Pleural Effusion e.c susp.

Congestive Heart Failure

Disusun Oleh :
Atika Damayanti, S.Ked
Agustya Dwi Ariani, S.Ked
Raisa Mahmudah, S.Ked
Hema Meliny Perangin-Angin, S.Ked
Precet!r : dr. Dedy "airus, S.P
SMF PENYAKIT DAAM !A"IAN P#M$N$$"I
%#MAH SAKIT #M#M A!D# M$E$EK
!ANDA% AMP#N"
&'()
1
I. PATIENT STAT#S
PATIENT IDENTITY
#nitial $ame : Mrs. K
Se% : &emale
Age : '( years !ld
$ati!nality : #nd!nesia )*a+anese,
Marital status : Married
Religi!n : #slam
Occuati!n : Merchant
-ducati!nal .ackgr!und : -lementary Sch!!l
Address : Pulau Seri.u Street, /andar 0amung
ANAMNESIS
1aken 2r!m : aut!anamnesis
Date : *une 3rd, 4(53
1ime : 53.(( m
6hie2 c!mlaint : 6hest ain
Additi!nal c!mlaint : Dry c!ugh, c!nstiati!n
Histor* of T+e Present Illness
Patient came t! the h!sital at May 35th, 4(53 with chest ain !n the right side since a week
ag!. 6hest ain aeared suddenly. 6hest ain was 2elt s! e%cruciating m!re!+er she had an
acti+ity. 1he ain als! getting w!rse when she was sleeing .ut getting .etter i2 she was
sitting. Patient als! c!mlained an intermitten dry c!ugh since !ne m!nth ag!. S!metimes,
c!ugh .eing acc!manied .y disneu. At night, she !2ten wake u .ecause she 2elt disneu
suddenly. She als! c!mlained c!nstiati!n since 5( days ag!.
2
Decreased aetite was claimed .y atient al!ng with decreased weight. A week ag! the
atient had underg!ne leural ungti!n !n the right ulm!. A2ter that, the atient 2elt .etter
until came !ut the h!sital. 1he hist!ry !2 taking ' m!nths drug ackage !r 2amily illness with
the same symt!m was denied. Hist!ry !2 Hyertensi!n was ar!+ed .ut she seld!m
c!ntr!led t! a d!ct!r. Hist!ry !2 Dia.etes Melitus was denied.
T+e Histor* of Illness ,
)-, Small !% )-, Malaria )-, Kidney st!ne
)-, 6hicken !% )-, Disentri )-, Hernia
)-, Di2thery )-, Heatitis )-, Pr!stat
)-, Pertusis )-, 1i2usA.d!minalis )-, Melena
)-, Measles )-, Skir!2ula )-, Dia.etic
)., #n2luen7a )-, Sihilis )-, Alergy
)-, 1!nsilitis )-, 8!n!re )-, 1 u m! r
)-,
,
Kh!lera ).,
,
Hiertensi!n. )-,
,
9askular Disease
)-,
Acute Rheumat!id &e+er
)-, 9entrikuli :lcer )-,
Oerati!n
)-,
,
Pneum!nia )-,
,
Du!deni :lcer
)-,
,
Pleuritic )-,
,
8astritis
)-, 1u.erkul!sis )-, 8all.ladder st!ne !thers :
Fa/il*0s 1iseases Histor*,
6!nnecti!n
Age
)years,
Se% Healthy
6ause !2 Death
8rand2ather unkn!wn Male Death :nkn!wn
8randm!ther unkn!wn &emale Death unkn!wn
&ather unkn!wn Male Death unkn!wn
M!ther unkn!wn &emale Death unkn!wn
Sister unkn!wn &emale Health
6hildren 3; Male Health
6hildren 3( &emale Health
3
#s there any 2amily wh! su22er :
#llness <es $! 6!nnecti!n
Alergy

Asthma
1u.erkul!sa

Arthritis

Rematisme

6!r

Kidney
SYSTEM ANAMNESE
$!te !2 P!siti+e 6!mlains .eside the title
Skin
)-, /!il )-, Hair )-, $ight sweat
)-, $ail )-, <ell!w =>erus )-, 6yan!tic
)-, Others
Head
)-, 1rauma )-, Headache
)-, Sync!e )-, Pain !2 the sinus
-ar
$!se
)-, 1rauma )-, 6l!gging
)-, Pain )-, $!se dis!rders
)-, Sekret )-, c!mm!n c!ld
)-, -istaksis
4
)-, Pain )-, 1initus
)-, Secret )-, -ar dis!rders
)-, Dea2ness
M!uth
)-, 0i )-, 1!ngue
)-, 8ums )-, M!uth dis!rders
)-, Mem.rane )-, St!matitis
1hr!at
)-, 1hr!at ain )-, 9!ice )change,
$eck
)-, Pr!truding )-, $eck ain
6!r = 0ung
)?, 6hest ain )?, Dysnea
)-,
Pulse
)-, Hem!t!e
)?,
,
Ort!n!e )?, 6!ugh
A.d!men )caster = intestine,
)-, Pu22ing )-, Acites
)-, $ausea )-, Hem!r!id
)-, -mesis )-, Diarrhea
)-, Hematemesis )-, Melena
)-, Dis2agi )-, Pale c!l!ur !2 2eses
)-, 6!lic )-, /lack c!l!ur !2 2eses
)-, $!dul
:r!genital
)-, Dysuria )-, Pyuria
)-, Stranguria )-, K!lik
)-, P!lyuria )-, Oliguria
)-, P!lakysuria )-, Anuria
)-, Hematuria )-, :rine retenti!n
)-, Kidney st!ne )-, Dri urine
)-, >et the .ed )-, Pr!stat
Katamenis
5
)-, 0euk!rh!e )-, /leeding
)-, Other
Muscle and neur!n
)-, Anestesi )-, Hard t! .ite
)-, Parestesi )-, Ataksia
)-, >eak muscle )-, Hi!=hier-estesi
Sync!e
)-, 6!n+ulti!n )-,
)-, A2asia )-, 1ick
)-, Amnesis )-, 9ertig!
)-, Others )-, Disartri
-%tremities
)-, -dema )-, De2!rmitas
)-, Hinge ain )-, 6yan!tic
2eig+t
A+erage weight )kg, : unkn!wn
height )cm, : 5@A cm
Present weight )kg, : ;5 kg
)i2 the atient d!esnBt kn!w certainly,
)-, Steady
),D!wn
)-, :
THE HIST$%Y $F IFE
6
/irth lace
in h!me )- , matrinity ) -, Matrinity h!sital
Heled .y
1raditi!nal matrinity ) -, D!ct!r ) -, nurse ) -, Others
I/unitation Histor* 3unkn!wn,
)-,Heatitis )-, /68 )-, 6amak )-, DP1 )-, P!li!1etanus
Foo1 Histor*
&rekuensi=day : 3%=day
Am!unt =day :5 late=eat )health,
9ariati!n =day : Rice, +egeta.les, 2ish
Aetite : decrease
E1ucational
)C , SD )-, S01P )- , S01A ) , SMK ) , 6!urse Academy
Pro4le/
&inancial : 0!w
>!rks : merchant
&amily : 8!!d relati!n
Others : )-,
!o1* C+ec5 #p
7
8eneral 6heck u
Height : 5@A cm.
>eight : ;5 kg, #M1 : 5','
/l!!d Pressure : 5;(= D( mmHg
Pulse : E( %=minute
1emerature : 3' F6
/reath )2reGuenceHtye, : 4; %=m
$utriti!n c!nditi!n : less
6!nsci!usness : 6!m!s mentis
6ian!tic : )-,
8eneral edema : )-,
1he way !2 walk : $!rmal
M!.ility )acti+e=asi+e, : akti+e
1he age redicti!n .ased !n check u : '(
Mentalit* Aspects
/eha+i!r : $!rmal
$ature !2 2eeling : $!rmal
1he thinking r!cess : $!rmal
S5in
6!l!r : Oli+e
Kel!id : )-,
Pigmentasi : )-,
Hair 8r!wth : $!rmal
Arteries : 1!ucha.le
1!uch temerature : A2e.ris
Humid=dry : dry
Sweat : $!rmal
1urg!r : $!rmal
8
#cterus : Anicteric
&at layers : -n!ugh
-2l!resensi : )-,
-dema : )-,
Others : )-,
*/p+atic "lan1
Su.mandi.ula : n! enlargement
$eck : n! enlargement
Surakla+ikula : n! enlargement
Armit : n! enlargement
Hea1
&ace e%ressi!n : $!rmal
&ace symmetric : Symmetric
Hair : 8ray and .lack
1em!ral artery : $!rmal
E*e
-%!thalmus : )-,
-n!thalmus : )-,
Pale.ra : edema )-,=edema)-,
0ens : clear=clear
6!nIungti+a : anemis= anemis
9isus : n!rmal
Sklera : anicteric
Ear
9
Dea2nes : )-,
&!ramen : )-,
Mem.rane tymhani : intak
O.structi!n : )-,
Serumen : )-,
/leeding : )-,
0iGuid : )-,
Mout+
lis : )-,
1!nsil : )-,
Palatal : $!rmal
Hali.sts : $!
1eeth : )-,
1rismus : )-,
&arings : :nhieremis
0iGuid layer : Sali+a
1!ngue : $!t dirty
Nec5
*9P : n!t #ncrease
1ir!id gland : n! enlargement
0im2e gland : n! enlargement
C+est
10
Shae : simetric
Artery : $!rmal
/reast : $!rmal
ung
#nseksi : 0e2t : simetric, retracti!n )-,
Right : asimetric, retracti!n )-,
Palasi : 0e2t : +!kal 2remitus decreased, ain )-,
Right : +!kal 2remitus increase, ain )-,
Perkusi : 0e2t : s!n!r
Right : dullness
Auskultasi : 0e2t : +esicular n!rmal, crackles )?,, whee7ing )-,
Right : +esicular decrease, crackles )?,, whee7ing )-,
C o r
#nsecti!n : #ctus 6!rdis n!t seen
Palati!n : #ctus 6!rdis 2eel in line le2t mid cla+icula
Percussi!n : di22icult t! essess
Auscultati!n : Heart s!und 5 H 4 Regular , murmur )-,, gall! )-,
Arter*
Artery tem!ralis : $! a.errati!n
Artery kar!tis : $! a.errati!n
Artery .rakhialis : $! a.errati!n
Artery radialis : $! a.errati!n
Artery 2em!ralis : $! a.errati!n
Artery !litea : $! a.errati!n
11
Artery ti.ilias !steri!r : $! a.errati!n
Sto/ac+
#nsecti!n : c!n+e%
Palati!n
St!mach wall : undulati!n )-,, ain )-,
Heart : heat!megali )-,
0im2e : Slen!megali )-,
Kidney : .all!ttement )-,
Percuti!n : shi2ting dullness )-,
Auscultati!n : intestine s!unds )?,
"enital 34ase1 on in1ication6
Move/ent 7oint
Arm Right 0e2t
Muscle n!rmal n!rmal
1!nes n!rmal n!rmal
Mass n!rmal n!rmal
*!int n!rmal n!rmal
M!+ement n!rmal n!rmal
Strength n!rmal n!rmal
Others
Heel an1 leg
12
>!und=inIury : n!t 2!und
9arices : )-,
Muscle )t!nesH mass, : n!rmal
*!int : n!rmal
M!+ement : n!rmal
Strength=!wer : n!rmal
-dema : )-,
Others : )-,
%efle8s
Right 0e2t
1end!n re2le% n!rmal n!rmal
/ise n!rmal n!rmal
1rise n!rmal n!rmal
Pattela n!rmal n!rmal
Achiles n!rmal n!rmal
6remaster n!rmal n!rmal
Skin re2le% n!rmal n!rmal
Pat!l!gic re2le% n!t 2!und n!t 2!und
A!$%AT$%Y
13
%outine 4loo1
- H. : E,' gr =dl )$ : 53,@ J 5E grK ,
- -SR : 5;( mm=*am )$ : ( J 5( mm=Iam ,
- >/6 : @.;(( =mmL )$ : ;@(( J 5(.A((=ul ,
- Di22. 6!unt :
/as!2il : ( K ) ( - 5 K,
-usin!2il : ( K ) 5 - 3 K,
Stem : ( K )4 M ' K,
Segment : A@ K )@( M A( K,
0im2!sit : 4( K )4( M ;( K,
M!n!sit : @ K )4 M E K,
C+e/ical !loo1
S8O1 : 43 :=0
S8P1 : 55 :=0
:reum : 45 mg=dl
6reatinine : (,A mg=dl
/l!!d Sugar : D' mg=dl
Patolog* of Clinical 3on 9une :
t+
&'()6
Makr!sk!ik : Pleura 2luid yell!w c!l!red, clean
Mikr!sk!ik : t!tal sel @(( sel=ul, gluc!se '; mg=dl, r!tein ;,D gr=dl, chl!ride )-,, PM$
5K, M$ DDK, ri+alta test )-,, 0DH : 5(5 mg=dl, PH : E
cyt!l!gic analisis : n! malignancy
C+est ;-ra*
Pulm! : Radi!!aGue lung de%tra, multile n!dule lung sinistra.
%ES#ME
14
Patient came t! the h!sital at May 35th, 4(53 with chest ain !n the right side since a week
ag!. 6hest ain aeared suddenly. 6hest ain was 2elt s! e%cruciating m!re!+er she had an
acti+ity. 1he ain als! getting w!rse when she was sleeing .ut getting .etter i2 she was
sitting. Patient als! c!mlained an intermitten dry c!ugh since !ne m!nth ag!. S!metimes,
c!ugh .eing acc!manied .y disneu. At night, she !2ten wake u .ecause she 2elt disneu
suddenly. She als! c!mlained c!nstiati!n since 5( days ag!.
Decreased aetite was claimed .y atient al!ng with decreased weight. A week ag! the
atient had underg!ne leural ungti!n !n the right ulm!. A2ter that, the atient 2elt .etter
until came !ut the h!sital. 1he hist!ry !2 taking ' m!nths drug ackage !r 2amily illness with
the same symt!m was denied. Hist!ry !2 Hyertensi!n was ar!+ed .ut she seld!m
c!ntr!led t! a d!ct!r. Hist!ry !2 Dia.etes Melitus was denied.
2or5ing 1iagnose
Pleural e22usi!n caused .y Sus. 6!ngesti+e Heart &ailure
!asic Diagnose
Anamnesis :
chest ain, disneu, c!ugh
6linical checku :
# : symmetric,
P: +!kal &remitus +!cal dan taktil RN0
P: dullness=s!n!r
A: +esicular RO 0, crackles ?=?, whee7ing -=-
Su!rt checku :
RP th!ra% )&!rg!t t! take a +iew,
/ut the +iew su!rt t! leural e22usi!n
Differential 1iagnose
15
Pleural -22usi!n e.c Hyh!al.uminemia
Anamnesis : c!ugh, chest ain, and dysnea,
6linical checku :
# : Asymmetric,
P: +!kal &remitus +!cal dantaktil 0OR
P: dullness=s!n!r
A: +esicular 0NR
Su!rt checku :
R!ntgen : radi!!aG!2 lung de%tra
0a. : hyh!al.umin
Treat/ent Plan
5. 8eneral 1reatment
/ed rest
$utriti!n )high cal!ry, high r!tein,
Pleural Puncti!n
4. Secial 1reatment
Medicament!sa
#9&D R0 gtt55(= minute
6e2tria%!ne 5gr=54 h!urs
&ur!semide 4%;( mg
#s!s!r.id Dinitrat 3%@ mg
O/H 3% 6 #
9itamin /5/'/54 3%5 ta.
16
Support C+ec5 #p
- sutum ss
- -K8
Prognose
Qu! ad +itam : du.ia ad .!nam
Qu! ad 2uncti!nam : du.ia ad .!nam
Qu! ad sanati!nam : du.ia ad .!nam
17
Pleural Effusion
A. $vervie<
A leural e22usi!n is an a.n!rmal c!llecti!n !2 2luid in the leural sace resulting 2r!m
e%cess 2luid r!ducti!n !r decreased a.s!rti!n. #t is the m!st c!mm!n mani2estati!n
!2 leural disease, with eti!l!gies ranging 2r!m cardi!ulm!nary dis!rders t!
symt!matic in2lammat!ry !r malignant diseases reGuiring urgent e+aluati!n and
treatment.
A.(. Anato/*
1he leural sace is .!rdered .y the arietal and +isceral leurae. 1he arietal leura
c!+ers the inner sur2ace !2 the th!racic ca+ity, including the mediastinum, diahragm,
and ri.s. 1he +isceral leura en+el!s all lung sur2aces, including the interl!.ar
2issures. 1he right and le2t leural saces are searated .y the mediastinum.
1he leural sace lays an im!rtant r!le in resirati!n .y c!uling the m!+ement !2
the chest wall with that !2 the lungs in 4 ways. &irst, a relati+e +acuum in the sace
kees the +isceral and arietal leurae in cl!se r!%imity. Sec!nd, the small +!lume !2
leural 2luid, which has .een calculated at (.53 m0=kg !2 .!dy weight under n!rmal
circumstances, ser+es as a lu.ricant t! 2acilitate m!+ement !2 the leural sur2aces
against each !ther in the c!urse !2 resirati!ns.

1his small +!lume !2 2luid is maintained
thr!ugh the .alance !2 hydr!static and !nc!tic ressure and lymhatic drainage, a
distur.ance !2 which may lead t! ath!l!gy.
A.&. Etiolog*
1he n!rmal leural sace c!ntains ar!%imately 5 m0 !2 2luid, reresenting the
.alance .etween )5, hydr!static and !nc!tic 2!rces in the +isceral and arietal leural
18
+essels and )4, e%tensi+e lymhatic drainage. Pleural e22usi!ns result 2r!m disruti!n !2
this .alance.
Pleural e22usi!n is an indicat!r !2 an underlying disease r!cess that may .e ulm!nary
!r n!nulm!nary in !rigin and may .e acute !r chr!nic. Alth!ugh the eti!l!gic
sectrum !2 leural e22usi!n is e%tensi+e, m!st leural e22usi!ns are caused .y
c!ngesti+e heart 2ailure, neum!nia, malignancy, !r ulm!nary em.!lism. 1he
2!ll!wing mechanisms lay a r!le in the 2!rmati!n !2 leural e22usi!n:
Altered ermea.ility !2 the leural mem.ranes )eg, in2lammati!n,
malignancy,ulm!nary em.!lus,
Reducti!n in intra+ascular !nc!tic ressure )eg, hy!al.uminemia, cirrh!sis,
#ncreased caillary ermea.ility !r +ascular disruti!n )eg, trauma, malignancy,
in2lammati!n, in2ecti!n, ulm!nary in2arcti!n, drug hyersensiti+ity,
uremia, ancreatitis,
#ncreased caillary hydr!static ressure in the systemic and=!r ulm!nary circulati!n
)eg, c!ngesti+e heart 2ailure, sueri!r +ena ca+a syndr!me,
Reducti!n !2 ressure in the leural sace, re+enting 2ull lung e%ansi!n )eg,
e%tensi+e atelectasis, mes!theli!ma,
Decreased lymhatic drainage !r c!mlete .l!ckage, including th!racic duct
!.structi!n !r ruture )eg, malignancy, trauma,
#ncreased erit!neal 2luid, with migrati!n acr!ss the diahragm +ia the lymhatics !r
structural de2ect )eg, cirrh!sis, erit!neal dialysis,
M!+ement !2 2luid 2r!m ulm!nary edema acr!ss the +isceral leura
Persistent increase in leural 2luid !nc!tic ressure 2r!m an e%isting leural e22usi!n,
causing 2urther 2luid accumulati!n
1he net result !2 e22usi!n 2!rmati!n is a 2lattening !r in+ersi!n !2 the diahragm,
mechanical diss!ciati!n !2 the +isceral and arietal leura, and a restricti+e +entilat!ry
de2ect.
19
Pleural e22usi!ns are generally classi2ied as transudates !r e%udates, .ased !n the
mechanism !2 2luid 2!rmati!n and leural 2luid chemistry. 1ransudates result 2r!m an
im.alance in !nc!tic and hydr!static ressures, whereas e%udates are the result !2
in2lammati!n !2 the leura !r decreased lymhatic drainage. #n s!me cases, the leural
2luid may ha+e a c!m.inati!n !2 transudati+e and e%udati+e characteristics.
A.) Prognosis
1he r!gn!sis in leural e22usi!n +aries in acc!rdance with the c!nditi!nRs underlying
eti!l!gy. H!we+er, atients wh! seek medical care earlier in the c!urse !2 their disease
and th!se wh! !.tain r!mt diagn!sis and treatment ha+e a su.stantially l!wer rate !2
c!mlicati!ns than d! atients wh! d! n!t.
Mor4i1it* an1 /ortalit*
M!r.idity and m!rtality !2 leural e22usi!ns are directly related t! cause, stage !2
disease at the time !2 resentati!n, and .i!chemical 2indings in the leural 2luid.
M!r.idity and m!rtality rates in atients with neum!nia and leural e22usi!ns are
higher than th!se in atients with neum!nia al!ne. Paraneum!nic e22usi!ns, when
rec!gni7ed and treated r!mtly, tyically res!l+e with!ut signi2icant seGuelae.
H!we+er, untreated !r inar!riately treated araneum!nic e22usi!ns may lead t!
emyema, c!nstricti+e 2i.r!sis, and sesis.
De+el!ment !2 a malignant leural e22usi!n is ass!ciated with a +ery !!r r!gn!sis,
with median sur+i+al !2 ; m!nths and mean sur+i+al !2 less than 5 year. 1he m!st
c!mm!n ass!ciated malignancy in men is lung cancer, and the m!st c!mm!n
ass!ciated malignancy in w!men is .reast cancer. Median sur+i+al ranges 2r!m 3-54
m!nths, deending !n the malignancy. -22usi!ns 2r!m cancers that are m!re res!nsi+e
t! chem!theray, such as lymh!ma !r .reast cancer, are m!re likely t! .e ass!ciated
with r!l!nged sur+i+al, c!mared with th!se 2r!m lung cancer !r mes!theli!ma.
20
6ellular and .i!chemical 2indings in the 2luid may als! .e indicat!rs !2 r!gn!sis. &!r
e%amle, a l!wer leural 2luid H is !2ten ass!ciated with a higher tum!r .urden and a
w!rse r!gn!sis.
!. Clinical Presentation
A detailed medical hist!ry sh!uld .e !.tained 2r!m all atients resenting with a
leural e22usi!n, as this may hel t! esta.lish the eti!l!gy. &!r e%amle, a hist!ry !2
chr!nic heatitis !r alc!h!lism with cirrh!sis suggests heatic hydr!th!ra% !r alc!h!l-
induced ancreatitis with e22usi!n. Recent trauma !r surgery t! the th!racic sine raises
the !ssi.ility !2 a 6S& leak. 1he atient sh!uld .e asked a.!ut a hist!ry !2 cancer,
e+en rem!te, as malignant leural e22usi!ns can de+el! many years a2ter initial
diagn!sis.
An !ccuati!nal hist!ry sh!uld als! .e !.tained, including !tential as.est!s e%!sure,
which c!uld redis!se the atient t! mes!theli!ma !r as.est!s leural e22usi!n. 1he
atient sh!uld als! .e asked a.!ut medicati!ns they are taking.
!.( Clinical Manifestations
1he clinical mani2estati!ns !2 leural e22usi!n are +aria.le and !2ten are related t! the
underlying disease r!cess. 1he m!st c!mm!nly ass!ciated symt!ms are r!gressi+e
dysnea, c!ugh, and leuritic chest ain.
D*spnea
Dysnea is the m!st c!mm!n symt!m ass!ciated with leural e22usi!n and is related
m!re t! dist!rti!n !2 the diahragm and chest wall during resirati!n than t!
hy!%emia. #n many atients, drainage !2 leural 2luid alle+iates symt!ms desite
limited imr!+ement in gas e%change. Drainage !2 leural 2luid may als! all!w the
underlying disease t! .e rec!gni7ed !n reeat chest radi!grahs. $!te that dysnea may
.e caused .y the c!nditi!n r!ducing the leural e22usi!n, such as underlying intrinsic
21
lung !r heart disease, !.structing end!.r!nchial lesi!ns, !r diahragmatic aralysis,
rather than .y the e22usi!n itsel2.
Coug+
6!ugh in atients with leural e22usi!n is !2ten mild and n!nr!ducti+e. M!re se+ere
c!ugh !r the r!ducti!n !2 urulent !r .l!!dy sutum suggests an underlying
neum!nia !r end!.r!nchial lesi!n.
C+est pain
1he resence !2 chest ain, which results 2r!m leural irritati!n, raises the likelih!!d !2
an e%udati+e eti!l!gy, such as leural in2ecti!n, mes!theli!ma, !r ulm!nary
in2arcti!n.
Pain may .e mild !r se+ere. #t is tyically descri.ed as shar !r sta..ing and is
e%acer.ated with dee insirati!n. Pain may .e l!cali7ed t! the chest wall !r re2erred t!
the isilateral sh!ulder !r uer a.d!men, usually .ecause !2 diahragmatic
in+!l+ement. Pain !2ten diminishes in intensity as the leural e22usi!n increases in si7e.
A11itional s*/pto/s
Other symt!ms in ass!ciati!n with leural e22usi!ns may suggest the underlying
disease r!cess. #ncreasing l!wer e%tremity edema, !rth!nea, and ar!%ysmal
n!cturnal dysnea may all !ccur with c!ngesti+e heart 2ailure.
$ight sweats, 2e+er, hem!tysis, and weight l!ss sh!uld suggest 1/. Hem!tysis als!
raises the !ssi.ility !2 malignancy, !ther end!tracheal !r end!.r!nchial ath!l!gy, !r
ulm!nary in2arcti!n. An acute 2e.rile eis!de, urulent sutum r!ducti!n, and
leuritic chest ain may !ccur in atients with an e22usi!n ass!ciated with neum!nia.
22
!.& P+*sical E8a/inations
Physical 2indings in leural e22usi!n are +aria.le and deend !n the +!lume !2 the
e22usi!n. 8enerally, there are n! hysical 2indings 2!r e22usi!ns smaller than 3(( m0.
>ith e22usi!ns larger than 3(( m0, 2indings may include the 2!ll!wing:
Dullness t! ercussi!n, decreased tactile 2remitus, and asymmetrical chest
e%ansi!n, with diminished !r delayed e%ansi!n !n the side !2 the e22usi!n, are the
m!st relia.le hysical 2indings !2 leural e22usi!n.
Mediastinal shi2t away 2r!m the e22usi!n - 1his is !.ser+ed with e22usi!ns !2 greater
than 5((( m0S dislacement !2 the trachea and mediastinum t!ward the side !2 the
e22usi!n is an im!rtant clue t! !.structi!n !2 a l!.ar .r!nchus .y an end!.r!nchial
lesi!n, which can .e due t! malignancy !r, less c!mm!nly, t! a n!nmalignant cause,
such as a 2!reign .!dy.
Diminished !r inaudi.le .reath s!unds
-g!h!ny )TeT t! TaT changes, at the m!st sueri!r asect !2 the leural e22usi!n
Pleural 2ricti!n ru.
Other hysical 2indings, as 2!ll!ws, may suggest the underlying cause !2 the leural
e22usi!n:
Periheral edema, distended neck +eins, and S
3
gall! suggest c!ngesti+e heart
2ailure. -dema may als! .e a mani2estati!n !2 nehr!tic syndr!meS ericardial
diseaseS !r, c!m.ined with yell!w nails, the yell!w nail syndr!me.
6utane!us changes with ascites suggest li+er disease
0ymhaden!athy !r a ala.le mass suggests malignancy.
C. 2or5up
C.( Approac+ Consi1eration
1h!racentesis sh!uld .e er2!rmed 2!r new and une%lained leural e22usi!ns when
su22icient 2luid is resent t! all!w a sa2e r!cedure. O.ser+ati!n !2 leural e22usi!n is
23
reas!na.le when .enign eti!l!gies are likely, as in the setting !2 !+ert c!ngesti+e heart
2ailure, +iral leurisy, !r recent th!racic !r a.d!minal surgery.
0a.!rat!ry testing hels t! distinguish leural 2luid transudates 2r!m e%udatesS
h!we+er, certain tyes !2 e%udati+e leural e22usi!ns might .e susected simly .y
!.ser+ing the gr!ss characteristics !2 the 2luid !.tained during th!racentesis. $!te the
2!ll!wing:
&rankly urulent 2luid indicates an emyema
A utrid !d!r suggests an anaer!.ic emyema
A milky, !alescent 2luid suggests a chyl!th!ra%, resulting m!st !2ten 2r!m
lymhatic !.structi!n .y malignancy !r th!racic duct inIury .y trauma !r surgical
r!cedure
8r!ssly .l!!dy 2luid may result 2r!m trauma, malignancy, !stericardi!t!my
syndr!me, !r as.est!s-related e22usi!n and indicates the need 2!r a sun hemat!crit
test !2 the samleS a leural 2luid hemat!crit le+el !2 m!re than @(K !2 the
eriheral hemat!crit le+el de2ines a hem!th!ra%, which !2ten reGuires tu.e
th!rac!st!my.
C.& Distinguis+ing Trans1uates fro/ E8u1ates
1ransudates are usually ultra2iltrates !2 lasma in the leura due t! im.alance in
hydr!static and !nc!tic 2!rces in the chest. H!we+er, they can als! .e caused .y the
m!+ement !2 2luid 2r!m erit!neal saces !r .y iatr!genic in2usi!n int! the leural
sace 2r!m mislaced !r migrated central +en!us catheters !r nas!gastric 2eeding tu.es.
-%udates are r!duced .y a +ariety !2 in2lammat!ry c!nditi!ns and !2ten reGuire m!re
e%tensi+e e+aluati!n and treatment than transudates. -%udates arise 2r!m leural !r
lung in2lammati!n, imaired lymhatic drainage !2 the leural sace,
transdiahragmatic m!+ement !2 in2lammat!ry 2luid 2r!m the erit!neal sace, altered
ermea.ility !2 leural mem.ranes, and increased caillary wall ermea.ility !r
+ascular disruti!n. Pleural mem.ranes are in+!l+ed in the ath!genesis !2 the 2luid
2!rmati!n. Permea.ility !2 leural caillaries t! r!teins is high, resulting in an
ele+ated r!tein c!ntent.
24
1he initial diagn!stic c!nsiderati!n is distinguishing transudates 2r!m e%udates.
Alth!ugh a num.er !2 chemical tests ha+e .een r!!sed t! di22erentiate leural 2luid
transudates 2r!m e%udates, the tests 2irst r!!sed .y 0ight et al ha+e .ec!me the
criteri!n standards.
1he 2luid is c!nsidered an e%udate i2 any !2 the 2!ll!wing alies:
Rati! !2 leural 2luid t! serum r!tein greater than (.@
Rati! !2 leural 2luid t! serum 0DH greater than (.'
Pleural 2luid 0DH greater than tw! thirds !2 the uer limits !2 n!rmal serum +alue
1hese criteria reGuire simultane!us measurement !2 leural 2luid and serum r!tein and
0DH. H!we+er, a meta-analysis !2 5;;E atients suggested that the 2!ll!wing
c!m.ined leural 2luid measurements might ha+e sensiti+ity and seci2icity c!mara.le
t! the criteria 2r!m 0ight et al 2!r distinguishing transudates 2r!m e%udates

:
Pleural 2luid 0DH +alue greater than (.;@ !2 the uer limit !2 n!rmal serum +alues
Pleural 2luid ch!lester!l le+el greater than ;@ mg=d0
Pleural 2luid r!tein le+el greater than 4.D g=d0
6linical Iudgment is reGuired when leural 2luid test results 2all near the cut!22 !ints.
1he criteria 2r!m 0ight et al and these alternati+e criteria identi2y nearly all e%udates
c!rrectly, .ut they misclassi2y ar!%imately 4(-4@K !2 transudates as e%udates,
usually in atients !n l!ng-term diuretic theray 2!r c!ngesti+e heart 2ailure ).ecause !2
the c!ncentrati!n !2 r!tein and 0DH within the leural sace due t! diuresis,.
:sing the criteri!n !2 serum minus leural r!tein c!ncentrati!n le+el !2 less than 3.5
g=d0, rather than a serum=leural 2luid rati! !2 greater than (.@, m!re c!rrectly
identi2ies e%udates in these atients.
Alth!ugh leural 2luid al.umin is n!t tyically measured, a gradient !2 serum al.umin
t! leural 2luid al.umin !2 less than 5.4 g=d0 als! identi2ies an e%udate in such atients.
25
#n additi!n, studies suggest that leural 2luid le+els !2 $-terminal r!-.rain natriuretic
etide )$1-r!/$P, are ele+ated in e22usi!ns due t! c!ngesti+e heart 2ailure.
M!re!+er, ele+ated leural $1-r!/$P was sh!wn t! !ut-er2!rm leural 2luid /$P as
a marker !2 heart 2ailureJrelated e22usi!n.

1hus, at instituti!ns where this test is
a+aila.le, high leural le+els !2 $1-r!/$P )de2ined in di22erent studies as N53((-
;((( ng=0, may hel t! c!n2irm heart 2ailure as the cause !2 an !therwise idi!athic
chr!nic e22usi!n.
1ransudates are caused .y a small, de2ined gr!u !2 eti!l!gies, including the 2!ll!wing:
6!ngesti+e heart 2ailure
6irrh!sis )heatic hydr!th!ra%,
Atelectasis - >hich may .e due t! malignancy !r ulm!nary em.!lism
Hy!al.uminemia
$ehr!tic syndr!me
Perit!neal dialysis
My%edema
6!nstricti+e ericarditis
:rin!th!ra% - :sually due t! !.structi+e ur!athy
6ere.r!sinal 2luid )6S&, leaks t! the leura - 8enerally in the setting !2
+entricul!leural shunting !r !2 trauma !r surgery t! the th!racic sine
Dur!leural 2istula - Rare, .ut may .e a c!mlicati!n !2 sinal c!rd surgery
-%tra+ascular migrati!n !2 central +en!us catheter
8lycin!th!ra% - A rare c!mlicati!n !2 .ladder irrigati!n with 5.@K glycine s!luti!n
2!ll!wing ur!l!gic surgery
1he m!re c!mm!n causes !2 e%udates include the 2!ll!wing:
Paraneum!nic causes
Malignancy )m!st c!mm!nly, lung !r .reast cancer, lymh!ma, leukemiaS less
c!mm!nly, !+arian carcin!ma, st!mach cancer, sarc!mas, melan!ma,
UDV
Pulm!nary em.!lism
6!llagen-+ascular c!nditi!ns )rheumat!id arthritis, systemic luus erythemat!sus

,
26
1u.ercul!sis )1/,
Pancreatitis
1rauma
P!stcardiac inIury syndr!me
-s!hageal er2!rati!n
Radiati!n leuritis
Sarc!id!sis
&ungal in2ecti!n
Pancreatic seud!cyst
#ntra-a.d!minal a.scess
Status-!st c!r!nary artery .yass gra2t surgery
Pericardial disease
Meigs syndr!me ).enign el+ic ne!lasm with ass!ciated ascites and leural
e22usi!n,
O+arian hyerstimulati!n syndr!me
Drug-induced leural disease )see Pneum!t!% On 0ine 2!r an e%tensi+e list !2 drugs
that can cause leural e22usi!n,
As.est!s-related leural disease
<ell!w nail syndr!me )yell!w nails, lymhedema, leural e22usi!ns,
:remia
1raed lung )l!cali7ed leural scarring with the 2!rmati!n !2 a 2i.rin eel re+ents
inc!mlete lung e%ansi!n, at times leading t! leural e22usi!n,
6hyl!th!ra% )acute illness with ele+ated triglycerides in leural 2luid,
Pseud!chyl!th!ra% )chr!nic c!nditi!n with ele+ated ch!lester!l in leural 2luid,
&istula )+entricul!leural, .ili!leural, gastr!leural,
C.) %a1iograp+*
-22usi!ns !2 m!re than 5A@ m0 are usually aarent as .lunting !2 the c!st!hrenic
angle !n uright !ster!anteri!r chest radi!grahs. On suine chest radi!grahs, which
are c!mm!nly used in the intensi+e care setting, m!derate t! large leural e22usi!ns
27
may aear as a h!m!gen!us increase in density sread !+er the l!wer lung 2ields.
Aarent ele+ati!n !2 the hemidiahragm, lateral dislacement !2 the d!me !2 the
diahragm, !r increased distance .etween the aarent le2t hemidiahragm and the
gastric air .u..le suggests su.ulm!nic e22usi!ns. )See the images .el!w.,
P!ster!anteri!r, uright chest radi!grah sh!ws is!lated, le2t-sided leural e22usi!n and
l!ss !2 le2t, lateral c!st!hrenic angle. #mage c!urtesy !2 Allen R. 1h!mas, MD.
28
Anter!!steri!r, uright chest radi!grah sh!ws .ilateral leural e22usi!ns and l!ss !2
.ilateral c!st!hrenic angles )meniscus sign,. #mage c!urtesy !2 Allen R. 1h!mas, MD.
6hest radi!grah, lateral +iew, sh!ws l!ss !2 .ilateral, !steri!r c!st!hrenic angles.
#mage c!urtesy !2 Allen R. 1h!mas, MD.
0ateral decu.itus 2ilms m!re relia.ly detect smaller leural e22usi!ns. 0ayering !2 an
e22usi!n !n lateral decu.itus 2ilms de2ines a 2reely 2l!wing e22usi!n and, i2 the layering
2luid is 5 cm thick, indicates an e22usi!n !2 greater than 4(( m0 that is amena.le t!
th!racentesis. &ailure !2 an e22usi!n t! layer !n lateral decu.itus 2ilms indicates the
resence !2 l!culated leural 2luid !r s!me !ther eti!l!gy causing the increased leural
density. )See the image .el!w.,
29
0e2t lateral decu.itus 2ilm sh!wing 2reely layering leural e22usi!n.
C.=. CT Scanning an1 #ltrasonograp+*
A study .y 8urung et al in+!l+ing ;5 c!nsecuti+e atients with heatic hydr!th!ra%
indicated that heatic hydr!th!ra% +irtually always resents with ascites that can .e
re+ealed .y ultras!n!grahy !r c!muted t!m!grahy )61, scanning.
6hest 61 scanning with c!ntrast sh!uld .e er2!rmed in all atients with an
undiagn!sed leural e22usi!n, i2 it has n!t re+i!usly .een er2!rmed, t! detect
thickened leura !r signs !2 in+asi!n !2 underlying !r adIacent structures. 1he 4
diagn!stic imerati+es in this situati!n are ulm!nary em.!lism and
tu.ercul!usleuritis. #n .!th cases, the leural e22usi!n is a har.inger !2 !tential 2uture
m!r.idity. #n c!ntrast, a sh!rt delay in diagn!sing metastatic malignancy t! the leural
sace has less imact !n 2uture clinical !utc!mes. 61 angi!grahy sh!uld .e !rdered i2
ulm!nary em.!lism is str!ngly suggested.
30
C.:. Diagnostic T+oracentesis
Per2!rm diagn!stic th!racentesis i2 the eti!l!gy !2 the e22usi!n is unclear !r i2 the
resumed cause !2 the e22usi!n d!es n!t res!nd t! theray as e%ected. Pleural
e22usi!ns d! n!t reGuire th!racentesis i2 they are t!! small t! sa2ely asirate !r, in
clinically sta.le atients, i2 their resence can .e e%lained .y underlying c!ngesti+e
heart 2ailure )esecially .ilateral e22usi!ns, !r .y recent th!racic !r a.d!minal surgery.
Deending !n the clinicianRs e%erience, a ulm!n!l!gist can .e c!nsulted 2!r
assistance with high-risk diagn!stic th!racentesis.
Contrain1ications
Relati+e c!ntraindicati!ns t! diagn!stic th!racentesis include a small +!lume !2 2luid )O
5 cm thickness !n a lateral decu.itus 2ilm,, .leeding diathesis !r systemic
antic!agulati!n, mechanical +entilati!n, and cutane!us disease !+er the r!!sed
uncture site. Mechanical +entilati!n with !siti+e end-e%irat!ry ressure d!es n!t
increase the risk !2 neum!th!ra% a2ter th!racentesis, .ut it increases the likelih!!d !2
se+ere c!mlicati!ns )tensi!n neum!th!ra% !r ersistent .r!nch!leural 2istula, i2 the
lung is unctured.
Co/plications
6!mlicati!ns !2 diagn!stic th!racentesis include ain at the uncture site, cutane!us
!r internal .leeding, neum!th!ra%, emyema, and sleen=li+er uncture.
Pneum!th!ra% c!mlicates ar!%imately 54-3(K !2 th!racenteses .ut reGuires
treatment with a chest tu.e in less than @K !2 cases. :se !2 needles larger than 4(
gauge increases the risk !2 a neum!th!ra% c!mlicating the th!racentesis. #n additi!n,
signi2icant chr!nic !.structi+e !r 2i.r!tic lung disease increases the risk !2 a
symt!matic neum!th!ra% c!mlicating the th!racentesis.
Proce1ure
#n atients with large, 2reely 2l!wing e22usi!ns and n! relati+e c!ntraindicati!ns t!
th!racentesis, diagn!stic th!racentesis can usually .e er2!rmed sa2ely, with the
31
uncture site initially ch!sen .ased !n the chest radi!grah and l!cated 5-4 ri.
intersaces .el!w the le+el !2 dullness t! ercussi!n !n hysical e%aminati!n. #n !ther
situati!ns, ultras!n!grahy !r chest 61 scanning sh!uld .e used t! guide th!racentesis.
A2ter the site is disin2ected with chl!rhe%idine )re2erred, !r !+id!ne=i!dine )n!
l!nger rec!mmended, s!luti!n and sterile draes are laced, anestheti7e the skin,
eri!steum, and arietal leura with 5K lid!caine thr!ugh a 4@-gauge needle. #2 leural
2luid is n!t !.tained with the sh!rter 4@-gauge needle, c!ntinue anestheti7ing with a
5.@-inch, 44-gauge needle. &!r atients with larger am!unts !2 su.cutane!us tissue, a
3.@-inch, 44-gauge sinal needle with inner stylet rem!+ed can .e used t! anestheti7e
the deeer tissues and 2ind the e22usi!n.
6!n2irm the c!rrect l!cati!n 2!r th!racentesis .y asirating leural 2luid thr!ugh the
4@- !r 44-gauge needle .e2!re intr!ducing larger-.!re th!racentesis needles !r
catheters. #2 leural 2luid is n!t easily asirated, st! the r!cedure and use
ultras!n!grahy !r chest 61 scanning t! guide th!racentesis.
>hen !ssi.le, atients sh!uld sit uright 2!r th!racentesis. Patients sh!uld n!t lean
2!rward, .ecause this causes leural 2luid t! m!+e t! the anteri!r c!st!hrenic sace
and increases the risk !2 uncture !2 the li+er !r sleen. &!r de.ilitated and +entilated
atients wh! cann!t sit uright, !.tain leural 2luid .y uncturing !+er the eighth ri. at
the mida%illar t! !steri!r a%illary line. #n such atients, imaging may .e reGuired t!
guide th!racentesis.
Sulemental !%ygen is !2ten administered during th!racentesis t! !22set hy!%emia
r!duced .y changes in +entilati!n-er2usi!n relati!nshis as 2luid is rem!+ed and t!
2acilitate rea.s!rti!n !2 leural air i2 neum!th!ra% c!mlicates the r!cedure.
1he 2reGuency !2 c!mlicati!ns 2r!m th!racentesis is l!wer when a m!re e%erienced
clinician er2!rms the r!cedure and when ultras!n!grahic guidance is used.
U33V
6!nseGuently, a skilled and e%erienced clinician sh!uld er2!rm th!racentesis in
32
atients wh! ha+e a higher risk !2 c!mlicati!ns !r relati+e c!ntraindicati!ns 2!r
th!racentesis and in atients wh! cann!t sit uright.
P!str!cedure e%irat!ry chest radi!grahs t! e%clude neum!th!ra% are n!t needed in
asymt!matic atients a2ter unc!mlicated r!cedures )single needle ass with!ut
asirati!n !2 air,. H!we+er, !str!cedure insirat!ry chest radi!grahs are
rec!mmended t! esta.lish a new .aseline 2!r atients likely t! ha+e recurrent
symt!matic e22usi!ns.
C.>. Pleural Flui1 e8a/inations
Nor/al pleural flui1
$!rmal leural 2luid has the 2!ll!wing characteristics:
6lear ultra2iltrate !2 lasma that !riginates 2r!m the arietal leura
A H !2 A.'(-A.';
Pr!tein c!ntent !2 less than 4K )5-4 g=d0,
&ewer than 5((( white .l!!d cells )>/6s, er cu.ic millimeter
8luc!se c!ntent similar t! that !2 lasma
0actate dehydr!genase )0DH, less than @(K !2 lasma
Pleural flui1 DH
Pleural 2luid 0DH le+els greater than 5((( #:=0 suggest emyema, malignant e22usi!n,
rheumat!id e22usi!n, !r leural arag!nimiasis. Pleural 2luid 0DH le+els are als!
increased in e22usi!ns 2r!m Pneumocystis jiroveci )2!rmerly, P carinii, neum!niaS the
diagn!sis is suggested .y a leural 2luid=serum 0DH rati! !2 greater than 5, with a
leural 2luid=serum r!tein rati! !2 less than (.@.
Pleural flui1 glucose an1 pH
#n additi!n t! the re+i!usly discussed tests, gluc!se and leural 2luid H sh!uld .e
measured during the initial th!racentesis in m!st situati!ns.
33
A l!w leural gluc!se c!ncentrati!n )3(-@( mg=d0, suggests malignant e22usi!n,
tu.ercul!usleuritis, es!hageal ruture, !r luus leuritis. A +ery l!w leural gluc!se
c!ncentrati!n )ie, O 3( mg=d0, 2urther restricts diagn!stic !ssi.ilities, t! rheumat!id
leurisy !r emyema.
Pleural 2luid H is highly c!rrelated with leural 2luid gluc!se le+els. A leural 2luid
H !2 less than A.3( with a n!rmal arterial .l!!d H le+el is caused .y the same
diagn!ses as listed a.!+e 2!r l!w leural 2luid gluc!se. H!we+er, 2!r araneum!nic
e22usi!ns, a l!w leural 2luid H le+el is m!re redicti+e !2 c!mlicated e22usi!ns )that
reGuire drainage, than is a l!w leural 2luid gluc!se le+el. #n such cases, a leural 2luid
H !2 less than A.5-A.4 indicates the need 2!r urgent drainage !2 the e22usi!n, while a
leural 2luid H !2 m!re than A.3 suggests that the e22usi!n may .e managed with
systemic anti.i!tics al!ne.
#n malignant e22usi!ns, a leural 2luid H !2 less than A.3 has .een ass!ciated in s!me
re!rts with m!re e%tensi+e leural in+!l+ement, higher yield !n cyt!l!gy, decreased
success !2 leur!desis, and sh!rter sur+i+al times.
Handle leural 2luid samles as care2ully as arterial samles 2!r H measurements, with
2luid c!llected in hearini7ed syringes and ideally trans!rted !n ice 2!r measurement
within ' h!urs. H!we+er, studies ha+e sh!wn that when c!llected in hearini7ed
syringes, leural 2luid H d!es n!t change signi2icantly e+en !+er se+eral h!urs at r!!m
temerature. 6!nseGuently, i2 ar!riately c!llected samles can .e r!cessed
Guickly, H measurements sh!uld n!t .e canceled simly .ecause the samle was n!t
trans!rted !n ice.
Pleural Flui1 Cell Count Differential
#2 an e%udate is susected clinically !r is c!n2irmed .y chemistry test results, send the
leural 2luid 2!r t!tal and di22erential cell c!unts, 8ram stain, culture, and cyt!l!gy.
34
Pleural 2luid lymh!cyt!sis, with lymh!cyte +alues greater than E@K !2 the t!tal
nucleated cells, suggests 1/, lymh!ma, sarc!id!sis, chr!nic rheumat!id leurisy,
yell!w nail syndr!me, !r chyl!th!ra%. Pleural lymh!cyte +alues !2 @(-A(K !2 the
nucleated cells suggest malignancy.
Pleural 2luid e!sin!hilia )P&-,, with e!sin!hil +alues greater than 5(K !2 nucleated
cells, is seen in ar!%imately 5(K !2 leural e22usi!ns and is n!t c!rrelated with
eriheral .l!!d e!sin!hilia. P&- is m!st !2ten caused .y air !r .l!!d in the leural
sace. /l!!d in the leural sace causing P&- may .e the result !2 ulm!nary
em.!lism with in2arcti!n !r .enign as.est!s leural e22usi!n. P&- may .e ass!ciated
with !ther n!nmalignant diseases, including arasitic disease )esecially
arag!nimiasis,, 2ungal in2ecti!n )c!ccidi!id!myc!sis, cryt!c!cc!sis, hist!lasm!sis,,
and a +ariety !2 medicati!ns.
1he resence !2 P&- d!es n!t e%clude a malignant e22usi!n, esecially in atient
!ulati!ns with a high re+alence !2 malignancy. 1he resence !2 P&- makes
tu.ercul!us leurisy unlikely and als! makes the r!gressi!n !2 a araneum!nic
e22usi!n t! an emyema unlikely.
Mes!thelial cells are 2!und in +aria.le num.ers in m!st e22usi!ns, .ut their resence at
greater than @K !2 t!tal nucleated cells makes a diagn!sis !2 1/ less likely. Markedly
increased num.ers !2 mes!thelial cells, esecially in .l!!dy !r e!sin!hilic e22usi!ns,
suggests ulm!nary em.!lism as the cause !2 e22usi!n.
Pleural Flui1 Culture an1 C*tolog*
6ulture !2 in2ected leural 2luid yields !siti+e results in ar!%imately '(K !2 casesS
this !ccurs e+en less !2ten 2!r anaer!.ic !rganisms. Diagn!stic yields, articularly 2!r
anaer!.ic ath!gens, may .e increased .y directly culturing leural 2luid int! .l!!d
culture .!ttles.
35
Malignancy is susected in atients with kn!wn cancer !r with lymh!cytic, e%udati+e
e22usi!ns, esecially when .l!!dy. Direct tum!r in+!l+ement !2 the leura is diagn!sed
m!st easily .y er2!rming leural 2luid cyt!l!gy.
Hearini7e samles )5 m0 !2 5:5((( hearin er @( m0 !2 leural 2luid, i2 .l!!dy, and
re2rigerate i2 samles will n!t .e r!cessed within 5 h!ur.
1he re!rted diagn!stic yields in cyt!l!gy +ary 2r!m '(-D(K, deending !n the e%tent
!2 leural in+!l+ement and the tye !2 rimary malignancy. 6yt!l!gy 2indings are
!siti+e in @EK !2 e22usi!ns related t! mes!theli!ma.
1he sensiti+ity !2 cyt!l!gy is n!t highly related t! the +!lume !2 leural 2luid testedS
sending m!re than @(-'( m0 !2 leural 2luid 2!r cyt!l!gy d!es n!t increase the yield !2
direct cyt!sin analysis,
U4D, 3(V
and +!lumes !2 ar!%imately 5@( m0 are su22icient when
.!th cyt!sin and cell .l!ck rearati!ns are analy7ed.
1um!r markers, such as carcin!em.ry!nic antigen, 0eu-5, and mucin, are suggesti+e !2
malignant e22usi!ns )esecially aden!carcin!ma, when leural 2luid +alues are +ery
high. H!we+er, .ecause !2 l!w sensiti+ity, they are n!t hel2ul i2 the +alues are n!rmal
!r !nly m!destly increased.
Tu4erculous pleuritis
Susect tu.ercul!usleuritis in atients with a hist!ry !2 e%!sure !r a !siti+e PPD
2inding and in atients with lymh!cytic e%udati+e e22usi!ns, esecially i2 less than @K
mes!thelial cells are detected !n di22erential .l!!d cell c!unts.
/ecause m!st tu.ercul!us leural e22usi!ns r!.a.ly result 2r!m a hyersensiti+ity
reacti!n t! the Mycobacterium rather than 2r!m micr!.ial in+asi!n !2 the leura, acid-
2ast .acillus stains !2 leural 2luid are rarely diagn!stic )O 5(K !2 cases,, and leural
2luid cultures gr!w M tuberculosis in less than '@K !2 cases.
#n c!ntrast, the c!m.inati!n !2 hist!l!gy and culture !2 leural tissue !.tained .y
leural .i!sy increases the diagn!stic yield t! D(K.
36
ADA acti+ity !2 greater than ;3 :=m0 in leural 2luid su!rts the diagn!sis !2
tu.ercul!usleuritis. H!we+er, the test has a sensiti+ity !2 !nly AEKS there2!re, leural
ADA +alues !2 less than ;3-@( :=m0 d! n!t e%clude the diagn!sis !2 1/ leuritis.
#nter2er!n-gamma c!ncentrati!ns !2 greater than 5;( g=m0 in leural 2luid als!
su!rt the diagn!sis !2 tu.ercul!usleuritis, .ut this test is n!t r!utinely a+aila.le.
C.?. A11itional a4orator* Test
Additi!nal seciali7ed tests are warranted when seci2ic eti!l!gies are susected.
Measure leural 2luid amylase le+els i2 a ancreatic !rigin !r rutured es!hagus is
susected !r i2 a unilateral, le2t-sided leural e22usi!n remains undiagn!sed a2ter initial
testing. O2 n!te, increased leural 2luid amylase can als! .e seen with malignancy. An
additi!nal assay !2 amylase is!en7ymes can hel distinguish a ancreatic s!urce
)diagn!sed .y ele+ated leural 2luid ancreatic is!en7ymes, 2r!m !ther eti!l!gies.
Measure triglyceride and ch!lester!l le+els in milky leural 2luids when chyl!th!ra% !r
seud!chyl!th!ra% is susected.
6!nsider immun!l!gic studies, including leural 2luid antinuclear anti.!dy and
rheumat!id 2act!r, when c!llagen-+ascular diseases are susected.
D. Differential Diagnoses
SIWgren syndr!me, li+er !r lung translantati!n, uer genit!urinary trauma, and
a.d!minal trauma are am!ng the c!nditi!ns t! c!nsider in the di22erential diagn!sis !2
leural e22usi!n, .ut n!te they are rare.
Transu1ative pleural effusion
6!nsiderati!ns in the di22erential diagn!sis !2 transudati+e leural e22usi!n include the
2!ll!wing:
6!ngesti+e heart 2ailure )m!st c!mm!n,
6irrh!sis with heatic hydr!th!ra%
37
$ehr!tic syndr!me
Perit!neal dialysis=c!ntinu!us am.ulat!ry erit!neal dialysis
Hy!r!teinemia
8l!merul!nehritis
Sueri!r +ena ca+a !.structi!n
&!ntan r!cedure
:rin!th!ra%
6S& leak t! the leural sace
E8u1ative pleural effusion
6!nditi!ns t! c!nsider in the di22erential diagn!sis !2 e%udati+e leural e22usi!n include
the 2!ll!wing:
Malignancy
Pneum!nia
1u.ercul!sis
Pulm!nary em.!lism
&ungal in2ecti!n
Pancreatic seud!cyst
#ntra-a.d!minal a.scess
A2ter c!r!nary artery .yass gra2t surgery
P!stcardiac inIury syndr!me
Pericardial disease
Meigs syndr!me
O+arian hyerstimulati!n syndr!me
Rheumat!id leuritis
0uus erythemat!sus
Drug-induced leural disease
As.est!s leural e22usi!n
<ell!w nail syndr!me
:remia
38
1raed lung
6hyl!th!ra%
Pseud!chyl!th!ra%
Acute resirat!ry distress syndr!me
6hr!nic leural thickening
Malignant mes!theli!ma
E. Treat/ent an1 Manage/ent
1ransudati+e e22usi!ns are usually managed .y treating the underlying medical
dis!rder. H!we+er, whether transudates !r e%udates, large, re2ract!ry leural e22usi!ns
causing se+ere resirat!ry symt!ms, e+en i2 the cause is underst!!d and disease-
seci2ic treatment is a+aila.le, can .e drained t! r!+ide relie2.
1he management !2 e%udati+e e22usi!ns deends !n the underlying eti!l!gy !2 the
e22usi!n. Pneum!nia, malignancy, !r 1/ causes m!st diagn!sed e%udati+e leural
e22usi!ns, with the remainder tyically deemed idi!athic. 6!mlicated araneum!nic
e22usi!ns and emyemas sh!uld .e drained t! re+ent de+el!ment !2
2i.r!singleuritis. Malignant e22usi!ns are usually drained t! alliate symt!ms and
may reGuire leur!desis t! re+ent recurrence.
Medicati!ns cause !nly a small r!!rti!n !2 all leural e22usi!ns and are ass!ciated
with e%udati+e leural e22usi!ns. H!we+er, early rec!gniti!n !2 these iatr!genic causes
!2 leural e22usi!n a+!ids unnecessary additi!nal diagn!stic r!cedures and leads t!
de2initi+e theray, which is disc!ntinuati!n !2 the medicati!n. #mlicated drugs include
medicati!ns that cause drug-induced luus syndr!me )eg, r!cainamide, hydrala7ine,
Guinidine,, nitr!2urant!in, dantr!lene, methysergide, r!car.a7ine, and meth!tre%ate.
Tu4erculouspleuritis
1u.ercul!usleuritis tyically is sel2-limited. H!we+er, .ecause '@K !2 atients with
rimary tu.ercul!usleuritis reacti+ate their disease within @ years, emiric anti-1/
39
treatment is usually .egun ending culture results when su22icient clinical susici!n is
resent, such as an une%lained e%udati+e !r lymh!cytic e22usi!n in a atient with a
!siti+e PPD 2inding.

C+*lous effusions
6hyl!us e22usi!ns are usually managed .y dietary and surgical m!dalities. H!we+er,
studies suggest that s!mat!statin anal!gues als! may hel in reducing the e22lu% !2
chyle int! the leural sace.
Surgical treat/ent
Surgical inter+enti!n is m!st !2ten reGuired 2!r araneum!nic e22usi!ns that cann!t .e
drained adeGuately .y needle !r small-.!re catheters. Surgery may als! .e reGuired 2!r
the diagn!sis and scler!sis !2 e%udati+e e22usi!ns.
9ide!-assisted th!rac!sc!y with the atient under l!cal !r general anesthesia all!ws
direct +isuali7ati!n and .i!sy !2 the leura 2!r diagn!sis !2 e%udati+e e22usi!ns.
Pleur!desis .y insu22lating talc directly !nt! the leural sur2ace using +ide!-assisted
th!rac!sc!y is an alternati+e t! using talc slurries.
Dec!rticati!n is usually needed 2!r traed lungs t! rem!+e a thick, inelastic leural
eel that restricts +entilati!n and r!duces r!gressi+e !r re2ract!ry dysnea. #n
atients with chr!nic, !rgani7ing araneum!nic leural e22usi!ns, technically
demanding !erati!ns may .e reGuired t! drain l!culated leural 2luid and t! !.literate
the leural sace.
Surgically imlanted leur!erit!neal shunts are an!ther treatment !ti!n 2!r recurrent,
symt!matic e22usi!ns, m!st !2ten in the setting !2 malignancy, .ut they are als! used
2!r management !2 chyl!us e22usi!ns. H!we+er, the shunts are r!ne t! mal2uncti!n
!+er time, are !!rly t!lerated .y atients, and can reGuire surgical re+isi!n.
40
#n unusual cases, surgery might .e reGuired t! cl!se diahragmatic de2ects )there.y
re+enting recurrent accumulati!n !2 leural e22usi!ns in atients with ascites, and t!
ligate the th!racic duct t! re+ent reaccumulati!n !2 chyl!us e22usi!ns.
E.(. T+erapeuaticT+oracentesis
1heraeutic th!racentesis t! rem!+e larger am!unts !2 leural 2luid is used t! alle+iate
dysnea and t! re+ent !ng!ing in2lammati!n and 2i.r!sis in araneum!nic e22usi!ns.
#n additi!n t! the recauti!ns listed re+i!usly 2!r diagn!stic th!racentesis, n!te 3
additi!nal c!nsiderati!ns when er2!rming theraeutic th!racentesis.
&irst, t! a+!id r!ducing a neum!th!ra% during the rem!+al !2 large Guantities !2
2luid, rem!+e 2luid during theraeutic th!racentesis with a catheter, rather than with a
shar needle, intr!duced int! the leural sace. 9ari!us secially designed
th!racentesis trays are a+aila.le 2!r intr!ducing small catheters int! the leural sace.
Alternati+ely, newer systems using sring-l!aded, .lunt-ti needles that a+!id lung
uncture are als! a+aila.le.
Sec!nd, m!nit!r !%ygenati!n cl!sely during and a2ter th!racentesis .ecause arterial
!%ygen tensi!n arad!%ically might w!rsen a2ter leural 2luid drainage due t! shi2ts in
er2usi!n and +entilati!n in the ree%anding lung. 6!nsider use !2 emiric
sulemental !%ygen during the r!cedure.
1hird, rem!+e !nly m!derate am!unts !2 leural 2luid t! a+!id ree%ansi!n ulm!nary
edema and t! a+!id causing a neum!th!ra%. Rem!+al !2 ;((-@(( m0 !2 leural 2luid
is !2ten su22icient t! alle+iate sh!rtness !2 .reath. 1he rec!mmended limit is 5(((-5@((
m0 in a single th!racentesis r!cedure.
0arger am!unts !2 leural 2luid can .e rem!+ed i2 leural ressure is m!nit!red .y
leural man!metry and is maintained a.!+e -4( cm water.
U3EV
H!we+er, this m!nit!ring
is rarely used .y m!st r!ceduralists.
1he !nset !2 chest ressure !r ain during the rem!+al !2 2luid indicates a lung that is
n!t 2reely e%anding, and the r!cedure sh!uld .e st!ed immediately t! a+!id
ree%ansi!n ulm!nary edema.
U3EV
#n c!ntrast, c!ugh 2reGuently !ccurs during rem!+al
41
!2 2luid, and this is n!t an indicati!n t! st! the r!cedure, unless the c!ugh is causing
the atient disc!m2!rt.
Me1iastinal position an1 lung entrap/ent
1he !siti!n !2 the mediastinum !n the chest radi!grah may redict whether a atient
is likely t! .ene2it 2r!m the r!cedure. A mediastinal shi2t away 2r!m the leural
e22usi!n indicates a !siti+e leural ressure and c!mressi!n !2 the underlying lung
that can .e relie+ed .y th!racentesis. )See the images .el!w.,
Massi+e right leural e22usi!n with shi2t !2 mediastinum t!wards le2t
42
Right leural e22usi!n a2ter artial drainage sh!wing decrease in shi2t !2 mediastinum
t!wards le2t
#n c!ntrast, a mediastinal shi2t t!wards the side !2 the e22usi!n indicates lung
entrament .y e%tensi+e leural in+!l+ement !r end!.r!nchial !.structi!n that re+ents
ree%ansi!n !2 the lung when the leural 2luid is rem!+ed, !r it indicates a lung traed
.y encasement .y chr!nic leural thickening. 0ung entrament with malignant
e22usi!ns is m!st c!mm!n with mes!theli!ma !r rimary lung cancer.
Attemts at theraeutic th!racentesis usually d! n!t imr!+e dysnea in atients with
lung entrament, due t! the ina.ility !2 the lung t! ree%and. #n 2act, attemts at
drainage !2 2luid in these atients usually results in a hydr!neum!th!ra% .eing
+isuali7ed !n !str!cedure imaging studies. )See the image .el!w.,
43
0ung entrament with right hydr!neum!th!ra% and leural drain in lace
E.&. Tu4e T+oracosto/*
Alth!ugh small, 2reely 2l!wing araneum!nic e22usi!ns can .e drained .y theraeutic
th!racentesis, m!st larger e22usi!ns and c!mlicated araneum!nic e22usi!ns !r
emyemas reGuire drainage .y tu.e th!rac!st!my.
1raditi!nally, large-.!re chest tu.es )4(-3'&, ha+e .een used t! drain thick leural
2luid and t! .reak u l!culati!ns in emyemas. H!we+er, such tu.es are n!t always
well t!lerated .y atients and are di22icult t! direct c!rrectly int! the leural sace.
H!we+er, small-.!re tu.es )A-5;&, inserted at the .edside !r under radi!grahic
guidance ha+e .een sh!wn t! r!+ide adeGuate drainage, e+en when emyema is
resent. 1hese tu.es cause less disc!m2!rt and are m!re likely t! .e laced success2ully
within a !cket !2 leural 2luid. :sing 4(-cm water sucti!n and 2lushing the tu.e with
n!rmal saline e+ery '-E h!urs may re+ent !cclusi!n !2 small-.!re catheters.
#nserti!n !2 additi!nal leural catheters, usually under radi!grahic guidance, !r
instilling 2i.rin!lytics )eg, stret!kinase, ur!kinase, !r altelase, thr!ugh the leural
catheter can hel t! drain multil!culated leural e22usi!ns.
44
A rand!mi7ed trial !2 45( articiants with leural in2ecti!n sh!wed that instillati!n !2
altelase and D$ase r!duced signi2icantly greater drainage !2 leural e22usi!n, less
need 2!r surgical re2erral !r surgical inter+enti!n, sh!rter h!sital stays, and a decrease
in leural 2luid in2lammat!ry markers c!mared with lace.!.
E.=. Pleuro1esis
Pleur!desis )als! kn!wn as leural scler!sis, in+!l+es instilling an irritant int! the
leural sace t! cause in2lammat!ry changes that result in .ridging 2i.r!sis .etween the
+isceral and arietal leural sur2aces, e22ecti+ely !.literating the !tential leural sace.
Pleur!desis is m!st !2ten used 2!r recurrent malignant e22usi!ns, such as in atients
with lung cancer !r metastatic .reast !r !+arian cancer. 8i+en the limited li2e
e%ectancy !2 these atients, the g!al !2 theray is t! alliate symt!ms while
minimi7ing atient disc!m2!rt, h!sital length !2 stay, and !+erall c!sts.
Patients with !!r er2!rmance status )Karn!2sky sc!re O A(, and a li2e e%ectancy !2
less than 3 m!nths can .e treated with reeated !utatient th!racentesis as needed t!
alliate symt!ms. :n2!rtunately, leural e22usi!ns can reaccumulate raidly, and the
risk !2 c!mlicati!ns increases with reeated drainage.
#n additi!n, atients with lung entrament 2r!m malignant e22usi!ns are n!t candidates
2!r reeated th!racentesis, which d!es n!t relie+e dysnea in such atients, n!r 2!r
leur!desis, as the +isceral and arietal leural sur2aces cann!t stay a!sed t! all!w
the .ridging 2i.r!sis. 1he .est treatment 2!r e22usi!ns in such atients is the inserti!n !2
an indwelling tunneled catheter, which all!ws atients t! rem!+e leural 2luid as
needed at h!me.
A 4((' systematic re+iew 2!und that in leur!desis, r!tating the atient thr!ugh
di22erent !siti!ns did n!t aear necessary t! ensure distri.uti!n !2 s!lu.le scler!sing
agents thr!ugh!ut the leural sace. #n additi!n, neither r!tracted drainage a2ter
45
instillati!n !2 scler!tics n!r the use !2 larger-.!re chest tu.es increased the
e22ecti+eness !2 leur!desis.
Pleur!desis is likely t! .e success2ul !nly i2 the leural sace is drained c!mletely
.e2!re leur!desis and i2 the lung is 2ully ree%anded t! a!se the +isceral and arietal
leura a2ter scler!sis. Animal studies suggest that systemic c!rtic!ster!ids can reduce
in2lammati!n during scler!sis and can cause leur!desis 2ailures.
Sclerosing agents
9ari!us agents, including talc, d!%ycycline, .le!mycin sul2ate )/len!%ane,, 7inc
sul2ate, and Guinacrine hydr!chl!ride, can scler!se the leural sace and e22ecti+ely
re+ent recurrence !2 the malignant leural e22usi!n.
1alc is the m!st e22ecti+e scler!sing agent and can .e administered as slurry thr!ugh
chest tu.es !r leural catheters. Alth!ugh a systematic re+iew suggested that direct
insu22lati!n !2 talc +ia th!rac!sc!y was m!re e22ecti+e than talc slurry, .!th were
eGually e22ecti+e in a 4((@ r!secti+e trial !2 malignant e22usi!ns. #m!rtantly, talc
articles tend t! !cclude the small drainage h!les in small leural catheters. 1here2!re,
leural catheters sh!uld .e at least 5(-54& i2 intended 2!r talc leur!desis.
D!%ycycline and .le!mycin are als! e22ecti+e in m!st atients and can .e administered
m!re easily thr!ugh small-.!re catheters, alth!ugh they are s!mewhat less e22ecti+e
and su.stantially m!re e%ensi+e than talc.
All scler!sing agents can r!duce 2e+er, chest ain, and nausea. 1alc rarely causes
m!re seri!us ad+erse e22ects, such as emyema and acute lung inIury. 1he latter
aears t! .e related t! the article si7e and the am!unt !2 talc inIected 2!r leur!desis.
#nIecti!n !2 @( m0 !2 5K lid!caine hydr!chl!ride ri!r t! instillati!n !2 the scler!sing
agent may hel t! alle+iate ain. Additi!nal analgesia might .e reGuired in s!me cases.
6lam chest tu.es 2!r ar!%imately 4 h!urs a2ter instillati!n !2 the scler!sing agent.
46
E.&. Monitoring Pleuaral Drainage
Rec!rd the am!unt and Guality !2 2luid drained and m!nit!r 2!r an air leak ).u..ling
thr!ugh the water seal, at each shi2t. 0arge air leaks )steady streams !2 air thr!ugh!ut
the resirat!ry cycle, may .e indicati!ns !2 l!!se c!nnect!rs !r !2 a drainage !rt !n
the catheter that has migrated !ut t! the skin. Alternati+ely, they may indicate large
.r!nch!leural 2istulae. 6!nseGuently, dressings sh!uld .e taken d!wn and the !siti!n
!2 the catheter insected at the uncture site.
/rie2ly claming the catheter at the skin hels t! determine whether the air leak is
!riginating 2r!m within the leural ca+ity )in which case, it st!s when the tu.e is
clamed, !r 2r!m !utside the chest )in which case, the leak ersists,.
Reeat the chest radi!grahs when drainage decreases t! less than 5(( m0=day t!
e+aluate whether the e22usi!n has .een 2ully drained. #2 a large e22usi!n ersists
radi!grahically, ree+aluate the !siti!n !2 the chest catheter using chest 61 scanning
t! ensure that the drainage !rts are still !siti!ned within the leural c!llecti!n. #2 the
catheter is !siti!ned ar!riately, c!nsider inIecting lytics thr!ugh the chest tu.e t!
.reak u cl!ts that may .e !.structing drainage. Alternati+ely, chest 61 scanning may
re+eal lung entrament=traed lung, which is unlikely t! res!nd t! 2urther drainage in
the h!sital.

47
!I!I$"%APHY
>, Aru. Sud!y!, et all. 4(('. Ilmu Peyakit Dalam Ed IV Jilid I. Deartemen #lmu Penyakit
Dalam &K:#, *akarta.
Arun 8!i, Sethu M. Madha+an, Surendra K. Sharma and Ste+en A.Sahn. 4((A. Diagnosis
and Treatment of Tuberculous Pleural Effusion in 200. American 6!llege !2 6hest
Physicians.
Halim, Hadi. 4((A. Penyaki!Penyakit Pleura dalam "uku #jar Ilmu Penyakit Dalam$ Jilid II$
Edisi IV. *akarta: Deartemen #lmu Penyakit Dalam &K:#. Hal: 5(@' dan 5(@E.
48