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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Wednesday, April 27, 2016

Pleural Effusions

Author: Cunningham A - Edited by: Byrne E - Expert Reviewer: Rosiere L
Citation: [Peer-Reviewed, Web Publication] Cunningham A, Byrne E (2016, April 26). Wet, Wacky Lungs: A Quick Look At Pleural Effusions. [NUEM Blog. Expert Commentary by Rosiere L]. Retrieved from http://www.nuemblog.com/blog/pleural-effusions-101
"Take Home Points
  • There are many, many different causes of pleural effusion, with the most common being congestive heart failure. A diagnostic thoracentesis in conjunction with the application of Light’s criteria can help narrow the diagnosis.
  • An X-ray is simple and a mainstay in diagnosis of any patient with suspected pleural effusion. Ultrasound is rising as a more sensitive means of diagnosing effusion, and is also helpful in aiding drainage of effusion. CT has value in determining more complex underlying characteristics of an effusion, but is typically not essential to perform in the ED.
  • If a patient comes in unstable and an X-ray showing a large pleural effusion causing mediastinal shift, drain it immediately! Any patient with a new effusion and an unclear etiology based on history should undergo a diagnostic thoracentesis at some point during their stay. There are no contraindications to performing a thoracentesis, and there is no fluid removal limit (just watch your patient’s pain level and symptomatology).
  • Stop your thoracentesis if your patient complains of chest discomfort (that is not pleuritic) as this is a sign of lower pleural pressures and you are unlikely to drain much more fluid.
Expert Commentary
Thanks Andrew, you provided a fantastic summary of pleural effusions. While we see these every day, rare is the new or hemodynamically significant pleural effusion. There are a few things I can add:
  1. Light's Criteria
    1. Highly sensitive at the expense of specificity. Our goal is to identify all exudates. In doing so, make sure you send both LDH and protein so you don't miss an exudate. You may, as a result, end up mis-diagnosing a transudate from CHF as an exudate. Fortunately, there is little danger in doing that and collateral clinical information will help the team upstairs get it right
    2. Some pathologies don't fit neatly into transudate or exudate. Examples include PE, malignancy, sarcoid, amyloid.
  2. Simple transudative effusions can become exudative
    1. Don't become complacent just because your CHF patient has always had an effusion. If effusions become largely asymmetric, there is pleurisy, a fever or no clinical signs of decompensated CHF, consider exudative processes and a thoracentesis
  3. Safe effusions to tap
    1. I like the criteria provided by O. Ma in the "Emergency Ultrasound" text: 1.5 cm from parietal to visceral pleura and covering 3 interspaces. Maximizes diagnostic yield and minimizes pneumothorax
  4. If you use ultrasound, bleeding complications are rare
    1. Much like considering contraindications to paracentesis, if you use an ultrasound to locate your effusion, you are very unlikely to cause bleeding even in the setting of anticoagulation, thrombocytopenia or uremia."