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Approaches to pleural effusion

Dr Slayer
Dr Slayer

Pleural effusion occurs when there is an imbalance between the formation and absorption of fluid in the pleural space. This document outlines the classification, pathogenesis, etiologies, clinical features, diagnosis, and management of pleural effusions. Pleural effusions are classified as transudative or exudative based on the composition of the pleural fluid and the mechanism causing it. Diagnosis involves chest x-ray, ultrasound or CT scan followed by diagnostic thoracentesis of the pleural fluid. Management depends on the underlying cause but may include supportive care, antibiotics, diuretics, chest tube placement, or chemical pleurodesis.

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APPROACHES TO
PLEURAL EFFUSION
OUTLINES
INTRODUCTION
CLASSIFICATION
PATHOGENESIS
ETIOLOGY
CLINICAL FEATURES AND ASSESSMENT
DIAGNOSIS
MANAGEMENT
INTRODUCTION
Abnormal fluid accumulation in potential space
in between parietal and visceral pleurae – there
is imbalance between formation and
absorption in response to injury, inflammation
or both locally and systematically
What is pleural effusion?
INTRODUCTION
• More definitions:
• Parapneumonic effusion - Pleural effusion
associated with bacterial pneumonia,
bronchiectasis, or lung abscess
• Loculated effusion - Fluid anatomically confined
and not freely flowing in the pleural space when
there are adhesions between the visceral and
the parietal pleura .
CXR OF PLEURAL
EFFUSION
COMPOSITION
OF PLEURAL
FLUID

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Approaches to pleural effusion

  • 3. INTRODUCTION Abnormal fluid accumulation in potential space in between parietal and visceral pleurae – there is imbalance between formation and absorption in response to injury, inflammation or both locally and systematically What is pleural effusion?
  • 4. INTRODUCTION • More definitions: • Parapneumonic effusion - Pleural effusion associated with bacterial pneumonia, bronchiectasis, or lung abscess • Loculated effusion - Fluid anatomically confined and not freely flowing in the pleural space when there are adhesions between the visceral and the parietal pleura .
  • 7. INTRODUCTION The pleural space contains normally 0.3ml/kg body weight of pleural fluid - which is an amount not detectable on conventional chest radiographs , and is secreted from the parietal pleura into the pleural space where it is absorbed by the visceral pleural microcirculation Fluid accumulates in the pleural cavity due to either altered hydrostatic and oncotic pressures or altered permeability of the pleura
  • 8. CLASSIFICATIONS • Can be unilateral or bilateral A)Based on site • Apical • Interlobar • Sub-pulmonic • Mediastinal B)Based on mechanism and type of pleural fluid • Transudative • Exudative C) Based on mechanism and type of pleural fluid formed • Pyogenic • Chylous • Haemothorax • Pseudochylous • Hydrothorax • Urinothorax
  • 9. • Numerous disorders can lead to formation of a pleural effusion. Pleural effusions classically are divided into two groups—transudates and exudates—according to the composition of the pleural fluid
  • 10. PATHOGENESIS • Transudative pleural effusion - Alteration of hydrostatic and oncotic factors that increase the formation or decrease the absorption of pleural fluid (e.g., increased mean capillary pressure [heart failure] or decreased oncotic pressure [cirrhosis or nephrotic syndrome])
  • 11. EXUDATIVE EFFUSION Increased vascular permeability allows migration of inflammatory cells (neutrophils, lymphocytes, and eosinophils) into the pleural space The process is mediated by a number of cytokines such as interleukin IL-1, IL-6, IL-8, tumour necrosis factor (TNF)-alpha and platelet activating factor released by mesothelial cells lining the pleural space. The result is the exudative stage of a pleural effusion. This progresses to the fibro-purulent stage due to increased fluid accumulation and bacterial invasion across the damaged epithelium Neutrophil migration occurs as well as activation of the coagulation cascade leading to pro-coagulant activity and decreased fibrinolysis. Deposition of fibrin in the pleural space then leads to septation or loculation. The pleural fluid pH and glucose level falls while LDH levels increase
  • 13. CLINICAL FEATURES The underlying cause of the effusion usually dictates the symptoms, although patients may be asymptomatic. Pleural inflammation, abnormal pulmonary mechanics, and worsened alveolar gas exchange produce symptoms and signs of disease
  • 14. CLINICAL FEATURES • History : – Dyspnea – Pleuritic chest pain – Cough – Fever – Hemoptysis – Wt. loss – Trauma – Hx. of cancer – Cardiac surgery • Physical : – Dullness to percussion – Decreased breath sounds – Absent tactile fremitus – Other findings: ascites, JVP, peripheral edema, friction rub, unilateral leg swelling
  • 15. DIAGNOSIS • Acute phase reactants-white cell count, total neutrophil count, CRP, ESR, pro- calcitonin distinguish bacterial from viral causes Full blood count with differential count • X-ray chest PA view done in erect position-a total of 300mL of fluid is needed to diagnose pleural effusion clinically and radiologically • Even 50mL of fluid can be demonstrated radiologically in lateral decubitus Radiological examination
  • 16. FINDING IN CHEST X RAY • Obliteration of cardiophrenic and costophrenic angles • Loculated effusions • Subpulmonic effusion-collection of fluid below the diaphragm will lead to elevation of diaphragm, confirmed by X-ray in lateral decubitus • Lateral decubitus on side of effusion will show a shift in the fluid level • Tracheal and mediastinal shifts are seen in massive effusion
  • 18. DIAGNOSIS Role of CT scan Visualization of underlying lung parenchymal processes that are obscured on chest radiographs by large pleural effusions Very Sensitive Can distinguish between Lung Abscess & Empyema
  • 20. DIAGNOSIS Role of ultrasound Free vs loculated pleural effusions, and loculated effusions vs solid masses. Thoracentesis of loculated pleural effusions is facilitated by ultrasound marking or guidance. Helpful in Confirming the Presence of a Small Pleural Effusion
  • 22. DIAGNOSIS • Diagnostic pleural fluid aspiration • An unexplained pleural effusion requires further investigation. Unless required to rule out an immediately life-threatening condition such as empyema or hemothorax, pleural fluid evaluation may be deferred to an inpatient or outpatient setting • Diagnostic: Helps to differentiate between exudates and transudates • Therapeutic: • Massive collection or rapid collection of pleural fluid • Severe respiratory distress • Suspected empyema • Massive mediastinal shift
  • 24. DIAGNOSIS • Pleural fluid aspiration: transudative vs exudative
  • 25. DIAGNOSIS • Pleural fluid aspiration • Need to send for  Gross Appearance Cell Count & Differential Gm Stain, C & S Cytology LDH Protein Glucose, Amylase
  • 26. DIAGNOSIS Gross appearance • <1% is nonsignificant • 1-20% indicates either cancer, PE or trauma • >50% indicates hemothorax. Bloody :Hematocrit compared to the blood : • Turbid supernatant indicates high lipid levels • Check TG - >110mg/dl – chylothorax • If TG>50mg/dl and cholesterol>250 – pseudochylothorax Cloudy or Turbid – Centrifugation : Putrid odour – Stain and Culture = Bacterial
  • 31. MANAGEMENT Supportive treatment • Pneumonia- initial antibiotic treatment Medical treatment – treat the causes • • Cefuroxime • • Co-amoxiclav • • Penicillin & flucloxacillin • • Amoxicillin & flucloxaxillin • • Clindamycin A) Following community acquired pneumonia • • Broader spectrum antibiotics that cover aerobic gram negative rods B) Hospital acquired pneumonia
  • 32. MANAGEMENT 2. Tuberculosis- Category I treatment • 2HRZE+4HRE • Prednisolone 1-2mg/kg orally 4-6weeks promotes rapid absorption of the pleural fluid and prevents fibrosis 3. Congestive cardiac failure- treat with diuretics and other anti-failure medications
  • 33. MANAGEMENT Chest tube thoracentesis • Pneumothorax • Pleural fluid loculated • Recurrent Pleural effusion – malignancy • Effusion filling more than half the hemithorax • Air fluid level – Hydro/Pyopneumothorax • Pus in the pleural space – Empyema • Hemothorax/Chylothorax • Para pneumonic effusion • Positive stain for microorganisms • Positive pleural fluid cultures • Pleural fluid pH <7.2 • Pleural fluid glucose <60 mg/dL Indicated in:
  • 34. MANAGEMENT Chemical pleurodesis an effective therapy for recurrent effusions. This treatment is recommended in patients whose symptoms are relieved with initial drainage but who have rapid reaccumulation of fluid Talc slurry - Effective and inexpensive. Doxycycline or minocycline can also be instilled into the pleural space via a chest tube.

Editor's Notes

  1. Complicated parapneumonic effusion-invasive procedure ie chest tube insertion is necessary for resolution @ bacterial culture positive Sub-Pulmonic Effusion:accumulation of fluid between the lung & the diaphragm which gives the false impression of an elevated hemi-diaphragm