What information would gether from analysis of pleural fuild to differentiate plural effusion?

1Information from pleural fluid analvsis
2What are the findings you expect in physical examination of a patient with left sided massive pleural effusion
3Radiological signs of moderate pleural effusion are
4Management of pleural effusion
5Treatment of pleural effusion

Lets discuss how to establishment of aetiology of effusion by pleural fluid study:

CauseAppearance of fluidType of fluidPredominant cells in fluidOther diagnostic features
TuberculosisSerous, usually amber colored(straw)ExudateLymphocytes (occasionally polymorphs) Isolation of M. tuberculosis from pleural fluid(20%). Positive pleural biopsy(80%). pleural fluid ADA is increased
PneumoniaTurbidExudateNeutrophilMicro organism on Gram stain.
Malignant diseaseSerous, often blood stainedExudateserosal cells and lymphocytes. Often clumps of malignant cells.Positive pleural biopsy(40%).

To detect pleural effusion first we need to know basic information about pleural fluid:

-Normal pleural fluid: 5 to 15 ml.
-Clinically detectable: At least 500 ml.
-Detectable by X-ray P/A view: At least 200 ml.
-Lateral decubitus position: At least 100 ml.
-Detectable by USG: Less than 100 ml can be detected.

Information from pleural fluid analvsis:

1) Physical examination:
A)Colour:
-Cloudy in parapneumonic effusion.
-Amber colour in TB.
-Haemorrhagic in malignancy.

2) Cvtological examination:
-Increased WBC with predominant neutrophil -› Parapneumonic effusion.
-Increased WBC with predominant lymphocyte -> TB, malignancy.
-Malignant cells by Papanicolau stain.

3 Biochemical examination:
-Increased protein in exudative effusion.
-Decreased glucose in parapneumonic and tubercular effusion.
-Increased ADA in tubercular effusion.

4) Microbiological examination:
-Pyogenic organisms in parapneumonic effusion.
-Acid fast bacilli in tubercular effusion.

Now lets know more about pleural effusion:
Pleural effusion: Pleural effusion is defined as accumulation of excessive fluid in the pleural cavity.

Causes of pleural effusion:

Unilateral pleural effusion cause:
Pneumonia (para-pneumonic effusion)
Tuberculosis
Bronchial carcinoma
Lymphoma
Connective tissue disorders (SLE, rheumatoid arthritis)
Liver abscess (right side)
Pancreatitis (left side)
Pulmonary infarction

Bilateral pleural effusion cause:
Congestive cardiac failure (CF)
Nephrotic syndrome
CLD / liver cirrhosis
Myxoedema
Uraemia
Connective tissue disorders (SLE, rheumatoid arthritis)

Clinically pleural effusion can be divided in to Exudative and transudative pleural effusion-

Exudative pleural effusion: (Protein > 3 gm/dl present in pleural fluid)
Para-pneumonic effusion
Pleural tuberculosis
Bronchial carcinoma
Collagen disease (SLE, rheumatoid arthritis)
Pulmonary infarction

Transudative pleural effusion: (Protein < 3gm/dl present in pleural fluid)
Congestive cardiac failure
Nephrotic syndrome
Cirrhosis of liver
Hypothyroidism
Meig’s syndrome (Ovarian fibroma + ascites + right sided pleural effusion)
Acute pancreatitis
Subphrenic abscess

Clinical findings of pleural effusion: Examination of respiratory system –

On inspection:
Restricted chest movement in affected side.

On palpation:
-Trachea and apex beat are shifted to opposite side (mediastinal shifting).
-Vocal fremitus is reduced or absent in affected side.

On percussion:
Percussion note is stony dull in affected side.

On auscultation:
Breath sound is diminished or absent in affected side.
Vocal resonance is diminished or absent in affected side.

How would you differentiate pleural effusion from pneumothorax clinically?
Answer

Pleural effusion:– Percussion note is stony dull in Pleural effusion.
Pneumothorax:– Percussion note is hyper-resonant in Pneumothorax.

What are the findings you expect in physical examination of a patient with left sided massive pleural effusion?

Physical findings in left sided massive pleural effusion are:

Inspection: Restricted chest movement in left side.

Palpation:
Trachea and apex beat are shifted to right side (along with mediastinal shifting).
Vocal fremitus is reduced or absent in left side.

Percussion:
Percussion note is stony dull in left side.

Auscultation:
Breath sound is diminished or absent in left side.
Vocal resonance is diminished or absent in left side.

What radiological signs are found in moderate pleural effusion?

Radiological signs of moderate pleural effusion are:
-Dense homogenous opacity occupying the lower and mid zones of the lung field with concave upper margin.
-Costophrenic and cardiophrenic angles are obliterated.
-Trachea is shifted to the opposite side.
-Heart is slightly shifted to the opposite side.

Management of pleural effusion:
History taking:
-Age of patient.
-Fever. If present, duration and grade.
-Cough.
-Sputum production.
-Haemoptysis.
-Weight loss.
-Abdominal pain (liver abscess, pancreatitis).
-History of cardiovascular, renal, hepatic or connective tissue disease.
-Removal of pleural fluid in the past.
-Past history of tuberculosis, malignancy.
-Any skin rash, swelling of joints, lymphadenopathy.
-History of edema, distension and pain in abdomen.

Clinical examination:
1) General examination:
-Body built.
-Temperature.
-Anaemia.
-Clubbing.
-Oedema.
-Thyroid gland – Goiter (as hypothyroidism can cause pleural effusion).

2) Systemic examination:
-Respiratory system: Please see above the findings of pleural effusion.
-Cardiovascular system: Features of heart failure.
-Abdomen: Hepatomegaly in liver abscess and heart failure.
-There may be ascites.
-Musculoskeletal system: To find any connective tissue disease.

Investigations:
-Blood for TC & DC of WBC.
-ESR.
-Chest X-ray.
-Pleural fluid aspiration and stud.
-Sputum for AFB.
-Pleural biopsy: Combining pleural aspiration with biopsy increases the diagnostic yield. An Abrams needle is most frequently employed.
-Ultrasonography of chest: To detect pleural fluid and exclude other pathology.
-CT scan of chest: Displays pleural abnormalities more readily than either plain radiography or ultrasound, and may distinguish benign from malignant pleural disease.

Treatment:
1) Therapeutic aspiration: -May be required to reduce breathlessness.
-Not more than 1.5 L at a time.
2) Treatment of the underlying cause: For example, pneumonia, tuberculosis and malignancy.
3)Treatment of tubercular pleural effusion:
-Anti-tubercular drugs.
-Steroid e.g. Tab. Prednisolone, 30-60 mg daily for 3 weeks, then gradually tapered.
-Therapeutic aspiration of pleural fluid, especially in moderate to large effusion with respiratory distress.

FAQ

Q. A 50 year old male presents with low grade fever and cough for two months. Recently he develops heaviness of right side of the chest. Examination findings of his chest are consistent with right sided pleural effusion.
A)Write down two important differential diagnoses of his illness.
Answer
: 2 differential diagnoses is-
1)Tuberculosis.
2)Bronchial carcinoma.

B)Mention other clinical information that would help you to differentiate possibilities at bed side.
Answer
: Other clinical information to differentiate them:
-H/O contact with tuberculosis patient, evening rise of temperature, night sweats- Goes in favour of tuberculosis.
-Features of any enlarged lymph node, if any-
>If tuberculosis- Matted, firm, may be discharging sinus.
>If metastatic carcinoma- Hard, irregular, fixed.
-Some features go in favour of bronchial carcinoma e.g. clubbing, compressive features e.g. hoarseness of voice, dysphagia, superior venacaval obstruction etc.

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