Learner Version
Module #4
Created by Dr. David Olson
5/2014
Objectives:
1)
2)
3)
4)
Understand the physical exam findings consistent with pleural effusions.
Recognize the indications and contraindications for a diagnostic thoracentesis.
Understand the evaluation of pleural fluid, and its implications.
Develop management plans based on history, physical and laboratory analysis.
References:
MKSAP 16
McGrath E, Anderson P. Diagnosis of Pleural Effusion: A Systematic Approach. American Journal of Critical Care;
March 2011, Volume 20, No. 2: 119-127.
Light RW. Pleural Effusions. N Engl J Med. 2002; 346(25): 1971-1977.
Wong CL, Holroyd-Leduc J, Straus SE. Does This Patient Have a Pleural Effusion? JAMA, January 21, 2009; Vol 301,
No. 3: 309-317.
Light RW. The Light Criteria: The Beginning and Why they are Useful 40 Years Later. Clin Chest Med; 34(2013): 2126.
Quinn T, Alam N, Marshall MB, Choong C. Decision Making and Algorithm for the Management of Pleural
Effusions. Thorac Surg Clin; 23(2013): 11-16.
Porcel JM, Light RW. Diagnostic Approach to Pleural Effusion in Adults. American Family Physician; April 2006, Vol
73, No. 7:1211-1220.
www.UpToDate.com “Diagnostic Evaluation of a Pleural Effusion in Adults”
Case
Mr. J is a 62 year old male who presents to the ED with progressive shortness of breath and mild chest pain that
has been getting worse over the past week. Normally he walks one mile every day, but recently he has only been
able to walk to the end of his block before getting “winded” and having to turn around. The chest pain is mostly
when he is breathing heavily, but he has also noted it at rest when he takes a deep breath or yawns. Subjectively
he has noticed recent episodes of chills, and he gets so hot at night that he starts to sweat. He has a chronic
cough, which he attributes to years of smoking, but it has been more productive recently. His past medical history
includes: Tobacco abuse (current), mild COPD without oxygen dependence, DM, Rheumatoid Arthritis. Currently
he takes ibuprofen for his arthritis, Spiriva and a rescue inhaler for his COPD, Glargine Insulin 15U at bedtime, and
Aspart 3U with each meal.
On physical examination his temperature is 100.9 oF (38.3 oC), blood pressure 114/74 mmHg, pulse rate 98 bpm,
respiratory rate 22, and O2 saturation 85% on RA. In general he is a thin man, appearing his stated age, but shows
signs of mild respiratory distress. Heart sounds are normal. Lungs are clear on the left, but decreased breath
sounds on the right. Abdomen is soft non-distended with normal bowel sounds, and no hepatosplenomegaly. He
does have mild edema in his legs, approximately 1+ to the knees.
Labs: wbc 8.7, Hgb 10.2, Hct 31, Plt 178. Differential shows 82%N, 9%L, 4%M, 2%E, 3.2%IG. NA 131, K 4.1, Cl 100,
HCO3 16, BUN 19, Cr 0.99, Glu 145. BNP 386. Liver function tests are normal. Last A1C 9.5%
Chest x-ray: moderately enlarged heart, hyperinflation consistent with COPD, moderate to large pleural effusion
(free flowing) on left with associated consolidation.
The ED physician provides you with the history above and requests that the patient be admitted for evaluation of a
new pleural effusion.
What more information should you ask for? What should you look for on physical exam?
The patient has been a long time smoker. He worked as a mechanic until he retired, and was a mechanic in the
Navy. He has noticed some weight loss recently; he estimates about 25 pounds in the last few months. Your
records indicate almost 40 pounds since his last PCP appointment 1 year ago. He does not drink, has no
exposures to sick people recently, and no history of TB exposure.
On exam: CV: no JVD, no HJR Chest: Right side clear to auscultation with minimal crackles noted in the base;
left side: decreased breath sounds, decreased fremitus 1/2 up the chest, above this an increase in bronchial
breath sounds and increased fremitus. Dullness to percussion extends up around 1/2 of chest. No egophony.
What are the indications for a thoracentesis? What studies are important to send?
What are Light’s Criteria?
The patient’s fluid analysis shows a wbc of 11,000 split evenly as neutrophils and lymphocytes, moderate blood,
no bacteria. Culture is negative. His TP is 3.3 (serum 6.1), LDH 1,200 (serum 1,300). pH 7.23. Cytology was sent
to the pathology department.
What is the most likely cause of this effusion?
What is your next step in managing the patient?
CT scan shows a 5cm mass obstructing the left lower lobe with associated consolidation and inflammation
behind consistent with post obstructive pneumonia. Bronchoscopy reveals a non-small cell carcinoma in the left
lung. The patient had no signs of metastasis and is started on chemotherapy treatments after antibiotic
treatment for his pneumonia is completed.
If time:
Large malignant pleural effusions very often recur, so there are several options for treatment of the
effusions. 1) Watchful waiting – if the patient is relatively symptom free, then treatment of the underlying
malignancy may eventually improve the effusions.
2) Repeated therapeutic thoracentesis, as many effusions will re-accumulate. They may take several
weeks to months to become symptomatic.
3) Pleurodesis can be achieved by introducing a sclerosing agent into the pleural space (most commonly
talc, tetracyclin or doxycycline) which creates a diffuse inflammatory state and adherence of the visceral and
parietal pleura.
4) For patients with a short life expectancy or who are too frail for pleurodesis, there are indwelling
catheters that can be introduced which allow for symptomatic removal of fluid over time.
Other fluid analysis that can be done on pleural fluid:
ADA (adenosine deaminase) is a marker for tuberculosis
Hematocrit can be performed to look for hemothorax
Amylase can be an indication of pancreatitis or esophageal rupture
NT-proBNP can be run on pleural fluid and would indicate active heart failure
Complement C4 is severely reduced in rheumatoid arthritis effusions
Cholesterol/triglycerides can diagnose a chylothorax
Appearance of the pleural fluid can also reveal its possible origin:
Milky white can be from chylothorax or empyema
Urine colored might indicate a urinothorax
Putrid/turbid is an indication of infection/empyema
Black can indicate the presence of a fungal infection (aspergillus)
Brown “anchovy paste” may indicate the presence of an aemebic abscess
Bloody could indicate a traumatic tap or a possible hemothorax
MKSAP Questions (Pulmonary Section)
# 14
# 71
# 74
# 100
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to Dr. Wendy Gerstein, Department of Medicine, VAMC
(111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
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4) Was the attending involved in the teaching of this module? Yes/no (please circle)
5) Please provide any further comments/feedback about this module, or the inpatient curriculum in general:
6) Please circle one:
Attending
Resident (R2/R3)
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