The document discusses pleural effusion, detailing its definition, signs and symptoms, diagnosis methods, and the differentiation between transudate and exudate types. It highlights common etiologies, diagnostic algorithms, and specific conditions associated with pleural effusions, such as heart failure, malignancies, and pneumonia. Additionally, it outlines the diagnostic criteria and tests necessary to determine the underlying causes and appropriate treatments for pleural effusions.

1. Pleural Effusion
Itamar Tzadok
Internal medicine department D
Kaplan medical center
18.02.2019

2. Outline
• Definition
• Signs and symptoms
• Diagnosis
• Transudate and exudate- selected etiologies
• Algorithm

5. Signs and symptoms
• Asymptomatic
• Dyspnea
• Cough (non-productive)
• Pleuritic chest pain
• In the effected side:
• Dullness to percussion
• Reduced chest expansion
• Reduced breath sounds

6. Signs and symptoms cont
Wong CL, et al. Does this patient have a pleural effusion? JAMA. 2009;301(3):309-317

8. Signs and symptoms – clues to etiology

9. Diagnosis
• Radiological verification
• Thoracentesis
• Gross appearance
• Transudate vs exudate
• Complimentary tests

10. Radiological verification
• Lateral decubitus
• Measurement of effusion
• Small- <1.5 cm
• Moderate- 1.5-4.5 cm
• Large- >4.5 cm
• More than 1cm can be tapped

11. Thoracentesis
• POCUS guided
• C/I:
• Hemodynamic instability
• Respiratory compromise
• Active skin infection
• Insufficient pleural fluid
• Coagulopathy (INR>2)
• Thrombocytopenia (<50k)

12. Light’s criteria
• Meeting one of the following- fluid = exudate
• Pleural fluid protein/serum protein >0.5
• Pleural fluid LDH/serum LDH >0.6
• Pleural fluid LDH more than two-thirds the normal upper limit for serum
• These criteria misidentify ~25% of transudates as exudates
• Serum-Pleural fluid protein gradient >31 g/L (3.1 g/dL) = transudate

13. Pleural effusion gross appearance

14. Pleural effusion complimentary tests
• Total protein + LDH
• Glucose levels
• Differential cell count
• pH
• Gram stain and culture
• TB markers
• Cytology

15. Transudate T

16. Effusion Due to Heart Failure
• Most common cause to pleural effusion
• When thoracentesis is indicated?
• Unilateral effusion or asymmetric effusions
• Febrile patient
• Pleuritic chest pain
• Persistent effusion after CHF therapy
• Diagnosis- pleural fluid N-terminal pro-brain natriuretic peptide
(NT-proBNP) >1500 pg/mL
T

17. Hepatic Hydrothorax
• 5% of patients with cirrhosis and ascites
• Usually right sided effusions
• Direct movement of peritoneal fluid
through defects in the diaphragm
T

18. Exudate E

19. Parapneumonic Effusion
• Most common cause of exudate
• History- bacterial pneumonia
• Complicated effusion = needs more than therapeutic thoracentesis
• Loculated pleural fluid
• pH <7.20
• Glucose <3.3 mmol/L (<60 mg/dL)
• Positive Gram stain / culture
• Gross pus (empyema)
E

20. Effusion Secondary to Malignancy
• 2nd most common cause of exudate
• 75% of cases:
• Lung CA
• Breast CA
• Lymphoma
• Diagnosis- cytology, thoracoscopy
E

21. Mesothelioma
• History- asbestos exposure
• Symptoms- pleuritic pain, dyspnea
• CXR- thickening of the pleura
• Diagnosis- biopsy
E

22. Effusion Secondary to Pulmonary
Embolization
• Almost always exudate
• Symptoms- pleuritic pain
• Diagnosis- spiral CT, CT-angio
E

23. Tuberculous Pleuritis
• Exudate
• Mechanism- hypersensitivity reaction to TB protein in the pleural space
• Symptoms- fever, weight loss, dyspnea, pleuritic chest pain
• Diagnosis-
• lymphocytic-to-neutrophil ratio >0.75*
• TB markers= adenosine deaminase, interferon γ
• Culture
• Pleural biopsy
E

24. Chylothorax
• Gross appearance- white milky fluid
• Etiologies-
• post thoracic surgery
• Mediastinal tumor
• Diagnosis- ↑triglyceride level in pleural fluid
• Treatment- chest tube + octreotide
E

25. Hemothorax
• Gross appearance- white milky fluid
• Etiology-
• Trauma
• Vascular tumor
• Diagnosis- pleural fluid Hct ≥ 0.5 peripheral blood Hct
• Treatment- tube thoracostomy
E

26. Drug-induced pleural disease
• 91 documented drugs
• Mentioned in Harrison 20th ed:
• Nitrofurantoin
• Dantrolene
• Methysergide
• Bromocriptine
• Procarbazine
• Amiodarone
• Dasatinib
E

27. Meigs' syndrome
• Ascites
• Pleural effusion
• Benign ovarian tumor
E

28. Yellow nail syndrome (YNS)
• Rare syndrome
• “Primary lymphedema associated with yellow nails and pleural effusion”
• Adults
• Pleural effusions
• Lymphedema
• Yellow dystrophic nails
E

31. Recap
• CXR + decubitus = first step in diagnosis
• Light’s criteria
• Unilateral effusion + no history of pneumonia => malignancy
• Bilateral effusion- usually cardiac/renal/hepatic problem => treat
underlying condition
• Exudate without findings in preliminary evaluation=> suspect PE

32. Recap cont.
• Common causes to transudate:
• CHF
• Cirrhosis
• Common causes to exudate:
• Malignancy
• Parapneumonic effusions
• TB
E
T

33. Thank you!
Questions?