PLEURAL EFFUSIONS

Pleural effusion
 Pleural effusion is the presence of fluid
within the pleural space, the pleural can be
the site of both benign and malignant
diseases that may represent primary pleural
processes, localized extrapleural diseases,
or systemic illnesses. Pain and dyspnea are
the most common symptoms of pleural
disease.
Anatomy of pleural membrane
and pleural space 1234

 Pleural membrane consists of parietal

pleura and visceral pleura
 A space situated between parietal and

visceral pleura is called pleural space

 It is normally filled with 5 - 10
milliliter
of serous fluid
Anatomy of pleural membrane
and pleural space 1234
Parietal pleura
Receiving its blood supply from the
systemic circulation and containing
sensory nerve ending
 Anatomy of pleural membrane
and pleural space 1234
Visceral pleura
Receiving its blood supply from the low
pressure pulmonary circulation and
containing no sensory nerve fibers
So the pleural pain is mediated through somatic
intercostal nerves of the chest wall and through
the phrenic nerve, causing chest wall or back
pain and pain referred to the shoulder,
respectively.
 Mechanism of formation-resorption
of pleural fluid
Parietal Visceral
pleura pleura
Hydrostatic
pressure(30) Pressure of pleural 11
space (5)

Permeability
of systemic Permeability of pleural 34
circulation(34) fluid (8)

5+8+30-34=9 34-(5+8+11)=10
 The mechanisms that lead to accumulation
of pleural fluid
l. Increased hydrostatic pressure in microvascular
circulation (congestive heart failure)
2. Decreased colloidal osmotic pressure in microvascular
circulation (severe hypoalbuminemia )
3. Increased permeability of the microvascular circulation
(pneumonia)
4. Decrease in the intrapleural pressure
5. Impaired lymphatic drainage from the pleural
space (malignant effusion)
6. Movement of fluid from peritoneal space ( ascites )
7.Rupture of a vascular or lymphatic structure (trauma,
cancer)
 Transudates and exudates

 Pleural effusions, being a common medical

problem, have been classically divided into
transudates and exudates. Differentiation is of
particular importance because in the case of a
transudate, aetiology and therapy are directed to
the underlying congestive heart failure, cirrhosis,
or nephrosis; Alternatively, if the effusion proves
to be an exudate, malignancy is suspected and a
more extensive diagnostic procedure is needed.
 Two kinds of pleural effusions
Transudates and exudates
Transudate Exudate
 Cause non-inflammatory flammatory,tumor
 Apperance light yellow yellow, purulent
 Specific gravity <1.018 >1.018
 Coagulability unable able
 Rivalta test negative positive
 Protein content <30g/L >30g/L
 ΘP. To serum Pre < 0.5 > 0.5
 LDH < 200 I U/ L > 200 I U / L
 Θ P. To s < 0.6 > 0.6
 Cell count < 100×10 6/ L > 500×10 6 / L
 Differential cell Lymphocyte Different
Common causes of pleural effusions
Transudates
1. Generalized salt and water retention, e.g.,
congestive heart failure, nephrotic syndrome,
hypoalbuminemia
2. Ascites, e.g.,
cirrhosis, meigs' syndrome, peritoneal dialysis
3. Vascular obstruction, e.g.,
superior vena cava obstruction
4. Tumor
Exudates
l. Infectious diseases, e.g.,
TB, bacterial pneumonias, and other
infectious diseases.
2. Tumor
3. Pulmonary infarction
4. Rheumatic diseases
 Clinical manifestations
 Symptoms:
asymptomatic
pain- "pleuritic" or "dull ache“
cough
Dyspnea
 Physical examination:
enlarged hemithorax
reduced vocal fremitus
dullness to percussion
decreased breath sounds,
friction-rub
Approach to a pleural effusion
 Plain chest X-ray -
Distribution is determined by gravity..
Obliteration off lateral costophrenic angle
Fluid higher laterally (PA film) and
semicircular meniscus on lateral films..
 Clinical approach- cont.
 x-rays
 Ultrasound
 Computerized tomography
 MRI
 Closedpleural biopsy
 Thoracoscopy
 Open pleural biopsy
 Empyema
 Empyema - "pus" in the pleural space
l. TB
2. Pulmonary infection
3. Trauma
4. Esophageal rupture
 Empyema
 "Complicated pleural effusion":
 Thick pus
 pH < 7.00 or glucose < 60mg/ dl
 Positive gram stain or culture
 pH <7.2 and LDH >1000U
 Hemothorax
 Defined as pleural fluid hematocrit of 50%
of blood hematocrit
 Will coagulate & may lead to loculation

with complications of fibrothorax &

possible empyema
 If small,, may defibrinate & remain free

flowing
 Hemothorax
l. Trauma
2. Tumor
3. Pulmonary infarction
4. TB
5. Spontaneous pneumothorax
Chylous effusion
1. Trauma
2. Tumor
3. TB
4. Thrombosis of the left subclavian vein
Bilateral effusion
1. Generalized salt and water
retention
e.g., congestive heart failure
nephrotic syndrome
2. Ascites
3. Pulmonary infarction
4. Tumor
5. TB
♦ T B ( Tuberculosis ) is the most
common cause of pleural effusion ,
especially in young people
♦ Malignant pleural effusion is frequently
met in aged people today
♦ Pleural transudation is most commonly
caused by congestive heart failure
Diagnostic procedures 12345

History(primary diseases)
clinical signs

physical examinations
 clinical signs
♦ pleural pain,
♦ dyspnea,
♦ tachypnea,
♦ mild outward bulging of the intercostal
spaces,
♦ decreased tactile fremitus,
♦ dullness or flatness,
♦ decreased transmission of breath and vocal
sounds in the area of the effusion,
♦ and occasionally pleural friction sound in its
early stage (dry pleurisy)
Diagnostic procedures 12345
Chest X-ray examination
Blunting of the normally sharp costophyrenic
angle, a concave shadow with its highest margin
along the pleural surface, shift of the mediastinum
and the trachus toward the normal side
Pleural effusion
Diagnostic procedures 12345

Ultrasonic examination
To localize a small pleural effusion and
determine the correct site for performance
of a thoracentesis
Diagnostic procedures 12345

Thoracentesis
To aspirate the effusion for laboratory
examination:
Appearance, Specific gravity, Protein content,
Cell counts, Glucose, LDH lipid content,
Rheumatoid factor (RF),
Gram stain and culture,
Cytologic examination, etc.
Diagnostic procedures 12345

Pleural biopsy
To obtain a specimen for histologic
examination and culture
 Diagnostic procedure
is there pleural effusion or not ?
Thoracentesis

transudates? exsudates?
what is the etiology?

Treatment based on the etiology

 Treatment
Treatment for pleural effusions, whether
transudates or exudates is primarily for the
underlying pulmonary or systemic disease:
♦ aspiration of fluid is usually indicated

to establish the diagnosis

It is also therapeutically used to relieve
dyspnea from a large effusion
 Tuberculous pleural effusion
 TB remains the most common cause of
pleural effusion in young people
 Etiology: tubercle bacillus
 Pathogenesis: host hypersensitivity to

tubercular protein in pleural tubercles

 Delayed hypersensitivity
Clinical Manifestations
 Generalized symptoms of toxicity of TB:
Fever, high sweat, fatigue and weight loss, etc.
 Those of pleural effusion:
Pleuritic pain, short breath and dyspnea, etc.
 Pleural fluid is exudative and usually

reveals lymphocytosis
 Rarely pleural fluid is blood stained
 The PPD or OT test usually positive
 Diagnosis

 Based on mentioned findings and some

examinations of pleural fluids,
and culture of material obtained at biopsy
of the pleura and pleural fluids.
 except for pleural effusions caused by
other causes.
Treatment

(1) Standard antituberculous regimens

( usually short course of antituberculous
chemotherapy is used )
(2) Administration of corticosteroid
during the first several weeks of
treatment
(3) Thoracentesis
 Empyema

 Thick purulent fluid with more than 100,000

cells per cubic millimeter or fluid with PH
values less than or equal to 7. 20 should
be treated as a presumptive empyema
 The general objectives of therapy of empyema

are the elimination of both the systemic and

local infection.
 Treatment of acute empyema

(1) Control of infection

systemic and local
(2) Repeated thoracentesis or
drainage of the empyema, removal
of the purulent material, with
obliteration and sterilization of the
pleural space
(3) elimination of the underlying disease
process
(4) Chronic empyema is primarily
treated operatively , Operative therapy
is also indicated in the empyema with
associated bronchopleural fistula or with
the ipsilateral ruined lung.
Treatment of malignant pleural
effusion

 Usesystemic anti-tumor medicines

 Local treatments