This document provides information on pleural effusion, including its definition, causes, classification, pathogenesis, clinical features, investigations, and management. A pleural effusion occurs when there is excess fluid in the pleural space between the lungs and chest wall. Effusions are classified as transudative or exudative based on the fluid characteristics. Common causes include infections, malignancies, heart failure, and kidney or liver diseases. Investigations include chest x-rays, thoracentesis, and biochemistry of pleural fluid. Management involves treating the underlying cause, relieving symptoms, and procedures like chest tube drainage or pleurodesis for recurrent effusions.

1. Shree sahAjanand institute of nursing,
PLEURAL EFFUSION
Presented by
Mr. AKRAM KHAN
M.S.N. (HOD)
ASST. PROFESSOR
SSIN, BHAVNAGAR

2. Introduction
• Normally, 10-20 mL of fluid is
spread thinly over the visceral and
parietal pleurae.
• The fluid is similar in composition to
plasma except that it is lower in
protein (< 1.5 g/dL).
• Incidence – 1 million cases per year
• Prevalence – 320/100,000 in
industrialised countries.

3. DEFINITION
• A pleural effusion is present when
there is an excess quantity of fluid in
the pleural space (space lies between
the lung and chest wall and normally
contains a very thin layer of fluid,
which serves as a coupling system).

4. AETIOLOGY
• In the normal pleural space, there is a steady state
in which there is a roughly equal rate of the
formation (entry) and absorption (exit) of liquid
• This balance must be disturbed in order to produce
a pleural effusion.
• It is likely that both mechanisms contribute to
effusion formation for the following reasons
• An isolated increase in entry rate, unless massive,
is unlikely to cause effusion because the absorbing
pleural lymphatics have a large reserve capacity to
deal with excess pleural liquid. 20 times
• An isolated decrease in exit rate is also unlikely to
cause effusions because the normal entry rate is
low.

5. CLASSIFICATION
• Classified into unilateral or bilateral
• Into transudative and exudative.
• Causes of bilateral effusion
– Hypoproteinemia
– Connective tissue diseases
– CCF

6. TRANSUDATE
• Due to systemic factors
• Transudates are due to an imbalance
between hydrostatic and oncotic
pressures .
• -Incr. Hydrostatic factors(pleural
fluid)
• -decr. Osmotic pressure(plasma)
• -decr. Oncotic pressure(plasma)

7. AETIOLOGY OF TRANSUDATIVE
• Nephrotic syndrome
• CCF
• Liver cirrhosis
• Myxedema
• SVC Obstruction
• Hypoproteinemia – malnutrition,
malabsorption
• Biliothorax
• Peritoneal dialysis

8. EXUDATE
• Due to local factors
• Change in pleural surface permeability
• -Incr. microvascular permeability- protein
leakage
• -Injury to adjacent lung tissue
• Exudates are secondary to a disturbance of
the systems regulating pleural fluid
formation and absorption/drainage (as in
bacterial, viral, or fungal infection,
rheumatologic disease, or malignancy).

9. AETIOLOGY OF EXUDATIVE
– TB, pneumonia, fungal
– Pulmonary embolism
– Malignancy-lung cancer,breast ca, lymphoma, metastatic
– Hemothorax
– Lymphatic obstruction
– Ureamia
– CT dse- SLE, rheumatoid arthritis
– Meig’s syndrome (triad of ovarian tumour w ascites and p effusion)
– Asbestos exposure
– Radiation
– Drugs- nitrofurantoin, phenytoin, methotrexate, amiodarone.
– Trauma
– Sarcoidosis
– Subdiaphragmatic abscess
– Acute pancreatitis

10. • Exudative pleural effusions meet at least one of
the following criteria, whereas transudative
pleural effusions meet none of these ratios
• 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
• If one or more of the exudative criteria are met
and the patient is clinically thought to have a
condition producing a transudative effusion, the
difference between the protein levels in the serum
and the pleural fluid should be measured. If this
gradient is greater than 31 g/L (3.1 g/dL), the
exudative categorization by the above criteria can
be ignored because almost all such patients have a
transudative pleural effusion.

11. PATHOGENESIS
• INCREASED FLUID ENTRY
• -Increase in permeability
• -Increase in microvascular
pressure
• -Decrease in pleural pressure
• -Decrease in plasma osmotic
pressure

12. DECREASED FLUID EXIT
• -Intrinsic factors
• -Cytokines & prod. of inflame
• - endotoxins
• - Endocrine abnormalities
• -hypothyroidism
• -Injury due to radiation /chemo
• -Infiltration of lymphatics by cancer
• -Anatomic abnormalities
• -yellow nail syndrome (reduced lymphatic drainage)

13. DECREASED FLUID EXIT
• -Extrinsic factors
• Limitation of respiratory motion- diaphragm
paralysis
• Extrinsic compression of lymphatics- pleural
fibrosis,
• Blockage of lymphatic stomata - pleural
malignancy
• Decreased intrapleural pressure -fibrous rind on the
visceral pleura
• Increased systemic venous pressure – decr.
lymphatic flow
• Decreased liquid availability - pneumothorax

14. CLINICAL FEATURES
• Symptoms
• -Dyspnea(most common) - because of distortion of
diaphragm and chest wall during resp more than from
hypoxemia
• -mild, nonproductive cough.
• -pleuritic chest pain
• - chest wall splinting(stiffening of body part to avoid
pain)
• -tachypnea esp with lung compression or more severe
infxn.
• -Fever
• -hemoptysis
• -Constitutional features ( wt loss, myalgia, general
malaise, headache)

15. Cont….
• Other symptoms may suggest the etiology
of the pleural effusion.
– More severe cough or production of purulent
or bloody sputum suggests an underlying
pneumonia or endobronchial lesion.
– Constant chest wall pain may reflect chest
wall invasion by bronchogenic carcinoma or
malignant mesothelioma.
– Pleuritic chest pain suggests either pulmonary
embolism or an inflammatory pleural process.
– Systemic toxicity evidenced by fever, weight
loss, and inanition suggests empyema.

16. Cont……• SIGNS
• -Resp distress( FAN, ICR, SCR, use of acces muscles)
• -Decr. Chest movement. Decreased motion of the
hemithorax
• -Trachea shifted to opp. Side (mostly if massive more
than 1000ml)
• -Tenderness
• -Tactile fremitus decr
• -Stony dullness
• -Diminished or absent breath sounds
• -Vocal fremitus decr.
• - Basal crepitations
• -Friction rub
• -Egophony (E-to-A change)

17. INVESTIGATIONS
• Chest x-ray –PA-Lateral
– Homogenous opacities with meniscus
– Blunting of the costo-phrenic angle
– Incr. upper lung field vasculature
– Mediastinal shift if large unilateral (>1000ml)
• CT scan of chest – mass,
• Pleural biopsy
• Thoracocentesis - pleural tap
• Thoracoscopy (provides direct view of both
parietal and visceral aspects of pleura)

18. Massive right-sided pleural effusion (white area) in a
patient presenting with lung cancer

19. CT scan of chest showing left sided pleural effusion. Effusion
fluid often settles at the lowest space due to gravity; here at the
back as the patient is lying under scanner

20. Contraindication to Pleural tap (relative)
• - Low volume of effusion <1cm thickness on
lateral decubitus Xray
– Bleeding diathesis or systemic anticoagulation
– Mechanical ventilation
– Cutaneous disease over the puncture site

21. COMPLICATIONS
– pain at site
– Spleen/liver puncture
– Pneumothorax -Use of needles larger
than 20 gauge increases the risk
– Cutaneous or internal bleeding

22. Pleural tap
Colour
• -pale yellow/straw-transudate
• -hrrghic-malignancy, trauma, TB,
• -milky/whitish-chylothorax
• -Brown-long standing hrrg(amoebic liver abscess)
• -Black- aspergillosis
• -Yellow green –arthritis
• -Dark green- biliothorax
• Fluid may be clear yellow (serous), milky
(chylous), blood-tinged (serosanguineous), grossly
bloody (sanguineous), or translucent or opaque and
thick (purulent).

23. – Character
presence of pus (empyema)
• -viscous(mesothelioma)
• -Debris (rheumatoid arthritis)
• -Turbid (inflamm. conditions)

24. Biochemistry (lights criteria)
• - All exudates evaluated for amylase
level, differential cell count,
glucose level.
• -Culture & sensitivity
• -Microbiology -Gram stain
• -ZN stain (TB)

25. • Cytology (Tumour markers: CEA,VIM)
– Pleural fluid lymphocytosis, with lymphocytes greater
than 85% of the total nucleated cells, suggests
tuberculosis (TB), lymphoma, sarcoidosis, chronic
rheumatoid pleurisy, yellow nail syndrome, or
chylothorax. Pleural lymphocytes of 50-70% of the
nucleated cells suggests malignancy.
– Pleural fluid eosinophilia, with eosinophils greater than
10% of nucleated cells, is seen in hydropneumothorax,
hemothorax, pulmonary infarction, benign asbestos
pleural effusion, parasitic disease, fungal infection,
drugs, and malignancy.
– Mesothelial cells are found in variable numbers in most
effusions, but their presence at more than 5% of total
nucleated cells makes a diagnosis of TB unlikely.
– Markedly increased numbers of mesothelial cells,
especially in bloody or eosinophilic effusions, suggests
pulmonary embolism as the cause.

26. Difference between transudate and exudate
(Lights criteria)

27. Two-test rule
• - Pleural fluid cholesterol greater than 45 mg/dL
• - Pleural fluid LDH greater than 0.45 times the
upper limit of the laboratory's normal serum LDH
• Three-test rule
• - Pleural fluid protein greater than 2.9 g/dL
• - Pleural fluid cholesterol greater than 45 mg/Dl
• - Pleural fluid LDH greater than 0.45 times the
upper limit of the laboratory's normal serum LDH

28. Test required
• CBC
• ESR
• UEC-nephrotic syndrome
• LFT-liver cirrhosis
• Urinalysis
• ANA, RF
• Pleural biopsy
• Thoracoscopy
• Bronchoscopy

29. • Suspect TB pleuritis in patients with a history of exposure or a
positive purified protein derivative (PPD) finding and in
patients with lymphocytic exudative effusions, especially if
less than 5% mesothelial cells are detected on differential cell
counts.
– Because most tuberculous pleural effusions probably result from a
hypersensitivity reaction to the mycobacterium rather than from
microbial invasion of the pleura, acid-fast bacillus stains of pleural
fluid are rarely diagnostic (<10% of cases), and pleural fluid
cultures grow Mycobacterium tuberculosis in less than 65% of
cases.
– In contrast, the combination of histology and culture of pleural
tissue obtained by pleural biopsy increases the diagnostic yield to
90%.
– Adenosine deaminase (ADA) activity of more than 43 U/mL in
pleural fluid supports the diagnosis of TB pleuritis. However, the
test has a sensitivity of only 78%; therefore, pleural ADA values
less than 43 U/mL do not exclude the diagnosis of TB pleuritis.
– Interferon-gamma concentrations in pleural fluid greater than 140
pg/mL also support the diagnosis of TB pleuritis, but this test is not
routinely available.

30. • Measure pleural fluid amylase if a pancreatic
origin or ruptured esophagus is suspected or if a
unilateral left pleural effusion remains
undiagnosed after initial testing. An additional
assay of amylase isoenzymes can help distinguish
a pancreatic source from other etiologies.
• Measure triglycerides and cholesterol on milky
pleural fluids when chylothorax or
pseudochylothorax is suspected.
• Consider immunologic studies, including pleural
fluid antinuclear antibody and rheumatoid factor,
when collagen-vascular diseases are suspected.

31. Management
• Supportive
• -Supplemental oxygen
• -IV fluid hydration
• -Chest physiotherapy
• -Therapeutic/diagnostic thoracentesis
• -Antibiotics
• -Empirically by age/social
circumstances and modified by blood
and pleural effusion fluid culture
results

32. Definitive
• Treat underlying cause
• chest tube for continuous drainage
• pleuroperitoneal shunt and chemical pleurodesis
• Chemical pleurodesis -Doxycycline 500 mg,
• Bleomycin 60 IU
• TALC in a slurry(rarely used)
• Empyema: -Antibiotics alone with close monitoring in children
• Antibiotics with chest tube drainage in adults
• Pleurectomy - trapped lung (Excision of pleura, usually parietal)
• Pleural fluid deloculation (If unsuccessful, then either thoracoscopic
adhesiolysis or decortications via thoracotomy are indicated)
• Diuresis as appropriate for effusions secondary to congestive heart failure
and ascites
• May inject 250,000 units of streptokinase or 100,000 units of urokinase
intrapleurally to dissolve fibrin meshes creating loculation.

33. • Indication for chest tube
Recurrent pleural effusion
Empyema
Pneumothorax & hydrothorax
• Malignant pleural effusion
– Repeated effusions- pleurodesis

34. Indications for surgery
• 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
• the presence of gross pus in the
pleural space

35. • Thanks to all