Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast Episode 35: Pleural effusions with Dr. David Feller-Kopman
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Feb 17, 2017 Dr. David Feller-Kopman, an expert in pleural disease and director of Bronchoscopy at Johns Hopkins, dives deep into the world of pleural effusions. He explains what they are, how to classify them using Light's criteria, and the implications of exudate versus transudate for patient management. David advocates for the use of point-of-care ultrasound over traditional imaging methods. He also covers when to drain versus medically manage effusions, techniques for thoracentesis, and the role of indwelling catheters for malignancy.
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Pleural Physiology Explains Small Effusions
- The pleural space normally contains about a teaspoon of fluid per hemithorax and becomes an effusion when production exceeds resorption.
- Lymphatics can increase resorption ~28-fold, so even small detectable effusions indicate a major imbalance of production versus removal.
Light's Criteria Still Work — With Caveats
- Light's criteria (protein ratio >0.5, LDH ratio >0.6, or pleural LDH >2/3 ULN) remains the best tool to separate exudates from transudates.
- In diuresed CHF patients Light's criteria can misclassify transudates, so use serum-pleural albumin or protein gradients to confirm.
Prefer Ultrasound Over ICU Chest X‑Rays
- Use point-of-care ultrasound rather than ICU chest x-rays to screen for pleural effusions because x-rays in semi-upright patients are poor.
- Round with an ultrasound probe: effusions are common (up to ~40% in ICU) and scanning changes management.