Pediatric emergency medicine trisk 704
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In pediatrics, the majority of effusions are exudative. Therefore, classification
focuses largely on whether pleural fluid collections are infectious or
noninfectious.
Goals of Treatment
The goals of treatment for patients with pleural disease are focused on rapidly
assessing and supporting respiratory function. Supporting oxygenation and
ventilation may be required passively or actively. Drainage is indicated for
therapeutic purposes in patients with respiratory compromise, and for diagnostic
purposes, including identification of likely etiology, including microbiology in
the case of infectious causes.
Clinical Considerations
Clinical Recognition
There exists a wide spectrum of conditions that lead to pleural inflammation (
Table 99.10 ). Infectious etiologies are most common and may include viruses
(e.g., Coxsackie virus, Epstein–Barr virus, herpes zoster), mycoplasma, bacteria
(e.g., S. aureus, Streptococcus pneumoniae, H. influenzae, group A streptococcus,
Mycobacterium
tuberculosis
),
and
fungi
(e.g.,
histoplasmosis,
coccidioidomycosis). Infections from pulmonary, subdiaphragmatic, or more
distant sites may all eventually involve the pleura. Neoplastic involvement may
also be primary or metastatic. When oncologic lesions obstruct the lymphatic
drainage, accumulation of pleural fluid can occur.
Medications including hydralazine and procainamide can also cause pleural
inflammation. PE may cause pleural inflammation with or without effusion as a
result of focal parenchymal necrosis. Trauma, both accidental and following
diagnostic and therapeutic procedures in the chest, can irritate the pleura and lead
to secondary infection. Pleuritis with or without effusion is seen in more than half
of patients who have a systemic vasculitis such as SLE or sarcoidosis.
TABLE 99.10
DIFFERENTIAL DIAGNOSIS OF PLEURAL EFFUSION
Transudative pleural effusions
Congestive heart failure
Cirrhosis
Nephrotic syndrome
Acute glomerulonephritis
Myxedema
Peritoneal dialysis
Hypoproteinemia
Meigs syndrome
Sarcoidosis
Vascular obstruction
Ex vacuo effusion
Exudative pleural effusions
Infectious diseases
Tuberculosis
Bacterial infections
Viral infections
Fungal infections
Parasitic infections
Neoplastic diseases
Mesotheliomas
Metastatic disease
Collagen vascular diseases
Systemic lupus erythematosus
Rheumatoid pleuritis
Pulmonary infarction/embolization
Gastrointestinal diseases
Pancreatitis
Esophageal rupture
Subphrenic abscess
Hepatic abscess
Whipple disease
Diaphragmatic hernia
Peritonitis
Trauma
Hemothorax
Chylothorax
Drug hypersensitivity
Nitrofurantoin
Methysergide
Miscellaneous diseases
Asbestos exposure
Pulmonary and lymph node myomatosis
Uremia
Postmyocardial infarction syndrome
Trapped lung
Congenital abnormalities of the lymphatics
Postradiation therapy
Drug reactions
Reprinted from Light RW. Pleural effusions. Med Clin North Am 1977;61:1339–1352. Copyright © 1977
Elsevier. With permission. See text for transudate/exudate criteria.
Triage
Patients with pleuritis often present with chest pain that may be severe.
Depending on the amount of pleural fluid, hypoxemia and significant respiratory
distress may be present. Promptly addressing pain and respiratory compromise is
a priority.
Initial Assessment/H&P
The hallmarks of pleural disease are chest pain, shortness of breath, fever, and in
many cases an abnormal CXR. Pain with respirations, or pleuritic chest pain, is
the most characteristic symptom with pleural inflammation, and may be localized.
Most patients also describe some degree of dyspnea. Additional symptoms vary
depending on the primary cause. In “dry” pleurisy, which is usually caused by a
minor pulmonary infection, the patient is often febrile with an irritating,
nonproductive cough. With oncologic etiologies, weight loss, night sweats, and
fatigue may be present.
On examination, the chest wall over the involved area may be tender, and a
coarse vibration may sometimes be appreciated on palpation. A pleural friction
rub is most apt to be heard when pleural inflammation is associated with little or
no effusion. The sound has been described as low pitched, sometimes with a
grating or squeaking quality. It has also been described as a “purring” noise. It is
usually loudest on inspiration, but often it may also be audible during expiration.
