugs – Methotrexate, Bromocriptine 5. Other – Asbestosis, Oesophageal rupture, Chylothorax, Yellow nail syndrome

8. What are the basic investigations you would do?

1. Chest X-ray / USS Chest 2. Pleural fluid analysis 3. Blood Investigations – FBC, ESR, CRP, LFT, U&E, LDH, TSH, Rheumatoid factor 4. ABG (Arterial Blood Gas)

9. What are the second line investigations you would do?

1. Pleural Biopsy 2. CECT Chest 3. Bronchoscopy

10. What is the normal volume of pleural fluid in pleural space?

1 mL.

11. What is the minimum volume of Pleural fluid that can be detected clinically?

500 mL.

12. What is the minimum volume of Pleural fluid that can be seen on Chest Radiograph PA?

180 mL.

13. How can you detect smaller pleural effusions?

1. Lateral decubitus X-ray 2. Ultrasound Chest

14. What is the use of ultrasonography in Pleural effusions?

1. Detect smaller effusions 2. Detect loculated effusions 3. Guided aspiration of pleural fluid & pleural biopsy 4. Differentiate pleural thickening from effusions

15. What is the normal composition of pleural fluid?

• pH – 7.6 to 7.64 • Proteins < 1-2g/L • WBC < 1000/mm3 • LDH < 50% of Plasma • Glucose = Plasma Glucose level

16. What are the basic investigations you would do from pleural fluid following aspiration?

1. Pleural fluid full report 2. Culture & ABST 3. Gram staining 4. Pleural fluid LDH 5. Pleural fluid cytology 6. Pleural fluid ADA (if TB is highly suspected) 7. Pleural fluid pH (if Empyema is suspected)

17. What is the investigation you must do immediately after the aspiration?

Post aspiration Chest X-ray.

18. What is the condition you are looking for in post aspiration Chest X-ray?

Acquired Pneumothorax.

19. What is Light’s Criteria for exudative effusions?

2 out of 3 of the following, 1. Pleural fluid protein: Serum protein > 0.5 2. Pleural fluid LDH: Serum LDH > 0.6 3. Pleural fluid LDH > 2/3 of upper limit of normal serum LDH

20. What is Pyothorax?

Presence of inflammatory fluid or pus within the pleural space.

21. What is the management of a Pyothorax?

Urgent IC tube insertion.

22. What is Chylothorax?

Milky white pleural fluid, when fluid cholesterol >4 g/L. Occurs due to lymphatic obstruction and Nephrotic syndrome.

23. What are the causes of haemorrhagic Pleural effusions?

1. Malignancy 2. Tuberculosis 3. Trauma

24. What are the causes of high LDH in Pleural fluid?

1. Empyema 2. Malignant Effusions 3. Rheumatoid Effusions

25. What are the causes of low glucose in Pleural fluid (same as causes for low pH)?

1. Empyema 2. Malignant Effusions 3. Rheumatoid Effusions 4. Tuberculosis 5. SLE

26. What is pleurodesis?

Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae. It can be done chemically or surgically.

27. What are the indications for pleurodesis?

1. Recurrent malignant effusions 2. Recurrent pneumothorax

28. What are the chemicals used for pleurodesis?

1. Talc 2. Doxycycline 3. Bleomycin

29. What is Meigs Syndrome?

It is defined as the triad of benign ovarian tumor with ascites and pleural effusion (right side) that resolves after resection of the tumor.

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