Pleural Effusion

Context and Definition

4 Topics

Normal Anatomy and Pleural Fluid Physiology

Transudates and Exudates

Pathophysiology of Malignant Pleural Effusion

Pathophysiology of Pleural Infection

Clinical Assessment

4 Topics

Pleural Fluid Analysis

3 Topics

Decision making in ED

Aspiration and Drainage

Specific conditions

3 Topics

Pleural Effusion

Pleural Effusion

Pleural Effusion Pleural Effusion

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Question 1 of 10

1. Question
1 point(s)
Which one of the following statements regarding the physiology of pleural fluid is the most appropriate?
- Parietal pleura lines the lungs and visceral pleura lines the inside of the chest wall
- The LDH level of pleural fluid is usually >50% that of plasma LDH
- The glucose content of pleural fluid and plasma are typically similar
- Transudate effusions can be caused by increase colloid oncotic pressure
- Malignancy is a cause of a transudate effusion
Question 2 of 10

2. Question
1 point(s)
A 68-year-old man with known bronchial carcinoma presents with severe breathlessness, tachycardia and low blood pressure. Clinical examination reveals a stony dull right hemithorax and subsequent chest x-ray confirms massive pleural effusion with midline shift.

Select the single best option from the statements below.
- The effusion should be rapidly and completely drained
- Since this patient probably has advanced malignancy, invasive intervention is inappropriate and palliative care should be initiated instead
- Following fluid drainage and improvement in the patient’s clinical condition, the chest drain should be removed in the ED
- A small bore chest drain should be used to drain some of the fluid from the right side of the chest
- Oxygen should not be applied unless he is still hypoxic after pleural drainage
Question 3 of 10

3. Question
1 point(s)
Whilst reviewing chest radiograph reports of patients who have been recently discharged for the Emergency Department you come across one referring to a 58 year old woman who underwent chest radiography during an attendance with a cough. The report reads “…there is a small left sided pleural effusion. This was not present on the chest x-ray of 3 years ago.”

Select the single best option from the statements below.
- You should contact the patient and ask them to return to the Emergency Department today for a repeat chest radiograph
- You should order an urgent CT scan of the thorax, abdomen and pelvis to look for evidence of malignancy
- You should order an routine high resolution CT scan of the thorax to assess for lung disease
- You should arrange appropriate follow up and investigation, either through their GP or appropriate medical specialty, depending on your local guidelines
- You can safely ignore it as effusion was reported as being small
Question 4 of 10

4. Question
1 point(s)
A 72 year old man underwent diagnostic pleural fluid aspiration for a right sided pleural effusion. The following results were obtained:

Protein 29g/L
pH = 7.5
LDH = 231 IU/L
White Cells: 15% eosinophils

What can you deduce from these results?
- Further information from the patient’s blood / serum results is needed before it is possible to say if the fluid is a transudate or an exudate
- Eosinophilia of the fluid indicates benign disease
- The fluid is an exudate
- Further information from imaging studies is needed before it is possible to say if the fluid is a transudate or an exudate
- The most likely diagnosis is severe right sided pneumonia with a complex parapneumonic effusion
Question 5 of 10

5. Question
1 point(s)
With regards to the diagnostic analysis of pleural fluid samples choose one test which is of least clinical value in the acute setting.
- Rheumatoid factor
- Amylase
- pH
- Glucose
- LDH
Question 6 of 10

6. Question
1 point(s)
Which one of the following statements regarding diagnostic pleural aspiration is the most appropriate?
- A haemothorax is less likely to occur if a posterior approach is used
- It is an essential part of the investigation of all pleural effusions
- It should be performed using ultrasound guidance
- If fluid cannot be aspirated using a 21G (green) needle, then you should proceed to chest drain insertion
- The 'safe triangle' for pleural aspiration is bordered by the serratus anterior muscle posteriorly
Question 7 of 10

7. Question
1 point(s)
A 48-year-old man presents with a 3 day history of right sided pleuritic chest pain, fever and a productive cough. His chest x-ray shows a moderate right sided pleural effusion with consolidation in the right mid and lower zones.

Select the most appropriate statement from those listed below.
- The effusion may resolve with antibiotics alone
- Further imaging studies will not be required
- Therapeutic chest drainage will be required
- Diagnostic pleural fluid aspiration has limited value in this setting
- The pleural fluid in this case is likely to have low protein content
Question 8 of 10

8. Question
1 point(s)
With regards to a newly diagnosed pleural effusion, which of the following are false?
- A unilateral effusion in a patient with HIV and a CD4 of 8 may a presentation of pulmonary TB
- An effusion after recent trauma may be considered to be a haemothorax until proved otherwise
- A recent reduction in furosemide may be responsible
- Missing regular dialysis sessions is unlikely to be related to the effusion
- Post-op patients may develop effusions due to infection, pulmonary embolism or fluid overload
Question 9 of 10

9. Question
1 point(s)
Which of the following statements about pleural effusions is true?
- Effusions without a meniscus may suggest a concurrent pneumothorax
- When aspirated, you should only send the pleural fluid for glucose if the patient is diabetic
- The main value of LDH testing in pleural aspiration is assess the likelihood of Non-Hodgkin’s Lymphoma
- If pus is aspirated, it should immediately be sent for MC&S and analysed in the blood gas machine
- All patients found to have bilateral pleural effusions should have an urgent aspiration attempt under ultrasound guidance
Question 10 of 10

10. Question
1 point(s)
It is 3am and a patient is admitted to the ED with a large pleural effusion

Which of the following statements about chest drain insertion is not true?
- Unless the patient has significant cardiovascular or respiratory compromise, chest drain insertion should be left until the day time where possible
- It is acceptable to not obtain formal written consent if it is an emergency, however verbal consent should always be sort as a minimum
- To ensure accurate measurement of what has been drained, the bottle should not be filled with water when a drain is inserted for empyema
- A post insertion chest x-ray is always required
- Chest drain insertion is a painful procedure that is likely to require copious multi-modal analgesia

4 Comments

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Mohamed Awadelkarim January 18, 2022 at 9:45 pm

Enjoyable read and Quiz. Thanks

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Dr Ziad Tariq Jasim Al-Ani February 7, 2022 at 10:33 am

Good, I enjoyed it too.Hope you are doing well Mohamed.

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Dr Nisreen Osman Ali Sulieman September 26, 2022 at 10:50 am

very good closure

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Dr Ramesh Kumar May 24, 2024 at 9:02 pm

Nice revision

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