Pleural effusion

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Pleural effusion
Classification and external resources

Massive left-sided pleural effusion (whiteness) in a patient presenting with lung cancer.
ICD-10 J90.-J91.
ICD-9 511.9
MeSH D010996
Pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that
surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of
the lungs during inhalation.
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[edit] Types of fluids
Four types of fluids can accumulate in the pleural space:
• Serous fluid (hydrothorax)
• Blood (hemothorax)
• Chyle (chylothorax)
• Pus (pyothorax or empyema)

[edit] Diagnosis
Pleural effusion is usually diagnosed on the basis of medical history and physical exam, and confirmed
by chest x-ray. Chest films acquired in the lateral decubitus position (with the patient lying on his side)
are more sensitive, and can pick up as little as 50 ml of fluid. At least 300 ml of fluid must be present
before upright chest films can pick up signs of pleural effusion (e.g., blunted costophrenic angles).
Once accumulated fluid is more than 500 ml, there are usually detectable clinical signs in the patient,
such as decreased movement of the chest on the affected side, dullness to percussion over the fluid,
diminished breath sounds on the affected side, decreased vocal resonance and fremitus (though this is
an inconsistent and unreliable sign), pleural friction rub. Above the effusion, where the lung is
compressed, there may be bronchial breathing and egophony. In large effusion there may be tracheal
deviation away from the effusion.

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.
Once a pleural effusion is diagnosed, the cause must be determined. Pleural fluid is drawn out of the
pleural space in a process called thoracentesis. A needle is inserted through the back of the chest wall in
the sixth, seventh or eighth intercostal space on the midaxillary line, into the pleural space. The fluid
may then be evaluated for the following:
1. Chemical composition including protein, lactate dehydrogenase (LDH), albumin, amylase, pH
and glucose
2. Gram stain and culture to identify possible bacterial infections
3. Cell count and differential
4. Cytology to identify cancer cells, but may also identify some infective organisms
5. Other tests as suggested by the clinical situation - lipids, fungal culture, viral culture, specific
immunoglobulins
[edit] Transudate vs. exudate

Needle biopsy of the pleura

The third step in the evaluation of pleural fluid is to determine whether the effusion is a transudate or
an exudate. Transudative pleural effusions are caused by systemic factors that alter the balance of the
formation and absorption of pleural fluid (e.g., left ventricular failure, renal failure, hepatic failure, and
cirrhosis), while exudative pleural effusions are caused by alterations in local factors that influence the
formation and absorption of pleural fluid (e.g., bacterial pneumonia, cancer, pulmonary embolism, and
viral infection).[1]
Transudative and exudative pleural effusions are differentiated by comparing chemistries in the pleural
fluid to those in the blood. According to a meta-analysis, exudative pleural effusions meet at least one
of the following criteria:[2]
1. Pleural fluid protein >2.9 g/dL (29 g/L)
2. Pleural fluid cholesterol >45 mg/dL (1.16 mmol/L)
3. Pleural fluid LDH >60 percent of upper limit for serum
Previously criteria proposed by Light for an exudative effusion are met if at least one of the following
exists (Light's criteria):[3]
1. The ratio of pleural fluid protein to serum protein is greater than 0.5
2. The ratio of pleural fluid LDH and serum LDH is greater than 0.6
3. Pleural fluid LDH is more than two-thirds normal upper limit for serum
Twenty-five percent of patients with transudative pleural effusions are mistakenly identified as having
exudative pleural effusions by Light's criteria. Therefore, additional testing is needed if a patient
identified as having an exudative pleural effusion appears clinically to have a condition that produces a
transudative effusion. In such cases albumin levels in blood and pleural fluid are measured. If the
difference between the albumin levels in the blood and the pleural fluid is greater than 1.2 g/dL (12
g/L), it can be assumed that the patient has a transudative pleural effusion[4].
[edit] Causes
[edit] Transudative
The most common causes of transudative pleural effusions in the United States are left ventricular
failure, and cirrhosis (causing hepatic hydrothorax). Pulmonary embolisms were once thought to be
transudative but have been recently shown to be exudative[5]

[edit] Exudative

Pleural effusion Chest x-ray of a pleural effusion. The arrow A shows fluid layering in the right pleural
cavity. The B arrow shows the normal width of the lung in the cavity
Once identified as exudative, additional evaluation is needed to determine the cause of the excess fluid,
and pleural fluid amylase, glucose, pH and cell counts are obtained.
• Pleural fluid amylase is elevated in cases of esophageal rupture, pancreatic pleural effusion, or
cancer.
• Glucose is decreased with cancer, bacterial infections, or rheumatoid pleuritis.
• Pleural fluid pH is low in empyema (<7.2) and may be low in cancer.
• If cancer is suspected, the pleural fluid is sent for cytology. If cytology is negative, and cancer is
still suspected, either a thoracoscopy, or needle biopsy[6] of the pleura may be performed.
• The fluid is also sent for Gram staining and culture, and, if suspicious for tuberculosis,
examination for TB markers (adenosine deaminase > 45 IU/L, interferon gamma > 140 pg/mL,
or positive polymerase chain reaction (PCR) for tuberculous DNA).
The most common causes of exudative pleural effusions are bacterial pneumonia, cancer (with lung
cancer, breast cancer, and lymphoma causing approximately 75% of all malignant pleural effusions),
viral infection, and pulmonary embolism.

[edit] Other/ungrouped
Other causes of pleural effusion include tuberculosis (though pleural fluid smears are rarely positive for
AFB, this is the most common cause of pleural effusion in some developing countries), autoimmune
disease such as systemic lupus erythematosus, bleeding (often due to chest trauma), chylothorax (most
commonly caused by trauma), and accidental infusion of fluids.
Less common causes include esophageal rupture or pancreatic disease, intraabdominal abscess,
rheumatoid arthritis, asbestos pleural effusion, Meigs syndrome (ascites and pleural effusion due to a
benign ovarian tumor), and ovarian hyperstimulation syndrome.
Pleural effusions may also occur through medical/surgical interventions, including the use of
medications (pleural fluid is usually eosinophilic), coronary artery bypass surgery, abdominal surgery,
endoscopic variceal sclerotherapy, radiation therapy, liver or lung transplantation, and intra- or
extravascular insertion of central lines.

[edit] Treatment

The free end of the Chest Drainage Device is usually attached to an underwater seal, below the level of
the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning
to the chest.
Treatment depends on the underlying cause of the pleural effusion.
Therapeutic aspiration may be sufficient; larger effusions may require insertion of an intercostal drain
(either pigtail or surgical). When managing these chest tubes it is important to make sure the chest
tubes do not become occluded or clogged. A clogged chest tube in the setting of continued production
of fluid will result in residual fluid left behind when the chest tube is removed. This fluid can lead to
complications such as hypoxia due to lung collapse from the fluid, or fibrothorax, late, when the space
scars down. Repeated effusions may require chemical (talc, bleomycin, tetracycline/doxycycline) or
surgical pleurodesis, in which the two pleural surfaces are scarred to each other so that no fluid can
accumulate between them. This is a surgical procedure that involves inserting a chest tube, then either
mechanically abrading the pleura, or inserting the chemicals to induce a scar. This require the chest
tube to stay in until the fluid drainage stops. This can be days to weeks and can require prolonged
hospitilizations. If the chest tube becomes clogged fluid will be left behind and the pleurodesis will fail.
Pleurodesis fails in as many as 30% of cases. An alternative is to place a Pleurex or Aspira Drainage
Catheter. This is a 15Fr chest tube with a one way valve. Each day the patient or care givers connect it
to a simple vacuum tube and remove from 600 cc to 1000 cc. This can be repeated daily. When not in
use, the tube is capped. This allows patients to be outside the hospital. For patients with malignant
pleural effusions, it allows them to continue chemotherapy, if indicated. Generally the tube is in about
30 days and then it is removed when the space undergoes a spontaneous pleurodesis.