This presentation discusses steps in diagnosis of pleural effusion using a simulated patient scenario. Besides talking about different findings we can possibly see in a pt with pleural effusion on examination, CXR, USG, CT and labs, It also briefly discuss the proper steps in performing thoracocentesis.

1. Diagnosing…
Pleural Effusion
By : Jagjit Khosla

2. Pleural Effusion – Common causes
Exudative
• Tuberculosis
• Parapneumonic
• Pneumonia
• Lung abscess
• Bronchiectasis
• Malignancy
• Pulmonary embolism
Transudative
• CHF
• Nephrotic syndrome
• Liver cirrhosis

3. Diagnosis of Pleural Effusion
History
Examination
Investigation
Diagnosis

4. Clinical Case Scenario
Ms. Manju, a 17 year old female, presented in OPD
with
Dry cough X 10 days
Pain in right lower chest X 10 days
Fever X 10 days
Breathlessness X 4 days

5. HISTORY OF
PRESENT ILLNESS

6. History of present illness
 Chest pain
 Duration – 10 days
 Onset – Insidious
 Progression – Gradually progressive
 Site – Right lower side of anterior chest
 Character – sharp, stabbing pain
 Severity – Severe initially, now dull
 Movement – Not moving anywhere
 Aggravating and relieving factors – Aggravated on
coughing, Relieved on left lateral decubitus position
 Associated symptoms – low grade fever without chills/
rigors

7. History of present illness
 Cough
 Duration – 10 days
 Onset – Insidious
 Progression – Gradually progressive
 Dry
 Severity – Mild
 No hemoptysis TB, Malignancy

8. History of present illness
 Breathlessness
 Duration – 4 days
 Onset – Insidious
 Progression – Gradually progressive
 Aggravating and relieving Factors – Relieved on lying
down in left lateral decubitus

9. History of present illness
 Negative history
 No H/o Weight loss, Night sweats
 No H/o lower extremity edema
 No H/o orthopnea, PND
 No H/o recurrent attacks of dyspnea
 No H/o Oliguria, Haematuria,
burning micturition
 No H/o vomiting, loose stool, pale stools, Jaundice
LVF
TB
GIT
Nephrotic
syndrome
Asthma

10. RESPIRATORY
EXAMINATION

11. On respiratory examination
 Inspection –
 Unilateral impaired chest movements
 Palpation –
 Unilateral decrease in chest movements
 Tactile fremitus is decreased
 Percussion –
 Dullness – Shifting dullness
 Auscultation –
 Decreased breath sounds
 Decreased vocal resonance
Only when
Fluid is
>500 mL
Ellis “S” Curve

12. INVESTIGATIONS

13. Investigations

14. PA view Chest X-ray
 Minimum 300 mL
required
 Blunting of
Costophrenic angle

15. PA view Chest X-ray
 Massive pleural
effusion
 Trachea deviates to
opposite side
 Mediastinum shifts
to opposite side

16. PA view Chest X-ray
 A subpulmonic
effusion can
simulate elevated
hemidiaphragm
 Lung is floating
above the fluid

17. PA view Chest X-ray
 Fluid in the fissure
may resemble an
intrapulmonary
mass
 Called as
“Pseudotumor”

18. PA view Chest X-ray
 Loculated pleural
effusion
 Produce opacity
with “D” shape or
“Tear drop” shape

19. Left lateral decubitus Chest X-ray
 Fluid Layering

20. Ultrasound Chest
 As small as 20 mL
pleural fluid can be
detected
 Pleural effusion vs
pleural thickening

21. CT scan Chest
 Aids in differentiation of
 Lung consolidation vs.
Pleural effusion
 Cystic vs. Solid lesions
 Peripheral lung abscess vs.
Loculated emypema
 Aids in identification of
 Necrotic areas
 Pleural thickening,
nodules, masses
 Extent of tumor

22. Clinical Case Scenario
In our case, Chest X-ray PA view was ordered.

23. Thoracocentesis
Indications
 To differentiate between
Exudative and transudative
pleural effusion
 To drain large pleural
effusion

24. Thoracocentesis
Absolute Contraindications
 Uncooperative patient
 Uncontrolled Coagulation disorder
Relative Contraindications
 Positive end-expiratory pressure
 Only one functioning lung
 Localised skin infection over the
proposed site of thoracocentesis

25. Thoracocentesis
STEP 1
PATIENT’S CONSENT IS TAKEN

26. Thoracocentesis
STEP 2
PATIENT POSITIONING
Patient sitting on
edge of bed
Arms folded in front
Leaning forward

27. Thoracocentesis
STEP 3
SITE SELECTION

28. Thoracocentesis
STEP 4
CLEANING THE SITE & DRAPING
First Iodinated antiseptics Then, Isopropyl alcohol

29. Thoracocentesis
STEP 5
LOCAL ANASTHESIA

30. Thoracocentesis
STEP 6
PROCEDURE

31. Thoracocentesis

32. Light’s criteria
Pleural fluid is an exudate if one or more of
following criteria are met :

33. Exudative Pleural Effusion
 Further tests are ordered –
 P. Fluid glucose <60 mg/dL
 P. Fluid amylase
 P. Fluid ADA > 40 IU/L
 P. Fluid Cytology
 Differential Cell count
 Culture and senstivity
Bacterial infections
like TB, pneumonia;
Malignancy
Pancreatic Pleural
effusion, Malignancy
TB
Malignancy

34. Clinical Case Scenario
Blood Analysis
Analyte Observed values Normal values
Haemoglobin 7.8 mg/dL 12-15 mg/dL
TLC 8,600 / mm3 4000 – 11000/mm3
ESR 27 mm/hr 3-15 mm/hr
Platelet count 178 X 103/mm3 165-415 X 103 /mm3
RBC 2.6 X 106 /mm3 4.0-5.2 X 106 /mm3
Total S. Protein 5.1 g/dL 6.7-8.6 g/dL
S. Albumin 2.8 g/dL 3.5-5.5 g/dL
S. Globulin 2.6 g/dL 2.0-3.5 g/dL
LFT and KFT were normal

35. Clinical Case Scenario
PLEURAL FLUID ANALYSIS
Volume 10 mL
Colour Yellowish
Turbidity Turbid
Coagulum - ve
Blood - ve
Deposit - ve
WBC 19,800
Neutrophils 92%
Lymphocytes 6%
Protein 4.7 g/dL
P. Fluid Protein = 0.92
S. Protein

36. Clinical Case Scenario
PLEURAL FLUID ANALYSIS
Glucose 46 mg/dL
ADA 24.5
ZN stain No AFB
Gram stain Gram positive bacilli seen
Blood culture Strep. pneumoniae

37. The Diagnosis is :
Right Lower Zone
Pneumonia with
Pleural Effusion