Sun28November0333PM 48

A 59-year-old painter and decorator comes to the acute medical unit complaining of a persistent cough, lethargy and increasing shortness of breath. He is a long term smoker. Over the past two months he has noticed a heavy, dull boring pain in his left chest and ribs.

Examination reveals reduced air entry to the left mid hemithorax with saturations of 96% on air. He is able to talk in full sentences but quickly becomes breathless on mobilising short distances.

The chest radiograph shows a moderate to large pleural effusion on the left hand side.

What would be the best management step at this point?

(Please select 1 option)

Ultrasound guided diagnostic pleural tap, with repeat tap if first sample negative on cytology Incorrect answer selected

Ultrasound guided therapeutic pleural tap This is the correct answer

CT thorax for possible malignancy

Ultrasound guided diagnostic pleural tap

Ultrasound guided Seldinger chest drain and possible talc pleurodesis

Explanation

This vignette is consistent with lung malignancy. However, malignancy cannot be confirmed without obtaining a specimen or seeing a suspected mass on imaging.

A CT thorax at this stage may not be able to visualise the area under the fluid and so could miss a mass. A diagnostic tap may be helpful but does not help the patient. A chest drain will help relieve the breathlessness but if the fluid analysis returns negative further opportunities to investigate the pleural effusion will be lost.

Pleural fluid can detect malignancy in 60% of cases. Sending a repeat sample does not tend to increase the yield and should be avoided. A therapeutic aspiration can remove approximately 1 litre of fluid to relieve breathlessness whilst keeping some of the effusion in the chest cavity.

If the fluid analysis is not helpful, a thoracoscopy would then be indicated to investigate the symptoms. Once the fluid is removed a staging CT would be the next step.

Reference:

British Thoracic Society. Pleural Disease Guideline.

Answer Statistics

1

17%

2

33%

3

28%

4

19%

5

5%

Times answered: 282