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R24 Respirology
Diseases of the Mediastinum and Pleura Toronto Notes 2019
Pleural Effusions Simple Effusion
pH >7.2, LDH <1/2 serum, glucose >2.2
Complicated Effusion
pH <7.2, LDH >1/2 serum, glucose <2.2, positive Gram stain Needs drainage
Table 26. Analysis of Pleural Effusion
Measure
Protein, LDH
Gram Stain, Ziehl-Nielsen Stain (TB), Culture Cell Count Differential
Cytology
Glucose
Rheumatoid Factor, ANA, Complement Amylase
pH
Blood Triglycerides Cholesterol
Treatment
Purpose
Transudate vs. exudate
LDH especially high (>1000 IU/L) in empyema, rheumatoid, malignancy Protein especially high in TB, myeloma
Looking for specific organisms
Neutrophils vs. lymphocytes (lymphocytic effusion in TB, cancer, lymphoma, serositis)
Malignancy, infection
Low (fluid:serum <0.5) in rheumatoid, TB, empyema, malignancy, esophageal rupture Collagen vascular disease
Pancreatitis, esophageal perforation, malignancy
Normally about 7.6
Very low (<7.0) in empyema, TB, rheumatoid, malignancy, esophageal rupture Mostly traumatic, malignancy, PE with infarction, TB
Chylothorax from thoracic duct leakage, mostly due to trauma, lung CA, or lymphoma Distinguish between chylous and chyliform effusion (seen in inflammation, e.g. TB, RA)
When possible, organism-directed therapy, guided by culture sensitivities or local patterns of drug resistance, should be utilized
• thoracentesis
• treatunderlyingcause
• considerindwellingpleuralcatheterorpleurodesisinrefractoryeffusions
Complicated Effusion
• persistentbacteriainthepleuralspacebutfluidisnon-purulent • neutrophils,pleuralfluidacidosis(pH<7.00),andhighLDH
• oftennobacteriagrownsincerapidlyclearedfrompleuralspace • fibrinlayerleadingtoloculationofpleuralfluid
• treatment:antibioticsdependingongramstainandchesttubedrainage
Empyema
Definition
• pusinpleuralspaceoraneffusionwithorganismsseenonaGramstainorculture(e.g.pleuralfluidis grossly purulent)
• positivecultureisnotrequiredfordiagnosis
Etiology
• contiguousspreadfromlunginfection(mostcommonlyanaerobes)orinfectionthroughchestwall(e.g. trauma, surgery)
Signs and Symptoms
• fever,pleuriticchestpain
Investigations
• CTchest
• thoracentesis
• PMNs(lymphocytesinTB)±visibleorganismsonGramstain
Treatment
• antibiotictherapyforatleast4-6wk(rarelyeffectivealone)
• completepleuraldrainagewithchesttube
• ifloculated,moredifficulttodrain–mayrequiresurgicaldrainagewithvideo-assistedthorascopicsurgery
(VATS), or removal of fibrin coating (surgical or tPA/DNAse) to allow lung re-expansion (decortication)
Atelectasis
• seeGeneralSurgery,GS10