Respiratory[autotexts]

Pleural disease / Consultation template

Undiagnosed unilateral pleural effusion

The workup in the order that avoids the two classic errors: draining before imaging, and sending too little fluid.

Fills in order
  1. 1Breathlessness, and over what period
  2. 2Chest pain, and whether pleuritic
  3. 3Cough and sputum
  4. 4Fever, night sweats, weight loss
  5. 5Orthopnoea, ankle swelling, known heart…
  6. 6Known malignancy, and treatment
  7. 7Asbestos exposure
  8. 8Smoking
  9. 9Recent surgery, immobility or thromboemb…
  10. 10Drug history, including anticoagulants a…
  11. 11Rheumatological or liver disease
  12. 12Recent travel and TB contact
  13. 13SpO2
  14. 14% on air, observations
  15. 15Side and estimated size
  16. 16Lymphadenopathy, clubbing, chest wall si…

and 24 more, in the block below.

Paste block 40 fields 
Unilateral pleural effusion, cause not yet established.

History:
Breathlessness, and over what period: []
Chest pain, and whether pleuritic: []
Cough and sputum: []
Fever, night sweats, weight loss: []
Orthopnoea, ankle swelling, known heart failure: []
Known malignancy, and treatment: []
Asbestos exposure: [job, years, and what was done]
Smoking: [pack-years]
Recent surgery, immobility or thromboembolism: []
Drug history, including anticoagulants and drugs causing effusions: []
Rheumatological or liver disease: []
Recent travel and TB contact: []

Examination:
SpO2 []% on air, observations []
Side and estimated size: []
Lymphadenopathy, clubbing, chest wall signs: []
Signs of heart failure, chronic liver disease or nephrotic syndrome: []

Imaging:
Chest x-ray: []
Thoracic ultrasound: [size, septations, echogenicity, pleural thickening,
diaphragmatic nodularity, safe site marked]
CT chest with contrast in the pleural phase, performed before full drainage:
[]

Pleural fluid:
Appearance: []
pH [] (measured on a blood gas analyser, not a dipstick)
Protein [] g/L, serum protein [] g/L
LDH [] U/L, serum LDH [] U/L
Glucose []
Light's criteria: [transudate or exudate]
Cytology sent, volume: [] mL
Microscopy, culture and sensitivity, including into blood culture bottles: []
Mycobacterial culture: []
Other: [amylase, triglycerides, cholesterol, haematocrit]

Blood tests:
Full blood count, renal, liver, bone profile, LDH, CRP: []
NT-proBNP: []
Autoantibodies if indicated: []

Impression:
[transudate with likely cause, or exudate with differential]

Plan:
1. [therapeutic aspiration, chest drain, local anaesthetic thoracoscopy,
image-guided pleural biopsy, or observation]
2. Volume drained and symptomatic response: []
3. Discussed at [pleural or lung cancer MDT] on []
4. Follow-up: [] with [repeat imaging or results]

How to use it

Two errors account for most of the diagnostic delay in this pathway. The first is draining the effusion completely before the CT: contrast-enhanced CT is much more informative with fluid still present, and once the chest is dry the chance to look for pleural nodularity has gone. The second is sending a token amount of fluid for cytology — send 25 to 50 mL. Measure pH on a blood gas analyser because it is the number that decides whether an infected effusion needs a drain, and a dipstick will not do. In someone with a known malignancy and a bilateral effusion or an obvious transudate, ask whether this needs a pleural workup at all before starting one.

Why it says that

None of this is in the copied text. It is here so you can check the block against its source, and change it when the source changes.

Trials behind it

  • TAPPS 2020 Talc poudrage at thoracoscopy was no better than talc slurry down a chest drain
  • MIST2 2011 Combined t-PA and DNase improved drainage and cut surgical referral; neither drug worked alone
  • MIST1 2005 Intrapleural streptokinase alone did not work, and caused more serious adverse events

Records on respiratorytrials.org.

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