Respiratory for PLAB 1

A 68 year old man with known heart failure has increasing breathlessness. He has bilateral pitting oedema, a raised jugular venous pressure and stony dullness at both lung bases with reduced breath sounds. A chest radiograph confirms bilateral effusions. An aspirate shows a pleural fluid protein to serum protein ratio of 0.3 and a pleural LDH well below the exudate threshold. What is the SINGLE most likely diagnosis?

1. Exudative effusion A protein-rich effusion from infection, malignancy, embolism or inflammation. Bilateral protein-poor effusions with signs of heart failure points to it.
2. Haemothorax Blood in the pleural space after trauma. Bilateral protein-poor effusions with signs of heart failure makes it worth distinguishing.
3. Pleural effusion Breathlessness with a stony dull base and reduced breath sounds from pleural fluid. Bilateral protein-poor effusions with signs of heart failure fits.
4. Pneumonia with parapneumonic effusion An effusion accompanying pneumonia, which may become complicated. Bilateral protein-poor effusions with signs of heart failure suggests it.
5. Transudative effusion correct Correct. Bilateral effusions with a low protein ratio and low LDH, in a patient with heart failure. Light's criteria classify this as a transudate.

The point: A pleural effusion gives breathlessness, a stony dull percussion note, reduced breath sounds and reduced vocal resonance over the fluid. Aspirate and apply Light's criteria to separate a transudate from an exudate: it is an exudate if the pleural fluid protein to serum protein ratio is over 0.5, the pleural fluid LDH to serum LDH ratio is over 0.6, or the pleural fluid LDH is over two-thirds the upper limit of normal serum LDH. Transudates come from heart failure, cirrhosis and nephrotic syndrome and are treated by treating the cause. Exudates come from infection, malignancy, pulmonary embolism and inflammation, and they need investigation. Send the fluid for protein, LDH, pH, glucose, cytology, microscopy and culture. A pH below 7.2 in an infective effusion means an empyema or a complicated parapleural effusion needing a chest drain. A bloody effusion suggests malignancy, and pus means an empyema.

Source: BTS Pleural Disease Guideline British Thoracic Society · tier 2, specialty society or college

A 68 year old man with known heart failure has increasing breathlessness. He has bilateral pitting oedema, a raised jugular venous pressure and stony dullness at both lung bases with reduced breath sounds. A chest radiograph confirms bilateral effusions. An aspirate shows a pleural fluid protein to serum protein ratio of 0.3 and a pleural LDH well below the exudate threshold. What is the SINGLE most appropriate initial investigation?

1. Pleural fluid protein, LDH, pH, glucose, cytology and culture The full panel that identifies infection, malignancy and an empyema. Bilateral protein-poor effusions with signs of heart failure makes it essential.
2. Assess for heart failure, liver and renal disease The transudative causes, identified clinically and with echocardiography and bloods. Bilateral protein-poor effusions with signs of heart failure makes it worthwhile.
3. Pleural aspiration and Light's criteria correct Correct. The criteria separate a transudate from an exudate, and here they confirm a transudate, which directs treatment at the cause rather than the pleura.
4. Chest radiograph Shows the effusion as blunting of the costophrenic angle and a meniscus, and estimates the size. Bilateral protein-poor effusions with signs of heart failure makes it first.
5. Pleural fluid pH A pH below 7.2 in an infective effusion indicates a chest drain. Bilateral protein-poor effusions with signs of heart failure makes it decisive.

The point: A pleural effusion gives breathlessness, a stony dull percussion note, reduced breath sounds and reduced vocal resonance over the fluid. Aspirate and apply Light's criteria to separate a transudate from an exudate: it is an exudate if the pleural fluid protein to serum protein ratio is over 0.5, the pleural fluid LDH to serum LDH ratio is over 0.6, or the pleural fluid LDH is over two-thirds the upper limit of normal serum LDH. Transudates come from heart failure, cirrhosis and nephrotic syndrome and are treated by treating the cause. Exudates come from infection, malignancy, pulmonary embolism and inflammation, and they need investigation. Send the fluid for protein, LDH, pH, glucose, cytology, microscopy and culture. A pH below 7.2 in an infective effusion means an empyema or a complicated parapleural effusion needing a chest drain. A bloody effusion suggests malignancy, and pus means an empyema.

Source: BTS Pleural Disease Guideline British Thoracic Society · tier 2, specialty society or college

A 68 year old man with known heart failure has increasing breathlessness. He has bilateral pitting oedema, a raised jugular venous pressure and stony dullness at both lung bases with reduced breath sounds. A chest radiograph confirms bilateral effusions. An aspirate shows a pleural fluid protein to serum protein ratio of 0.3 and a pleural LDH well below the exudate threshold. What is the SINGLE most appropriate immediate management?

1. Therapeutic aspiration or drainage for symptom relief Drains a large symptomatic effusion, removing no more than 1 to 1.5 litres at a time to avoid re-expansion oedema. Bilateral protein-poor effusions with signs of heart failure meets that.
2. Antibiotics for a parapneumonic effusion Alongside drainage where the effusion is complicated. Bilateral protein-poor effusions with signs of heart failure makes it necessary.
3. Pleurodesis or an indwelling pleural catheter for a recurrent malignant effusion To prevent reaccumulation and relieve symptoms. Bilateral protein-poor effusions with signs of heart failure makes it appropriate.
4. Treat the underlying cause of a transudate correct Correct. Diuresis and optimisation of the heart failure will resolve the effusion, because it is a consequence of the raised venous pressure.
5. Intrapleural fibrinolytics for a loculated empyema Where a drain alone does not clear a loculated collection. Bilateral protein-poor effusions with signs of heart failure makes it selective.

The point: A pleural effusion gives breathlessness, a stony dull percussion note, reduced breath sounds and reduced vocal resonance over the fluid. Aspirate and apply Light's criteria to separate a transudate from an exudate: it is an exudate if the pleural fluid protein to serum protein ratio is over 0.5, the pleural fluid LDH to serum LDH ratio is over 0.6, or the pleural fluid LDH is over two-thirds the upper limit of normal serum LDH. Transudates come from heart failure, cirrhosis and nephrotic syndrome and are treated by treating the cause. Exudates come from infection, malignancy, pulmonary embolism and inflammation, and they need investigation. Send the fluid for protein, LDH, pH, glucose, cytology, microscopy and culture. A pH below 7.2 in an infective effusion means an empyema or a complicated parapleural effusion needing a chest drain. A bloody effusion suggests malignancy, and pus means an empyema.

Source: BTS Pleural Disease Guideline British Thoracic Society · tier 2, specialty society or college