RESPIRATORY

ResponseLarge pleural effusion + pneumothorax = hydropneumothorax
Tracheal deviation to left - radiologic signs of tension

No surgical emphysema
No oxygen tubing
No mass/infection seen
No bony lesions

ResponseHomogenous opacification right middle and lower zones
Loss of right hemidoaphragm
Rim of opacity around periphery of pleural cavity consistent with fluid

DDx
Parapneumonic effusion
Malignancy
PE
Hydrothorax from massive ascites

ResponseThere was no description of this. But you aspirate it.

ResponseEffusion
Loculated
Consolidated lung

Dx = Empyema

ResponsePleural fluid culture - identify organisms and target antibiotic therapy
Pleural fluid biochemistry - LDH, Protein - Transudate vs exudate (lights criteria). Glucose, pH
Pleural fluid cytology - identify malignancy
Pleural fluid AFB ? TB
Serum protein + LDH for comparison (Light’s criteria)
CT - look for malignancy (Especially after fluid is drained)
CTPA - Diagnose PE

ResponseUse Lights criteria - you will need to order
Pleural fluid and serum LDH
Pleural fluid and serum Cholesterol
Pleural fluid and serum Albumin

ResponseExudate if 1 or more of
Pleural fluid protein:serum protein >0.5
Pleural fluid LDH:Serum LDH >0.6
Pleural fluid LDH > ⅔ upper value of serum LDH (Lab reference range

If equivocal
Serum albumin - pleural fluid albuman <1.2g/dL
Pleural fluid albumin >30g/L

ResponseInfective - pneumonia, TB
Inflammatory - Rheumatoid arthritis, SLE, Dressler’s syndrome
Malignancy
PE (Pulmonary infarction from PE)
Benign asbestos related
Abdominal - pancreatitis, intraabdominal abscess, esophageal perforation, ascites

ResponseCCF
Cirrhosis
Hypoalbuminaemia
Hypothyroid
Nephrotic syndrome

ResponseRespiratory compromise
Haemodynamic instability
Massive effusion with mediastinal shift
Some stable but symptomatic patients.

ResponseIdentify and establish goals of care
Improve oxygenation - O2 via NRBM
Decompression + Formal ICC insertion

ResponsePurulent pleural fluid
Positive gram stain/culture
WCC >50,000
Pleural fluid glucose <3
Pleural fluid pH <7.2
Pleural fluid LDH >1000

ResponseSupportive

• Supplemental O2
• Analgesia
• Fluids/nutrition

Specific (medical)

• IVABx - broad spectrum (Tazocin/cefepime, Add vancomycin if MRSA suspected)
• Large bore chest drain ~20 F

Specific (Surgical)

• Fibrinolytics via chest drain
• VATS (Video assisted thoracoscopic surgery
• Open thoracotomy

ResponseAge <30
Lung collapse >7 days
>3L pleural fluid
Use of suction
Rapid drainage >1.5L/hr