The document discusses pleural effusion, which is the accumulation of fluid in the pleural space. Common causes include pneumonia, tuberculosis, pulmonary infarction, and malignant diseases. The fluid can be classified as a transudate or exudate based on biochemical analysis. Diagnosis involves chest x-ray, ultrasound, or CT scan to detect fluid levels. Diagnostic thoracentesis allows classification and identification of causative organisms if infected. Treatment focuses on draining large fluid volumes and addressing the underlying cause.

1. PLEURAL EFFUSION
Rana Shankor Roy

2. INTRODUCTION
 The accumulation of serous fluid within the
pleural space is termed pleural effusion.
 This fluid may be------
Water(Hydrothorax)
Blood(Hemothorax)
Chyle(Chylothorax)
Pus(Pyothorax or Empyema)

3. PLEURAL FLUID
 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.

4. PLEURAL EFFUSION

5. WHAT ARE THE CAUSES?
 Common causes are—
Pneumonia
TB
Pulmonary Infarction
Malignant disease
Cardiac failure
 Uncommon causes are---
Hypoproteinaemia(NS, Liver failure)
CT disease(SLE, RA)
Acute Rheumatic fever
Meig’s syndrome(With ovarian tumor & Ascites)

6. CAUSES ACCORDING TO AGE
 Young:
Pulmonary TB,
Para-pneumonic
 Middle aged or elderly:
Pulmonary TB,
Para-pneumonic
Bronchial carcinoma

7. CAUSES ACCORDING TO SIDE PREDOMINANT
 Right:
Liver abscess
Meig's syndrome
Dengue hemorrhagic fever
 Left:
Acute pancreatitis
RA

8. TYPE
 Transudative (Protein<3gm/dl), due to decreased oncotic
pressure or elevated hydrostatic pressure ------
CCF
NS
Cirrhosis of liver
Hypoproteinaemia
Meig’s syndrome
 Exudative (Protein>3gm/dl), due to increased capillary leak and
diminished fluid resorption --------
Pulmonary TB
Para-pneumonic effusion
Bronchial carcinoma
SLE, RA
Acute pancreatitis

9. 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 >
0.5
• Pleural fluid LDH : serum LDH ratio > 0.6
• Pleural fluid LDH > two-thirds of the upper
limit of normal serum LDH

10. CASE PRESENTATION
 Asymptomatic until it is large enough to
cause respiratory compromise.
 Breathlessness, particularly on exertion.
 Chest pain(Due to pleurisy) on inspiration
and coughing.
 According to cause( Cough, Fever, Sputum,
Weight loss, Hemoptysis)

11. WHAT YOU EXPECT IN PHYSICAL EXAMINATION?
 Inspection:
Restriction of movement in affected side.
 Palpation:
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:
Percussion note is stony dull in affected side.
 Auscultation:
Breath sound diminished or absent in affected side.
Vocal resonance is also diminished or absent in affected side.

12. DEFINITIVE SIGNS
 Reduced or absent breath sound
 Stony dull percussion note.

13. INVESTIGATIONS
 Imaging:
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

14. INVESTIGATIONS
 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
effusion.
iv) A low pH suggests infection but may also be
seen in rheumatoid arthritis, ruptured oesophagus
or advanced malignancy.

15. BED SIDE CONFIRMATION
 By needle aspiration

16. HOW TO ESTABLISH AETIOLOGY OF EFFUSION

17. PLEURAL EFFUSION

18. D/D
 Thickened pleura.(No medistinal shifting,
dullness impaired)
 Mass lesion.

19. MANAGEMENT
 Therapeutic aspiration:
required to palliate breathlessness but
removing more than 1.5 L at a time is
associated with a small risk of re-expansion
pulmonary oedema.
 Treatment of the underlying cause.

20. IF CLINICALLY PLEURAL EFFUSION BUT NO FLUID
ON ASPIRATION. CAUSES ARE-----
 Fluid may be thick(Empyema).
 Thickened pleura.
 Mass lesion