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Pleural effusions:
Evaluation and management
■ A B S T R AC T can cause pleural effu-
M sions, including diseases
ANY CONDITIONS
that are local
Pleural effusions are very common, and physicians of all (in the lungs or pleura), extrapulmonic, or sys-
specialties encounter them. A pleural effusion represents temic. In many cases the cause is a chronic
the disruption of the normal mechanisms of formation condition for which the patient is already
and drainage of fluid from the pleural space. A rational receiving treatment; therefore, a patient with
diagnostic workup, emphasizing the most common pleural effusion may present to a pulmonolo-
causes, will reveal the etiology in most cases. gist—or to a general internist, other medical
specialist, or surgeon. In up to 20% of cases
■ KEY POINTS the cause remains unknown despite a diagnos-
tic workup.
Symptoms depend on the amount of fluid accumulated
and the underlying cause of the effusion. Many patients ■ AN IMBALANCE OF FLUID
have no symptoms at the time a pleural effusion is FORMATION AND DRAINAGE
discovered. Possible symptoms include pleuritic chest
pain, dyspnea, and dry nonproductive cough. A pleural effusion—an excessive accumula-
tion of fluid in the pleural space—indicates an
imbalance between pleural fluid formation
A key question in evaluating an effusion is whether the and removal.
excess pleural fluid is transudative or exudative. The normal pleural space contains a rela-
tively small amount of fluid, 0.1 to 0.2 mL/kg
Treatment depends on the severity and the cause. of body weight on each side.1,2
Thoracentesis is done to relieve symptoms. Chest tubes Pleural fluid is formed and removed slow-
provide continuous drainage in cases of pneumothorax, ly, at an equivalent rate, and has a lower pro-
hemothorax, penetrating chest trauma, complicated tein concentration than lung and peripheral
parapneumonic effusion or empyema, or chylothorax. lymph. It can accumulate by one or more of
Pleural sclerosis (pleurodesis) is usually indicated for the following mechanisms1–3:
patients with uncontrolled symptomatic malignant • Increased hydrostatic pressure in the
effusions. microvascular circulation: clinical data
suggest that an elevation in capillary
wedge pressure is the most important
determinant in the development of pleur-
al effusion in congestive heart failure.
• Decreased oncotic pressure in the
microvascular circulation due to hypoal-
buminemia, which increases the tendency
to form pleural interstitial fluid.
• Increased negative pressure in the pleural
space, also increasing the tendency for
TA B L E 1
Causes of pleural effusions
FREQUENCY TRANSUDATES EXUDATES
pleural effusions in the intensive care setting. effusions, thereby increasing the yield and
Loculated effusions, defined as effusions safety of the procedure. However, it is not
that do not shift freely in the pleural space, practical to recommend ultrasonography for
occur when there are adhesions between the all effusions. Portable ultrasound units can be
visceral and parietal pleura. The lateral decu- brought to the bedside of extremely ill
Even large bitus view helps in differentiating free fluid patients.11
effusions may from loculated fluid. The patient should be
positioned with the affected side down on the Computed tomography
be missed on x-ray table. Computed tomography (CT), with its cross-
supine chest Chest radiographs can also provide impor- sectional images, can be used to evaluate com-
tant clues to the cause of an effusion. Bilateral plex situations in which the anatomy cannot
radiographs effusions accompanied by cardiomegaly are be fully assessed by plain radiography or ultra-
because the usually caused by congestive heart failure. sonography (FIGURE 1). For instance, CT is
pleural fluid Large unilateral effusions without contralateral helpful in distinguishing empyema from lung
mediastinal shift suggest a large atelectasis, abscess, in detecting pleural masses (eg,
settles to the infiltration of the lung with tumor, a mesothe- mesothelioma, plaques), in detecting lung
back lioma, or a fixed mediastinum due to tumor or parenchymal abnormalities “hidden” by an
fibrosis.6 effusion, and in outlining loculated fluid col-
lections.10
Ultrasonography
The major advantage of ultrasonography over ■ THORACENTESIS AND LABORATORY
radiography is its ability to differentiate STUDIES
between solid components (eg, tumor or
thickened pleura) and liquid components of a Transudate vs exudate
pleural process. It is useful in detecting abnor- Although the history, physical examination,
malities that are subpulmonic (under the and radiographic studies may provide impor-
lung) or subphrenic (below the diaphragm) tant clues to the cause of a pleural effusion,
and in differentiating them.9–11 almost all cases should be evaluated with diag-
A major use of ultrasonography is to guide nostic thoracentesis.12,13
thoracentesis in small or loculated pleural Possible situations in which thoracentesis
TA B L E 2
Light’s criteria for distinguishing transudative
from exudative pleural fluid
PLEURAL/SERUM PLEURAL/SERUM LACTATE SERUM LACTATE
PROTEIN RATIO DEHYDROGENASE RATIO DEHYDROGENASE
TA B L E 3
Sensitivity and specificity of tests
to distinguish exudative from transudative effusions
SENSITIVITY SPECIFICITY
FOR EXUDATES FOR EXUDATES
(%) (%)
Light’s criteria 98 83
Pleural-fluid cholesterol level > 60 mg/dL 54 92
Pleural-fluid cholesterol level > 43 mg/dL 75 80
Ratio pleural-fluid cholesterol/serum cholesterol > 0.3 89 81
Serum albumin level minus pleural fluid albumin level ≤ 1.2 g/dL 87 92
Almost all MODIFIED WITH PERMISSION FROM LIGHT RW. PLEURAL EFFUSION. N ENGL J MED 2002; 346:1971–1977.
effusions
should be
evaluated with should not be done are when the effusion is diagnostic tests are required (TABLE 1).
too small to be safely aspirated (< 10 mm thick Several tests of the pleural fluid have been
a diagnostic on ultrasonography or lateral decubitus radi- proposed to differentiate transudates from
thoracentesis ography) or when it can be explained by exudates. Light’s criteria (TABLE 2), originally
underlying congestive heart failure (especially published in 1972 and still the gold standard,
bilateral effusions that improve with diuresis), require simultaneous measurement of the lev-
recent thoracic or abdominal surgery, or post- els of protein and lactate dehydrogenase in the
partum status. However, the procedure may pleural fluid and in the serum.2,12,13 Newer
still be indicated in these situations if the proposed criteria are not much more sensitive
patient’s clinical condition deteriorates. or specific (TABLE 3).14–16
After obtaining a sample of pleural fluid, A particular use for some of the newer cri-
the clinician should determine whether the teria is to differentiate between transudates
effusion is transudative (ie, due to hydrostatic and exudates in some patients with congestive
forces, and with a low protein content) or heart failure who receive diuretics—which
exudative (due to increased permeability of can cause a transient increase in protein con-
the pleural surfaces and blood vessels, with a centration in the pleural fluid due to move-
relatively high protein content). If the fluid is ment of water from the pleural fluid into the
a transudate, the possible causes are relatively blood—and are found to have an exudative
few, and further diagnostic procedures are not effusion by Lights’s criteria. If the clinical
necessary. In contrast, if the fluid is an exu- appearance suggests an uncomplicated tran-
date, there are many possible causes, and more sudative effusion, the albumin levels in the
Symptomatic effusion with significant volume of fluid Very small effusion (< 10 mm thick on lateral decubitus
view) or asymptomatic with obvious cause (eg, congestive
heart failure, postoperative status)
Determine if fluid is a transudate or exudate (TABLE 2, No need to perform thoracentesis unless clinical
TABLE 4), consider common causes (TABLE 1) deterioration occurs
*Cytology may be ordered if malignant disease is suspected. If infection is considered in the differential diagnosis, then testing of the pH
and glucose in pleural fluid must be ordered on initial evaluation.
arthritis during the course of the disease. al effusions in the absence of demonstrable
SLE. The pleural fluid antinuclear anti- pulmonary disease. Rupture of a subpleural
body (ANA) titer may help in separating SLE caseous focus into the pleural space allows
effusions from effusions due to other causes, tuberculous protein to enter the pleural space
In tuberculous even in patients with known SLE. A pleural and to generate a hypersensitivity reaction
pleuritis, fluid ANA titer greater than 1:160 or a pleur- responsible for most of the clinical manifesta-
al fluid-to-serum ANA ratio greater than 1.0 tions.
pleural effusion suggests lupus pleuritis.26 Although these cri- Pleural effusion in tuberculous pleuritis
can mimic teria appear to be highly specific, they are not manifests as an acute illness that can mimic
highly sensitive. acute bacterial pneumonia. It is usually uni-
acute bacterial Rheumatoid arthritis. Pleural effusions in lateral and can be of any size. Coexistence of
pneumonia rheumatoid arthritis are often asymptomatic. parenchymal disease is visible on standard
They may be quite large and often persist for radiographs in 19% of patients.23
many months without change. Rheumatoid The pleural fluid in tuberculosis is invari-
effusions usually occur in patients with high ably an exudate with more than 50% lympho-
serum rheumatoid factor titers and rheuma- cytes in the white cell differential count. It
toid nodules. The fluid typically has a very rarely contains more than 5% mesothelial
low glucose level. Pleural rheumatoid factor cells, which is explained by the extensive
titers are not helpful in diagnosis because they involvement of the pleural surface by the
may be elevated in pneumonia, tuberculosis, inflammatory process.2 A definitive diagnosis
malignancy, and SLE. may be difficult and depends on the demon-
In patients with rheumatoid arthritis stration of acid-fast bacilli in sputum, pleural
being treated with anti-tumor-necrosis factor fluid, or pleural biopsy specimen, or the
therapy, special concern is warranted to demonstration of granulomas in the pleura.
exclude tuberculosis. Pleural fluid analysis and cultures for acid-fast
bacilli are positive in less than 25% of cases.
Tuberculosis Pleural biopsy culture can increase the yield to
In many areas of the world, tuberculosis con- 55%.2,23
tinues to be the most common cause of pleur- Additional measurements that suggest the
Very low Minimal free-flowing effusion AND > 7.2 AND Negative or unknown No
(< 10 mm on lateral decubitus)
Low Small to moderate AND ≥ 7.2 AND Negative No‡
free-flowing effusion
(> 10 mm and < 1/2 hemithorax)
Moderate Large free-flowing OR < 7.2 OR Positive Yes
or loculated effusion
(≥ 1/2 hemithorax)
High Pus Yes
*It is not necessary to have a proven bacterial pneumonia: clinical diagnosis is enough
†pH and bacteriologic study results have priority over amount of fluid
‡If clinical condition deteriorates, repeating thoracentesis and drainage should be considered
ADAPTED FROM COLICE GL, CURTIS A, DESLAURIERS J, ET AL; FOR THE AMERICAN COLLEGE OF CHEST PHYSICIANS PARAPNEUMONIC EFFUSIONS PANEL. ACCP CONSENSUS
STATEMENT. MEDICAL AND SURGICAL TREATMENT OF PARAPNEUMONIC EFFUSIONS: AN EVIDENCE-BASED GUIDELINE. CHEST 2000; 118:1158–1171.
diagnosis include pleural fluid adenosine deam- after coronary artery bypass grafting
inase, interferon-gamma, and polymerase chain (CABG). 32 The reported prevalence 1
reaction for mycobacterial DNA. Elevations of week after surgery has ranged from 40% to Pleural
pleural adenosine deaminase levels have been 75%. effusions are
observed in tuberculous pleurisy, rheumatoid Most of these effusions are small, unilater-
arthritis, and empyema. Adenosine deaminase al, left-sided, and asymptomatic. In general, common
levels above 40 U/L distinguish tuberculous they gradually resolve over several weeks. immediately
effusions from other lymphocytic pleural effu- Large pleural effusions (> 25% of hemithorax)
sions (ie, malignancies, lymphoma, collagen not explained by any other cause occur in a after CABG
vascular diseases),27,28 as do interferon-gamma small proportion of patients.
levels above 140 pg/mL.29 The fluid is invariably an exudate and
can be classified according to its gross
Urinothorax description.32 Bloody effusions tend to occur
Urinothorax, a rare cause of pleural effusion, is earlier (< 4 weeks after surgery) and are easy
believed to occur when urine moves retroperi- to control with one to three therapeutic tho-
toneally into the pleural space owing to uri- racenteses. Nonbloody effusions tend to
nary obstruction, trauma, a retroperitoneal occur later (> 4 weeks after surgery) and
inflammatory or malignant process, failed have a relatively low lactate dehydrogenase
nephrostomy, or kidney biopsy.2,30 The pleural level and a high percentage of lymphocytes.
fluid is a transudate with the unique feature of Nonbloody effusions are more difficult to
having a pleural fluid-to-serum creatinine control despite repeat thoracentesis and may
ratio greater than 1.0. It also can have a low require anti-inflammatory agents or chemi-
pH (< 7.3) or low glucose level, both of which cal pleurodesis.
are uncommon in transudative effusions.31
Chylous effusion
After coronary artery bypass grafting A true chylous pleural effusion develops when
Pleural effusions are common immediately chyle enters the pleural space owing to disrup-
tion of the thoracic duct by trauma (surgical tion. In one study of clinically documented
or nonsurgical) or by malignancy. Continuous effusions, routine thoracentesis was compli-
drainage of a chylous effusion may result in cated by pneumothorax in only 7% of
malnutrition and immunosuppression due to patients.36 The same study showed that thora-
significant loss of protein, fats, electrolytes, centesis altered the diagnosis in 45% of
and lymphocytes. patients and changed the treatment in 33%.
Initial conservative treatment consists of Use of ultrasound guidance has been shown to
limiting dietary fat to medium-chain triglyc- improve the safety of thoracentesis in
erides that are absorbed through the portal mechanically ventilated patients.37
venous system and not carried by lymph, in an
attempt to decrease the lymph flow rate. If ■ UNEXPLAINED EFFUSIONS
necessary, lymph flow can be further reduced
by using total parenteral nutrition and avoid- The cause of 15% to 20% of all pleural effu-
ing oral intake.33,34 sions will remain unknown despite intensive
Surgical therapy for chylothorax, with diagnostic efforts.38 An unexplained pleural
thoracic duct ligation or pleuroperitoneal effusion has been defined as one without an
shunt implantation, may be necessary before apparent cause despite repeat thoracentesis.
the patient becomes too cachectic to tolerate The clinician should ensure that all the
the intervention.33,34 unusual causes of pleural effusion are consid-
ered and requisite studies are obtained.
Pleural effusions Roughly 50% of these effusions resolve
due to pulmonary embolism spontaneously, and no disease is apparent on
Pleural effusions occur in 30% to 50% of long-term follow-up. Many unresolved pleural
patients with pulmonary emboli. It is possible effusions will turn out to be caused by malig-
that a significant number of undiagnosed effu- nant disease, which is obvious clinically or is
sions are due to pulmonary embolism. incurable in any event. The most common
The fluid may be transudative (24%) or treatable cause of an unexplained effusion is
The cause of exudative, depending on the mechanism. A tuberculosis.39
15% to 20% of transudate occurs when there is right-sided Thus, invasive procedures such as video-
heart failure and increased capillary pressure assisted thoracoscopy or thoracotomy with
all pleural in the parietal pleura. An exudate occurs due direct sampling of the pleura are frequently
effusions will to increased permeability of the capillaries in recommended for these patients.
the lung (caused by ischemia or inflammatory
remain mediators from the platelet-rich thrombi). ■ THERAPY
unknown Standard anticoagulation is the treatment
of choice. Therapeutic thoracentesis
Any pleural effusion large enough to cause
Pleural effusions in the intensive care unit severe respiratory symptoms should be drained
The incidence of pleural effusions in the regardless of the cause and regardless of con-
intensive care unit (ICU) varies according to comitant disease-specific treatment. Relief of
the screening method. One study, using rou- symptoms is the main goal of therapeutic
tine ultrasonography, found pleural effusions drainage in these patients.
in 62% of medical ICU patients, with a pre- The only absolute contraindication to
dominance of transudates.35 On the other thoracentesis is active cutaneous infection at
hand, pleural effusions were detected by phys- the puncture site. Some relative contraindica-
ical examination and opacification of at least tions include severe bleeding diathesis, sys-
one third of the lung field on radiography in temic anticoagulation, and a small volume of
only 8.4% of ICU patients. With the latter fluid.
method, exudates related to infection were Possible complications of the procedure
more common.36 include bleeding (due to accidental puncture
Thoracentesis is not contraindicated in of a vessel or lung parenchyma), pneumotho-
ICU patients receiving mechanical ventila- rax, infections (soft-tissue infection or empye-
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NOW AVAILABLE!
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of To Act As A Unit: The Story of The placed percutaneously under imaging guidance. AJR
Cleveland Clinic is now available. Am J Roentgenol 1989; 152:1189–1191.
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This 405-page book will rivet your drainage. Radiology 1988; 169:5–9.
attention as it describes the origin 47. Bouros D, Schiza S, Siafakas N. Utility of fibrinolytic
and maturation of one of the nation’s agents for draining intrapleural infections. Semin
leading academic medical centers. Learn Respir Infect 1999; 14:39–47.
48. Sahn SA. Use of fibrinolytic agents in the management
how the founders incorporated the best of complicated parapneumonic effusions and empye-
features of military medicine into The mas. Thorax 1998; 53(suppl 2):S65–S72.
Cleveland Clinic’s unique and innovative 49. Walker-Renard PB, Vaughan LM, Sahn SA. Chemical
model of medicine. See how major pleurodesis for malignant pleural effusions. Ann Intern
adversity helped to shape the Med 1994; 120:56–64.
50. Management of malignant pleural effusions. Am J
organization’s character. Respir Crit Care Med 2000; 162:1987–2001.
51. Cassina PC, Hauser M, Hillejan L, Greschuchna D,
Spanning most of the 20th century, Stamatis G. Video-assisted thoracoscopy in the treat-
this inspirational story recounts The ment of pleural empyema: stage-based management
Cleveland Clinic’s humble origins, its and outcome. J Thorac Cardiovasc Surg 1999;
117:234–238.
survival of the ravages of war, disaster,
and ostracism by the medical
ADDRESS: Raed A. Dweik, MD, Department of Pulmonary,
establishment, and its emergence, Allergy and Critical Care Medicine, A90, The Cleveland Clinic
stronger than ever, into the 21st century Foundation, 9500 Euclid Avenue, Cleveland, OH 44195-5038;
as a thriving and respected health care e-mail dweikr@ccf.org.
institution.
The fourth edition contains new sections
describing the formation of The
Cleveland Clinic Health System, the
creation of The Cleveland Clinic Lerner
College of Medicine of Case Western
Reserve University, the new-found CME ANSWERS
success of philanthropy, and phenomenal
growth in all areas of activity. Answers to the credit test on page 951
of this issue
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your copy now. Get it from 1C2B3D4C5E6B7D
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