Pleural effusion

Dr.Md.Toufiqur RahmanFCPS, MD

Associate Professor of cardiologyNICVD, Dhaka

CLINICAL EXAMINATION OF THE RESPIRATORY SYSTEM

Essentials of Diagnosis

• May be asymptomatic; chest pain frequently seen in the setting of pleuritis, trauma, or infection; dyspnea is common with large effusions.

• Dullness to percussion and decreased breath sounds over the effusion.

• Radiographic evidence of pleural effusion. • Diagnostic findings on thoracentesis.

Causes of pleural effusion

Common causes

Pneumonia ('para-pneumonic effusion')

Tuberculosis

Pulmonary infarction*

Malignant disease

Cardiac failure*

Subdiaphragmatic disorders (subphrenic abscess, pancreatitis etc.)

Uncommon causes Hypoproteinaemia* (nephrotic syndrome, liver failure,

malnutrition) Connective tissue diseases* (particularly systemic lupus

erythematosus (SLE) and rheumatoid arthritis) Acute rheumatic fever Post-myocardial infarction syndrome Meigs' syndrome (ovarian tumour plus pleural effusion) Myxoedema* Uraemia* Asbestos-related benign pleural effusion

Causes of pleural effusion

Causes of pleural fluid transudates and exudates.

Pleural effusion: main causes and features

Light's criteria for distinguishing pleural transudate from exudate

Pleural fluid is an exudate if one or more of the following criteria are met:

• Pleural fluid protein:serum protein ratio > 0.5

• Pleural fluid LDH:serum LDH ratio > 0.6

• Pleural fluid LDH > two-thirds of the upper limit of normal serum LDH

Management• Therapeutic aspiration may be required to palliate

breathlessness, but removing more than 1.5 L in one episode is inadvisable as there is a small risk of re-expansion pulmonary oedema.

• An effusion should never be drained to dryness before establishing a diagnosis, as further biopsy may be precluded until further fluid accumulates.

• Treatment of the underlying cause-for example, heart failure, pneumonia, pulmonary embolism or subphrenic abscess-will often be followed by resolution of the effusion.

• The management of pleural effusion in association with pneumonia, tuberculosis and malignancy is discussed in the relevant sections.

Position of patient and operator for the posterior approach to thoracentesis

Technique of thoracentesis using a regular steel needle. A. Successful tap, with fluid obtained. B. Air is obtained if the position of the needle is too high. C. A bloody tap may result if the position of the needle is too low.

Catheter, three-way stopcock, syringe, and collection bag ready for evacuation of pleural fluid.

Characteristics of important exudative pleural effusions.

Pleural effusion. The elevation of the left hemidiaphragm may be caused by a pleural effusion at the left base. The appropriate way to determine the nature of this abnormality is to obtain a left lateral decubitus film. Lateral decubitus film shows that a small effusion was also present

on the right side.

MECHANISMS THAT LEAD TO ACCUMULATION OF PLEURAL FLUID

• Increased hydrostatic pressure in the microvascular circulation (heart failure)Decreased oncotic pressure in the microvascular circulation (severe hypoalbuminemia)Decreased pressure in the pleural space (lung collapse)Increased permeability of the microvascular circulation (pneumonia)Impaired lymphatic drainage from the pleural space (malignant effusion)Movement of fluid from the peritoneal space (ascites)

Pleural effusion. A, Blood-stained pleural aspirate. This patient had pleural metastases from carcinoma of the breast. B, Chylous pleural effusion. This patient had bronchial carcinoma that

had invaded and obstructed the thoracic duct. C, Pleural transudate. This pale effusion is typically found in patients with heart failure or other causes of generalized edema.

Ultrasound image of the left hemithorax.

Computed tomography of the patient .Bilateral pleural effusions are present as a result of pneumonia

CHARACTERISTICS OF PLEURAL FLUID TRANSUDATES

CORRELATION OF PLEURAL FLUID EXUDATE FINDINGS AND CAUSATIVE DISEASE

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