PLEURAL EFFUSION

IVAN E. ROSALDO
RTRMF MED CLERK
Definition
Excess quantity of fluid in the pleural space
Etiology
1. Pleural fluid formation exceeds pleural fluid absorption.
Fluid enters the pleural space :
from the capillaries in the parietal pleura and is removed via
the lymphatics in the parietal pleura.
from the interstitial spaces of the lung via the visceral pleura
or from the peritoneal cavity via small holes in the
diaphragm
2. When there is excess pleural fluid formation (from the
interstitial spaces of the lung, the parietal pleura, or the
peritoneal cavity).
3. When there is decreased fluid removal by the lymphatics.
 TRANSUDATIVE EXUDATIVE PLEURAL EFFUSION
PLEURAL
EFFUSION
-systemic factors are -local factors (bacterial pneumonia, malignancy,
altered ( left-ventricular viral infection and PE)
failure and cirrhosis)
None Meet at least one of the criteria:
1. Pleural fluid protein/serum protein >0.5
2. Pleural fluid LDH/serum LDH >0.6
3. Pleural fluid LDH more than two-thirds the normal
upper limit for serum
If one or more of the exudative criteria are met and the
patient is clinically thought to have a condition producing
a transudative effusion, the difference between the
protein levels in the serum and the pleural fluid should be
measured. If this gradient is >31 g/L (3.1 g/dL), the
exudative categorization by these criteria can be ignored
because almost all such patients have a transudative
pleural effusion.
Tests: description of the appearance of the fluid, glucose
Effusion Due to Heart Failure
Most common cause of pleural effusion is left ventricular
failure.
Diagnostic thoracentesis should be performed if the
effusions are not
bilateral and comparable in size, if the patient is febrile, or
if the patient
has pleuritic chest pain to verify that the patient has a
transudative effusion.
(NT-proBNP) >1500 pg/mL - diagnostic that the effusion is
secondary to congestive heart failure.
Hepatic Hydrothorax - occur in ~5% of patients with
cirrhosis and ascites.
-direct movement of peritoneal fluid through
small openings in the diaphragm into the pleural space
- is usually right-sided and frequently is large
enough to produce severe dyspnea.
Parapneumonic Effusion - associated with bacterial
pneumonia, lung abscess, or bronchiectasis
-most common cause of exudative pleural
effusion in the United States
-Empyema refers to a grossly purulent effusion.
Free Pleural fluid
Lateral decubitus, CT scan of chest wall, UTZ
If fluid separates the lung from the chest wall by >10
mm, a therapeutic thoracentesis should be performed.
Factors indicating the likely need for a procedure more
invasive.
1. Loculated pleural fluid
2. Pleural fluid pH <7.20
3. Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
4. Positive Gram stain or culture of the pleural fluid
5. Presence of gross pus in the pleural space
Effusion secondary to
Malignancy
-secondary to metastatic disease are the second most
common type of exudative pleural effusion.
3 tumors that cause ~75% of all malignant pleural effusions are
lung carcinoma, breast carcinoma, and lymphoma. Most
patients complain of dyspnea, which is frequently out of
proportion to the size of the effusion. The pleural fluid is an
exudate, and its glucose level may be reduced if the tumor
burden in the pleural space is high.
The only symptom is dyspnea
One of the following procedures should be considered: (1)
insertion of a small indwelling catheter or (2) tube
thoracostomy with the instillation of a sclerosing agent such
as doxycycline, 500 mg.
Mesothelioma
- Are primary tumors that arise from the mesothelial cells
that line the pleural cavities; most are related to
asbestos exposure
- Chest pain and shortness of breath.
- Thoracoscopy or open pleural biopsy is usually
necessary to establish the diagnosis.
- Chest pain should be treated with opiates, and
shortness of breath with oxygen and/or opiates.
Effusion secondary to Pulmonary
Embolism
Dyspnea is the most common symptom
Pleural fluid is almost always an exudate.
The diagnosis is established by spiral CT scan or
pulmonary arteriography
Treatment is the same as it is for any patient with
pulmonary emboli.
Tuberculous pleuritis
Most common cause of an exudative pleural effusion is
tuberculosis
Associated with primary TB and are thought to be due
primarily to a hypersensitivity reaction to tuberculous
protein in the pleural space
Presents with fever, weight loss, dyspnea, and/or
pleuritic chest pain
Exudate with predominantly small lymphocytes.
TB markers in the pleural fluid (adenosine deaminase
>40 IU/L or interferon >140 pg/mL). Alternatively, the
diagnosis can be established by culture of the pleural
fluid, needle biopsy of the pleura, or thoracoscopy
Effusion secondary to viral infection
Exudative pleural effusions
No diagnosis is established for ~20% of exudative
effusions, and these effusions resolve spontaneously
with no long-term residua.
The importance of these effusions is that one should
not be too aggressive in trying to establish a diagnosis
for the undiagnosed effusion, particularly if the patient
is improving clinically.
Chylothorax
occurs when the thoracic duct is disrupted and chyle
accumulates in the pleural space.
most common cause iis trauma (most frequently
thoracic surgery), but it also may result from tumors in
the mediastinum
 Thoracentesis reveals milky fluid, and
biochemical analysis reveals a triglyceride
level that exceeds 1.2 mmol/L (110 mg/dL).
Patients with chylothorax and no obvious
trauma should have a lymphangiogram and a
mediastinal CT scan to assess the mediastinum
for lymph nodes. The treatment of choice for
most chylothoraxes is insertion of a chest tube
plus the administration of octreotide.
Hemothorax
When a diagnostic thoracentesis reveals bloody
pleural fluid, a hematocrit should be obtained on the
pleural fluid. If the hema-tocrit is more than one-half of
that in the peripheral blood, the patient is considered to
have a hemothorax. Most hemothoraxes are the result
of trauma; other causes include rupture of a blood
vessel.
Tx: Tube Thoracostomy
 Miscellaneous causes
If the pleural fluid amylase level is elevated, the
diagnosis of esophageal rupture or pancreatic disease is
likely. If the patient is febrile, has predominantly
polymorphonuclear cells in the pleural fluid, and has no
pulmonary parenchymal abnormalities, an
intraabdominal abscess should be considered.
Benign ovarian tumors can produce ascites and a
pleural effusion (Meigs syndrome), as can the ovarian
hyperstimulation syndrome.
Coronary artery bypass graft
In the first weeks are typically left-sided and bloody,
with large numbers of eosinophils, and respond to one
or two therapeutic thoracenteses.
After the first few weeks are typically left-sided and
clear yellow, with predominantly small lymphocytes,
and tend to recur.
Other medical manipulations that induce pleural
effusions include abdominal surgery; radiation therapy;
liver, lung, or heart transplantation; and the
intravascular insertion of central lines.
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