Pleural Effusion

Harrisons Manual of Medicine 18th

edition
Chapter 144; Section 9
p. 939-44
Pleural effusion is defined as excess
fluid accumulation in the pleural
space.
-Increased of pleural fluid (PF)
formation, or
- Decreased of pleural fluid (PF)
removal by the parietal pleural
lymphatics
Classification
Transudate (systemic)
Left ventricular heart failure
Cirrhosis
nephrotic syndrome
Exudate (local)
Bacterial pneumonia
Malignancy
Viral infection
Pulmonary embolism
Transudative Pleural
Effusion
Present of pleuritic chest pain, febrile
thoracentesis
Thoracentesis is not always required
if CHF is present
Pleural fluid NT-proBNP > 1500
pg/mL effusion related to CHF
 Transudative Pleural
Effusion
1. Congestive heart failure
2. Cirrhosis
3. Pulmonary embolization
4. Nephrotic syndrome
5. Peritoneal dialysis
6. Superior vena cava obstruction
7. Myxedema
8. Urinothorax
Exudative Pleural
Effusion
1. Neoplastic diseases
a. Metastatic disease
b. Mesothelioma
2. Infectious diseases
a. Bacterial infections
b. Tuberculosis
c. Fungal infections
d. Viral infections
e. Parasitic infections
3. Pulmonary embolization
4. Gastrointestinal disease
a. Esophageal perforation
b. Pancreatic disease
c. Intraabdominal abscesses
d. Diaphragmatic hernia
e. After abdominal surgery
f. Endoscopic variceal sclerotherapy
g. After liver transplant
5. Collagen vascular diseases
a. Rheumatoid pleuritis
b. Systemic lupus erythematosus
c. Drug-induced lupus
d. Immunoblastic lymphadenopathy
Exudative Pleural
Effusion
Exudative pleural effusion meet at least 1 of
the following criteria:
Lights criteria
Pleural fluid protein/serum protein >0,5
Pleural fluid LDH/serum LDH >0,6
Pleural fluid LDH > 2/3 normal upper limit for
serum

Following tests : pH, glucose, WBC with diff

count, microbiologis studies, cytology, amylase
Exudative Pleural
Effusion
6. Post-coronary artery bypass surgery
7. Asbestos exposure
8. Sarcoidosis
9. Uremia
10.Meigs' syndrome
11.Yellow nail syndrome
12.Drug-induced pleural disease
a. Nitrofurantoin
b. Dantrolene
c. Methysergide
d. Bromocriptine
e. Procarbazine
f. Amiodarone
g. Dasatinib
13.Trapped lung
14.Radiation therapy
15.Post-cardiac injury syndrome
16.Hemothorax
17.Iatrogenic injury
18.Ovarian hyperstimulation syndrome
19.Pericardial disease
20.Chylothorax
Parapneumonic Effusion
Associated with bacterial lung infections,
including pneumonia and lung abscess
Empyema refers to grossly purulent
effusion
Tube thoracostomy is indicated if:
Gross pus is present
Grams stain or culture of PF is positive
PF glucose >60mg/dL (>3,3 mmol/L)
pH <7.20
Loculated pleural fluid
Malignant Pleural
Effusion
Metastatic cancer common cause of
exudative pleural effusion
Malignant effusion frequently caused by
lung cancer, breast cancer, and lymphoma
PF glucose level may be reduced
Cytologic examination of the pleural fluid is
usually diagnostic.
If negative, thoracoscopy should be considered
Symptomatic relief of dyspnea can be provided
by therapeutic thoracentesis
Effusion Related to Pulmonary
Thromboembolism
Usually exudative but can be
transudative.
The presence of a pleural effusion
does not alter the standard
treatment for pulmonary embolism
Tuberculous Pleuritis
Exudative with predominant lymphocytosis
Usually associated with primary
tuberculosis (Tb) infection
Diagnosis :
High levels of Tb markers in the pleural fluid
(adenosine deaminase and interferon )
PF mycobacterial cultures low positive
culture rate
Pleural biopsy high positive culture rate with
needle biopsy or thoracoscopy
Effusion Secondary to Viral
Infection
No diagnosis is established for
approximately 20% of exudative
effusions
Viral infections likely account for
many of these cases
Pleural effusions related to viral
infection resolve spontaneously.
Rheumatoid Pleural Effusion

RA can cause exudative pleural

effusions
Effusions may precede particular
symptoms
Pleural fluid very low glucose and
pH
Rheumatoid pleural effusions are
usually seen in males
Chylothorax
Exudative pleural effusion with milky fluid
and an elevated triglyceride level (>1.2
mmol/L or >110 mg/dL).
Most common etiologies :
Trauma to the thoracic duct
Mediastinal tumors.
Chest tube placement is often required, and
octreotide administration may be beneficial.
Prolonged chest tube drainage can lead to
malnutrition.
Hemothorax
Commonly results from trauma; blood vessel
rupture and tumor are other potential etiologies
When frankly bloody pleural fluid is noted at
thoracentesis, the hematocrit should be tested
If PFs hematocrit >50% of the bloodstream
hematocrit, a hemothorax is present.
Chest tube placement is typically required
If pleural blood loss is >200 mL/h, thoracic
surgical intervention should be pursued