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Rana Shankor Roy
The accumulation of serous fluid within the
pleural space is termed pleural effusion.
This fluid may be------
Pus(Pyothorax or Empyema)
Normal fluid in pleural space: 5-15ml.
At least 500ml fluid need to detect clinically.
At least 300ml fluid need to detect
radiologically in PA view.
At least 100ml fluid need to detect
radiologically in Lateral decubitus position.
Less than 100ml or small fluid can be
detected by USG.
WHAT ARE THE CAUSES?
Common causes are—
Uncommon causes are---
Hypoproteinaemia(NS, Liver failure)
CT disease(SLE, RA)
Acute Rheumatic fever
Meig’s syndrome(With ovarian tumor & Ascites)
CAUSES ACCORDING TO AGE
Middle aged or elderly:
CAUSES ACCORDING TO SIDE PREDOMINANT
Dengue hemorrhagic fever
Transudative (Protein<3gm/dl), due to decreased oncotic
pressure or elevated hydrostatic pressure ------
Cirrhosis of liver
Exudative (Protein>3gm/dl), due to increased capillary leak and
diminished fluid resorption --------
LIGHT’S CRITERIA: TRANSUDATE VS. EXUDATE
Exudate is likely if one or more of the following
criteria are met:
• Pleural fluid protein : serum protein ratio >
• Pleural fluid LDH : serum LDH ratio > 0.6
• Pleural fluid LDH > two-thirds of the upper
limit of normal serum LDH
Asymptomatic until it is large enough to
cause respiratory compromise.
Breathlessness, particularly on exertion.
Chest pain(Due to pleurisy) on inspiration
According to cause( Cough, Fever, Sputum,
Weight loss, Hemoptysis)
WHAT YOU EXPECT IN PHYSICAL EXAMINATION?
Restriction of movement in affected side.
Incase of massive pleural effusion trachea & apex beat shifted
the opposite side.
Vocal fremitus reduced or absent in affected side.
Total chest expansibility reduced.
Percussion note is stony dull in affected side.
Breath sound diminished or absent in affected side.
Vocal resonance is also diminished or absent in affected side.
Reduced or absent breath sound
Stony dull percussion note.
i) Erect chest X-ray P/A view:
The classical appearance of pleural fluid on
the erect PA chest film is of a curved shadow
at the lung base, blunting the costophrenic
angle and ascending towards the axilla.
ii) USG of chest
iii) CT scan of chest
Pleural aspiration and biopsy:
i) The presence of blood is consistent with
pulmonary infarction or malignancy, but may
result from a traumatic tap.
ii) Biochemical analysis allows classification into
transudate and exudates
iii) Gram stain may suggest parapneumonic
iv) A low pH suggests infection but may also be
seen in rheumatoid arthritis, ruptured oesophagus
or advanced malignancy.
BED SIDE CONFIRMATION
By needle aspiration
HOW TO ESTABLISH AETIOLOGY OF EFFUSION
Thickened pleura.(No medistinal shifting,
required to palliate breathlessness but
removing more than 1.5 L at a time is
associated with a small risk of re-expansion
Treatment of the underlying cause.
IF CLINICALLY PLEURAL EFFUSION BUT NO FLUID
ON ASPIRATION. CAUSES ARE-----
Fluid may be thick(Empyema).