Pleural Effusion
By Dr / Islam Nomeir Salama
potential space
اﻟطﺑﯾﻌﻲ اﻧﮫ ﻓﺎرغ
diseases of pleura:
-effusion
-plurisy (infection)
اﻟﻠﻲ ﺑﺗﺣس
Pleural Effusion
Pleural effusions are a common medical problem with more than 50
recognized causes including disease local to the pleura or underlying
lung, systemic conditions, organ dysfunction and drugs
It occur as a result of increased fluid formation and/or reduced fluid
resorption.
Mechanism
Increase permeability
Increase pulmonary capillary pressure
Decrease negative pleural pressure
Decrease oncotic pressure
Obstructed lymphatics
Types of pleural effusions
Transudates pleural fluid proteins < 30
OR
Exudates pleural fluid proteins >30
Causes of pleural effusion
Transudates
Very Common causes :
Heart failure
Liver cirrhosis
Causes of pleural exudates
Common causes :
Malignancy
Parapneumonic effusions
Tuberculosis
Exudates
Less Common causes :
Pulmonary embolism
Rheumatoid arthritis and other autoimmune pleuritis
Benign Asbestos effusion
Pancreatitis
Post-myocardial infarction
Post CABG
Clinical assessment and history
Through history and physical examination.
Symptoms :
Asymptomatic
Breathlessness
Chest pain
Cough
Fever
Approximately 75% of patients with pulmonary embolism
and pleural effusion have a history of pleuritic pain.
Dyspnea is often out of proportion to the size of the
effusion
Signs
Decrease expansion
Dull percusion node
Decrease vocal resonance
Decrease air entry
Signs of associated disease
(for example :chronic liver disease-CCF-nephrotic
syndrome -SLE-RA-Ca lung)
DIAGNOSIS
CXR
PLEURAL ASPIRATION
PLEURAL BIOPSY
Medical thoracoscopy
CT scan
VAT
Bronchoscopy
normal
CXR
obliterated costophrenic angle arising toward axilla
sever
CT
Pleural aspiration
The initial step in assessing a pleural effusion is to
ascertain whether the effusion is a transudate or exudate
Aspiration should not be performed for bilateral effusions
in a clinical setting strongly suggestive of a transudate,
unless there are atypical features or they fail to respond
to therapy
appearance and odour should be noted.
(colour usually Straw colour - normal)
Smell , unpleasant aroma of anaerobic infection may
guide antibiotic
The appearance may be serous blood tinged or frankly
bloody
Milky fluid :
Empyema
Chylothorax
PesudChylothorax
Centrifuging turbid or milky pleural fluid will distinguish
between empyema and lipid effusions.
Appearance
Grossly bloody pleural fluid is usually due to; malignancy, pulmonary
embolus with infarction, trauma, benign asbestos pleural effusions or
post-cardiac injury syndrome
A haemothorax can be distinguished from other blood stained
effusions by performing a haematocrit on the pleural fluid. A pleural
fluid haematocrit is greater than 50% of the patient's peripheral blood
haematocrit, is diagnostic of a haemothorax
Differentiating between a pleural fluid
exudate and transudate
Protein of > 30g/l an exudate
Protein of <30 g/l a transudate.
Other tests
Glucose < 3.3 mmol/l : Infection
PH <7.2 empyaema
Amylase pancreatic cancer , rupture oesophagus
Rheumatoid factor RA
ANA SLE
Complement level (reduced in SLE,RA,Ca)
PH
Pleural fluid pH should be measured in non-purulent effusions
providing that appropriate collection technique can be observed
and a blood gas analyser is available.
In a parapneumonic effusion, a pH <7.2 indicates the need for tube
drainage
In clinical practice, the most important use for pleural fluid pH is
aiding the decision to treat pleural infection with tube drainage.
Pleural effusion cells(cont.)
Neutrophil are associated with acute processes. parapneumonic
effusions:
pulmonary embolism,
acute TB
Eosinophils greater than 10% of cells are defined as eosinophilic
effusion
Causes of lymphocytic pleural
effusions
lymphocytes account for > 50% nucleated cells)
Malignancy (including metastatic adenocarcinoma and
mesothelioma)
Lymphoma
Tuberculosis
Causes of lymphocytic pleural
effusions
Cardiac failure
Post CABG
Rheumatoid effusion
Chylothorax
Uraemic pleuritis
Sarcoidosis
Yellow Nail Syndrome
Cytology & Tumour markers :
The diagnostic yield for malignancy depends on :
The skill and interest of the cytologist
Tumour type. The diagnostic rate is higher for adenocarcinoma than
for mesothelioma, squamous cell carcinoma, lymphoma and sarcoma.
Pleural fluid and serum tumour markers do not have a role in the
investigation of pleural effusions.
Management
Treatment of the cause
Drainage (stop drain for 1-2 hours after 1st 1500 ml) may
presipitate pul oedema
Pleurodesis with – talc
– tetracycline
-Bleomycin
Surgery
Thank You
