Resume of

Chapter 8th
Approach to the Patient
Page 128-139
A. Isra Azraeni M
Approach to The Patient

Pleural effusion should be considered. Increased densities on the chest

radiograph are frequently attributed to parenchymal infiltrates when they
actually represent pleural fluid.

Most patients with pleural effusions have blunting of the posterior

costophrenic sulcus on the lateral chest radiograph.

If this angle is blunted, the patient should be evaluated with ultrasound, CT

scan, or bilateral decubitus chest radiographs.

Pleural effusions can occur as complications of many different diseases (Table

8.1)
FREQUENCIES OF VARIOUS
DIAGNOSES
An epidemiologic study from the Czech Republic
found causes of pleural effusions in order of
incidence
• were congestive heart failure, malignancy, pneumonia, and
pulmonary embolism
• Congestive heart failure and cirrhosis cause almost all transudative
pleural
effusions
• malignant disease, pneumonia, and pulmonary embolization are
the three main causes of exudative pleural effusions.
• Two other frequent causes of exudative pleural effusions are viral
infections and the effusion that occurs after coronary artery bypass
graft
(CABG) surgery.
 Algorithm for Distinguishing
Transudative from Exudative Pleural Effusions.
Appearance of Pleural Fluid
 Routine Measurements
on Exudative Pleural Fluids
• Nutrophils predominate in the pleural fluid, an acute process is affecting
1. Pleural Fluid the pleural surfaces
Differential Cell • The presence of an infiltrate indicates that the patient probably has a
Count parapneumonic effusion

• Most patients with a reduced pleural fluid glucose level (<60 mg/dL) have
2. Pleural Fluid one of four conditions: parapneumonic effusion, malignant pleural
Glucose effusion, tuberculous pleuritis, or rheumatoid pleural effusion

3. Pleural Fluid • The pleural fluid LDH is a reliable indicator of the degree of pleural
lactate inflammation
Dehydrogenase (LDH)

• If a patient has malignancy, cytologic examination of the pleural fluid is a

4. Pleural Fluid fast, efficient, and minimally invasive
Cytology • The percentage of malignant pleural effusions that are diagnosed
between 40% and 87%.

5. Pleural Fluid • Over the last 50 years, the diagnosis of tuberculous pleuritis
Markers for was usually established with needle biopsy of the pleura
Tuberculosis
Algorithm For Evaluating Exudates With An Unknown Etiology
 Pleural Fluid Adenosine Pleural Fluid Interferon-Gamma
Deaminase Level Levels

• Diagnosis of tuberculosis is • Pleural fluid interferon-gamma

virtually established if the levels are also elevated with
pleural fluid ADA level is more tuberculous pleuritis
than 40 U/L • Pleural fluid interferon-gamma
• The higher the pleural fluid levels are very efficient at
ADA level, the more likely the differentiating tuberculous
patient is to have tuberculous from nontuberculous pleural
pleuritis effusion. Using a cutoff level of
• 5 of 1 73 patients (3%) with 3.7 U/mL
pleural effusions due to
other etiologies, including 46
with malignancy and
30 with pneumonia, had ADA
levels that exceeded
45 U/L
 Options When No Diagnosis is Obtained
After Initial Thoracentesis

Observation Bronchoscopy Thoracoscopy

Needle Biopsy Open Pleural

of the Pleura Biopsy
 Special Situations

Pleural Effusions
Massive Pleural
in the Intensive
Effusions
Care Unit

Bilateral Pleural
Effusion
Thank You