Vancouver IM LMR

This week, Dr. Sudarshan Bala, current UBC Respirology fellow, provided us with a very helpful approach to pleural effusions—a common encounter on CTU!

Check out this link for the full slide deck.

Here are some key points from Dr. Bala’s helpful session:

• Imaging modality to assess for pleural effusions:
  • Ultrasound is the most sensitive modality for detecting pleural effusions when used by a skilled operator. CT chest with contrast is also quite sensitive and can provide additional information about complicated effusions.

• Light’s criteria is utilized for distinction between transduative vs. exudative effusion. Designed to be highly sensitive, Light’s criteria help ensure that exudative effusions are not missed:
  • Serum to pleural fluid albumin gradient can be used if you are suspecting a misclassified-exudative heart failure effusions

• Pearls on managing parapneumonic effusions:
  • Monitor radiographically if small
  • Prolonged antibiotics are needed
    • Simple parapneumonic: 1-2 weeks
    • Complicated parapneumonic: 2-3 weeks
    • Empyema: 4-6 weeks
  • Chest tube insertion if:
    • High risk of complex effusion -> pH < 7.2
    • Intermediate risk -> pH between 7.2-7.4 AND pleural LDH > 900
      • Especially if febrile, large effusion, pleural glucose <4, pleural enhancement, or septations on POCUS
    • If pH is not available, then use pleural glucose < 3.3mmol/L
  • Chest tube should be irrigated daily with 10-30ml of normal saline
  • For persistent effusions
    • Consider intrapleural lytics if minimal drainage or presence of loculations -> this should be discussed withh respirology first
    • Consider reinsertion of larger bore chest tube
    • Truly persistent effusions need VATS +/- decortication