Morning Report 2.12.20

Today we had an excellent case of progressive SOB / DOE with a finding of bilateral pleural effusions and thickening presented by Dr. Bowmaster.

Some take-aways from the case are as follows;

  1. Pleural effusion – who and when to tap?
    • In general, ALL new effusions!
    • Exceptions include if SMALL effusion AND clear clinical diagnosis, ex. viral – pleurisy, CHF
    • Atypical features to consider tapping; s/sx of infection or cancer, high A-a gradient, bilateral effusions of different sizes
  2. (Some) Chest tube indications
    • Complicated parapneumonic effusion
      • Empyema
      • Positive gram stain or fluid cultures
      • Loculations
      • Large (>0.5 hemithorax)
      • Sepsis from pleural source
      • Low pH (<7.2)
    • Recurrent malignant pleural effusion
    • Symptomatic pleural effusion
  3. Pleural thickening Ddx 
    • Think of malignant mesothelioma and asbestos exposure!
    • Pleural metastasis; adenoCa of the lung, breast, stomach, ovary, lymphoma, thymoma
    • Previous pleurisy or infectious disease
    • Silicosis
    • Sarcoidosis
    • Drug induced; ergotamine, cyclophosphamide

Clinical Pearl: If by Light’s criteria, your patient is considered borderline exudative, consider if the patient has been / is being actively diuresed (ex. for CHF or hepatic hydrothorax). In this scenario, protein and LDH concentrations may be slightly higher. You can consider using an albumin gradient (serum-pleural) which if greater than 1.2 g/dL may be an indicator of a transudative effusion.



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