A 65-year-old male smoker presented with left-sided chest pain and difficulty breathing for 2 weeks and was found to have a left pleural effusion secondary to tuberculosis based on symptoms, examination findings showing dullness and absent breath sounds on the left side, and imaging showing pleural effusion on the left.

1. • 65 years old Male, smoker came with left-
sided chest pain and increasing difficulty
breathing since 2 weeks. He reports having
fever and decreased appetite. He recalls being
treated for tuberculosis when he was a child.
He has a clear chest x-ray taken 15 years ago.
• On examination pallor present, trachea
shifted to the right, chest expansion
decreased on left side, dullness in the
mammary, infra axillary areas, absent breath
sounds in the same area.

2. • Pleural Effusion on the left side, secondary to
TB with anemia

3. Clinical Features
Symptoms
• Chest pain (pleurisy)
• Breathlessness
• Symptoms associated with the actual cause of
pleural effusion
– Pnemonia
– Renal disorder, Cardiac and liver disease
– TB
– Risk for thromboembolism
– Exposure to asbestos (occupation)

4. Signs
• Trachea shifted to opposite side
• Bulge ?
• Chest movements decreased
• Stony dullness
• Absent breath sounds. Above
effusion, crackles may be present.
• Decreased vocal resonance and fremitus on
same side
• Traubes space percussion and tidal percussion

5. ETIOPATHOGENESIS OF PLEURAL
EFFUSION

6. Normal Physiology
• Normally pleural space contains a thin layer of
fluid.
• Fluid enters the pleural space from the capillaries
in the parietal pleural and is removed by the
lymphatics in the parietal pleura.
• Fluid can also enter the pleural space from the
interstitial spaces of the lung via the visceral
pleura or from the peritoneal cavity through the
diaphragm.

7. PATHOGENESIS
• Pleural fluid accumulates when
Formation increases
Absorption decreases
• Pleural effusion can be
Transudative
Exudative

8. • Transudative effusion occurs commonly due to
systemic factors which either increase the
hydrostatic pressure or decrease the plasma
oncotic pressure.
• Exudative effusion occurs due to local
pathology in the lung or the pleura.

9. AETIOLOGY
• Transudative pleural effusion
– Congestive cardiac failure
– Cirrhosis
– Pulmonary embolism
– Nephrotic syndrome
– Peritoneal dialysis
– Myxoedema

10. Exudative Pleural Effusion
• Neoplastic diseases
– Metastatic diseases
– Mesothelioma
• Infectious diseases
– Pneumonia
– Tuberculosis
• Gastrointestinal diseases
– Pancreatic disease
– Esophageal perforation
– Intraabdominal abscess
– Diaphragmatic hernia

11. Exudative Pleural Effusion
• Collagen vascular diseases
– Rheumatoid arthritis
– SLE
– Drug-induced lupus
– Immunoblastic lymphadenopathy
– Sjogrens syndrome
– Wegener’s granulomatosis
– Churg-strauss syndrome
• Asbestos exposure
• Sarcoidosis
• Uremia
• Meigs’ syndrome

12. Investigations
Aaron John Mascarenhas
080201022

13. Radiological examination
Types of Pleural Effusion on X-ray:
1. Free fluid in the pleural space
a. Lamellar effusion
b. Subpulmonary effusion
c. Fissural effusion
2. Loculated effusion
3. Massive pleural effusion

14. Free fluid
1. First appears in the posterior CP angle (100-
200ml fluid): Lateral film
2. Meniscus sign:
– Dense homogenous opacity
– Well defined concave upper edge
– Higher laterally than medially
– Obscures the diaphragmatic shadow

15. Atypical distribution of fluid
• Lamellar effusions:
– Shallow collections between lung surface and visceral
pleural
– Represent interstial pulmonary fluid
• When large they form subpulmonary effusion
– Contour of diaphragm altered, apex shifted
– Blunting of CP angles and tracking into fissures
– Left: distance between gastric bubble and lung base
– Postural shifts in fluid

16. Loculated effusion
1. No change by gravitational methods
2. ?Extrapleural opacity, ?Peripheral lung lesion
Fissural effusion:
1. Lenticular, round or oval shadow
2. “Thickened” fissure
3. ‘Pseudo’ or ‘ Vanishing’ tumors?

17. Also look for?
1. Positioning?
2. Breast shadows?
3. Rib: Erosions, #
4. Trachea: Shift, Paratracheal shadows
5. Cardiac shadow
6. Lung fields: Cavity, “cotton wool” infiltrates,
Cannon ball mets
7. Hilum: Lymphadenopathy
8. Air-fluid level
9. Pleura: Masses, thickening.

18. Massive Pleural effusion
1. White out lung(WOL) + Contralateral
Mediastinal shift
D/D:
1. Collapse (WOL + Ipsilateral Mediastinal Shift)
2. Consolidation (WOL + Central trachea)

19. Ultrasonography
• Detects even 5ml of fluid in excess on normal
• Differentiation of pleural thickening from
loculated pleural effusion
• Associated abnormalities

20. Pleural aspiration and Analysis
Transudative or Exudative?
LIGHT’S CRITERIA:
1. Pleural fluid protein/Serum Protein >0.5
2. Pleural fluid LDH/Serum LDH >0.6
3. Pleural fluid LDH > 2/3rd the upper limit of
serum LDH

22. Tuberculous effusion
1. “Amber” coloured to sero-sanguineous
2. >10%eosinophils; <5%: Mesothelial cells
3. Centrifuged deposits:
– AFB +ve: <10% immunocompetent host
– Culture +ve: 25%
4. ADA elevated (>40U/L)
5. Others: LDH, Soluble IL-2 receptors, IFN-γ
6. Detection of Mycobacteria DNA by PCR
7. Nucleic acid amplification assays
8. Pleural biopsy: Non-caseating granulomas > 80%

23. MANAGEMENT OF PLEURAL EFFUSION
MEDICAL MANAGEMNT
Treatment of underlying cause
Therapeutic aspiration is necessary in order to
relieve dyspnoea
Precautions:
Removing more than 1L in one episode in inadvisable
Can result in re-expansion pulmonary oedema
Should never be aspirated to dryness before the exact
etiology is determined

24. THORACOCENTESIS
INDICATIONS
Diagnostic
therapeutic
POSITION
Sitting position, leaning forward over a support
SITE
 Below the scapula, posteriorly through the seventh
intercostal space

25. PROCEDURE
Informed consent
Clean the are with povidine
iodine
Local anesthesia
Insert the needle and flexible
catheter over the needle
Aspirate pleural fluid

26. COMPLICATIONS
Iatrogenic pneumothorax
Infection
Dry tap or bloody tap
Re-expansion pulmonary oedema
Pain and respiratory distress

27. Surgical Management
of Pleural Effusion

28. Effusion due to Heart Failure
• Most common cause of pleural effusion
• a diagnostic thoracentesis is done if:
– the effusions are not bilateral and comparable in size
– the patient is febrile
– the patient has pleuritic chest pain to verify that the effusion is
transudative
• Otherwise the patient's heart failure is treated
• If the effusion persists despite therapy, a diagnostic thoracentesis should
be done
• A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP)
>1500 pg/mL is diagnostic of an effusion secondary to congestive heart
failure

29. Parapneumonic Effusions
• most common cause of exudative pleural effusion (bacterial
pneumonias, lung abscess, bronchiectasis)
• The presence of free pleural fluid can be demonstrated with a lateral
decubitus radiograph, CT of the chest, or ultrasound
• If the free fluid separates the lung from the chest wall by >10 mm, a
therapeutic thoracentesis should be performed
• A procedure more invasive than thoracentesis is needed if the
following factors are present:
– Loculated pleural fluid
– Pleural fluid pH <7.20
– Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
– Positive Gram stain or culture of the pleural fluid
– Presence of gross pus in the pleural space

30. Parapneumonic Effusion
• If the fluid recurs after the initial therapeutic thoracentesis and if
any of these characteristics are present - a repeat thoracentesis
• If the fluid cannot be completely removed with the therapeutic
thoracentesis,
– insert a chest tube and instill a fibrinolytic agent (e.g., tissue
plasminogen activator, 10 mg)
– perform a thoracoscopy with the breakdown of adhesions
– Decortication (if these measures are ineffective)

31. Malignant Pleural Effusions
• 2nd most common type of exudative pleural effusion (lung carcinoma,
breast carcinoma, & lymphoma)
• Diagnosis: cytology of the pleural fluid
• If cytology is negative, thoracoscopy is done if malignancy is suspected
• Pleural abrasion should be performed to effect a pleurodesis
• Pleural abrasion: a scourer is used to scrape off the surface of parietal
pleura
• An alternative to thoracoscopy : CT- or ultrasound-guided needle
biopsy of pleural thickening or nodules
• Patients with a malignant pleural effusion are treated symptomatically
• Dyspnea if present and is relieved with a therapeutic thoracentesis,
one of the following procedures should be considered:
– insertion of a small indwelling catheter or
– tube thoracostomy with the instillation of a sclerosing agent such as
doxycycline, 500 mg

32. Chylothorax
• Occurs when thoracic duct is disrupted and chyle
accumulates in the pleural space.
• Thoracentesis shows milky fluid, and biochemical
analysis reveals a triglyceride level that exceeds
1.2 mmol/L (110 mg/dL)
• Treatment: insertion of a chest tube plus the
administration of octreotide
• If these measures fail, a pleuroperitoneal shunt
should be placed
• An alternative treatment is ligation of the thoracic
duct

33. Hemothorax
• Diagnostic thoracentesis shows bloody pleural fluid,
• Hematocrit :if >1/2 of that in the peripheral blood, the
patient is considered to have a hemothorax
• Treatment: tube thoracostomy ( helps quantify
bleeding)
• If the bleeding emanates from a laceration of the
pleura, apposition of the two pleural surfaces is likely
to stop the bleeding.
• If the pleural hemorrhage exceeds 200 mL/h, perform
thoracoscopy or thoracotomy