pleural effusion

1. PLEURAL EFFUSSION
DR.Bilal Natiq Nuaman,MD
C.A.B.M.,F.I.B.M.S.,D.I.M.
2016-20171

2. Pleural Effusion
• Accumulation of fluid within the pleural space
when there is an imbalance between formation and
absorption in various disease states.
• The accumulation of frank pus is termed
empyema, that of blood is haemothorax, and that
of chyle is a chylothorax.
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Pulmonary embolic disease,
cardiac failure,
malignant pleural infiltration and
pneumonia (including TB).
are the four most important
conditions, which are responsible
for more than 90 per cent of
pleural effusions seen in clinical
practice.

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9. Classification
• Transudate- is an ultra filtrate of plasma, resulting
from increased hydrostatic pressure or decreased
serum oncotic pressure. An effusion with normal
pleura.
• Exudate- resembles plasma, and is rich in
proteins. Results from increased capillary
permeability. An effusion with diseased pleura.
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11. Transudative Pleural effusions
• Congestive heart failure
• Cirrhosis
• Nephrotic syndrome
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12. Exudative Pleural Effusions
➢ Neoplastic diseases
Metastatic disease
Mesothelioma
➢Infectious diseases
Bacterial infections
Tuberculosis
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13. Exudative Pleural Effusions
➢ Pulmonary embolism
➢ Collagen-vascular diseases
Rheumatoid pleuritis
Systemic lupus erythematosus
Drug-induced lupus
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Clinical features
The symptoms associated with the accumulation of fluid in the pleural
space depend upon
the cause,
volume and
rate of formation of fluid.
Small effusions are often symptomless, and even quite large effusions can
cause little disability, provided the fluid has accumulated slowly.
Effusions caused by inflammatory disease often present with pleuritic
pain, which may be relieved as the fluid accumulates.
Large effusions eventually cause symptoms including dry cough,
shortness of breath, initially on exercise and later at rest, together with
dull, aching discomfort over the affected side of the chest.

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Historical clues
• Trauma history suggests hemothorax
• Cancer history suggests malignant effusion
• Chronic hemodialysis suggests heart failure or uremic pleuritis
• Cirrhosis suggests hepatic hydrothorax.
•Dyspnea on exertion,orthopnea,peripheral edema:CHF
• Asbestos exposure suggests mesothelioma.
• HIV infection suggests pneumonia,TB,lymphoma,Kaposi’s sarcoma
• Rheumatoid arthritis suggests rheumatoid pleuritis
• Lupus suggests lupus pleuritis.

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Physical examination
The characteristic findings of stony dullness to
percussion and distant or absent breath sounds
are most prominent at the lung bases.
Bronchial breath sounds or aegophony may be
heard directly above an effusion.
Large effusions displace the mediastinum
towards the unaffected side unless the
underlying lung is fibrosed from previous
inflammation (tuberculosis) or collapsed due
to a proximal bronchial lesion.

17. Clues in the physical to the common etiologies
• Distended neck veins, an S3 gallop, or peripheral edema
suggests congestive heart failure.
• Unilateral leg swelling or thrombophlebitis and sinus
tachycardia suggests pulmonary embolus.
• The presence of lymphadenopathy or
hepatosplenomegaly suggests neoplastic disease.
• Ascites may suggest a hepatic cause, ovarian cancer.
• Signs of consolidation above the level of the fluid in a
febrile patient suggests parapneumonic effusion.
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• Yellowish nails, lymphedema suggest yellow nail syndrome

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INVESTIGATIONS Role Of Imaging
– Detection and the differential diagnosis are
highly dependent upon imaging of the pleural
space.
– conventional radiographic methods used are
frontal, lateral, oblique and decubitus
radiographs.
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19. CXR
OBLITERATION OF COSTOPHRENIC ANGLE
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On Lateral decubitus chest x-ray view
Minimum volume to diagnose pleural
effusion is 50 ml.

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On PA view Minimum volume to
diagnose pleural effusion is 250 ml.
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22. 500 mL will obscure the diaphragmatic
contour on an upright chest radiograph
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23. 1000 ml of effusion reaches the level of
the fourth anterior rib
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Massive pleural effusion > 2000 ml

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Malignancy is the most
common cause of
massive pleural effusions that
cause complete opacification
of one hemithorax

26. Role of CT scan
– Visualization of underlying lung
parenchymal processes that are obscured
on chest radiographs by large pleural
effusions
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29. Diagnostic thoracentesis
• Indicated if the effusion is clinically
significant with no known cause.
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Aspiration should not be performed for bilateral effusions
in a clinical setting strongly suggestive of a
transudate unless there are atypical features or they fail
to respond to therapy. All unilateral pleural effusions
require further investigation, starting with aspiration.

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32. Appearance of the fluid.
• Bloody- Cancer, PE, Trauma, Pneumonia in
that order
• Turbid- either due to cells or debris or a high
lipid level.
• Putrid odor- Anaerobic infection.
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33. Exudates Vs transudates
Light’s criteria
• Pleural fluid protein/serum protein >0.5
• Pleural fluid LDH/serum LDH >0.6
• Pleural fluid LDH more than two-thirds
normal upper limit for serum
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34. Further work up based on…
• Exudate or transudate.
• If transudative, rule out a diagnosis of congestive
heart failure, cirrhosis.
• If exudative send for total and differential cell
counts, smears and cultures for organisms,
measurement of glucose and lactate dehydrogenase
levels, cytologic analysis, and testing for a pleural-
fluid marker of tuberculosis.
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35. Total and Differential Cell Counts
• Predominance of neutrophils in the fluid >50%
indicates that an acute process is affecting the
pleura.
Common causes include
– parapneumonic effusions .
• Mononuclear cells like small lymphocytes >50%
indicates a chronic process.
– cancer or tuberculous pleuritis.
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36. Glucose Level
low glucose concentration (< 60 mg per dl)
indicates a complicated parapneumonic or a
malignant effusion, tuberculosis ,or rheumatoid
pleuritis.
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37. Fluid Tests for Cancer
– Cytology is a fast, efficient, and minimally invasive
– not routinely warranted in young patients with evidence
of acute illness.
– establishes the diagnosis in more than 70 percent .
– If cytology is negative – go for needle biopsy and
thoracoscopy
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38. Markers of Tuberculosis
• warranted if there is pleural fluid lymphocytosis.
Including:
– adenosine deaminase (>40 U/L) (99.6% sensitive and
97.1 % specific)) or
– Interferon (>140 pg/ml) comparable to ADA or
– the PCR for mycobacterial DNA – definitive for TB.
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40. Treatment
• Thoracentesis – Not more than 1 lt should be
removed at a sitting because of risk of pulmonary
edema.
• then treat underlying disease
Uncomplicated pneumonia – antibiotics
TB effusion – anti TB drugs
• Hemithorax involved/ empyema –chest tube
thoracostomy
• Malignant effusion- chest tube +/- pleurodesis
(sclerosants)
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41. Thank
you
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