1. Pleural Effusion
By: Dr Akhtar Totakhail
Jamhuriat Hospital
E-Mail: akhtartotakhil@yahoo.com
Kabul

3. Outline:
• General consideration
• Pathology
• Diagnostic Approach
• Diagnostic Algorithm
• Causes
• Clinical Findings
• Treatment & Prognosis

4. General consideration
Fluid in the Pleural Cavity:
Facilitate expansion and contraction and sliding back
and forth
 Normal pleural fluid approximately 0.2–0.3 mL/kg
Continuous turnover of production and removal
Rate of production is 0.01 mL/kg/h
Normal pleural fluid is low in protein (1 g/dL),

5. General consideration....
 fluid enters the pleural space from the capillaries in the
parietal pleura
 Also can enter the pleural space from the peritoneal
cavity via small holes in the diaphragm
removed via the lymphatics in the parietal pleura
Definition of the PE:
Presence of excess quantity of fluid in the pleural space

6. Pathology
5 Pathophysiological process involved in increase of fluid
in the pleural cavity
1) Increase hydrostatic pressure or Decreased oncotic
pressure (Transudates)
2) Abnormal capillary permeability (Exudates)
3) Decreased lymphatic clearance (Exudates)
4) Infection (Empyema)
5) Bleeding (Hemothorax)

7. Diagnostic Approach
determine whether the effusion is a transudate or an
exudate
 A transudative pleural effusion occurs when
systemic factors that influence
• left-ventricular failure
• cirrhosis
• etc..
 An exudative pleural effusion occurs when local
factors that influence
• bacterial pneumonia,
• Malignancy
• viral infection
• pulmonary embolism
• Etc…

8. Diagnostic Approach ....
 Exudative pleural effusions meet at least one of the
following criteria,
 whereas transudative pleural effusions meet none
a) Pleural fluid protein/serum protein >0.5
b) Pleural fluid LDH/serum LDH >0.6
c) Pleural fluid LDH more than two-thirds normal upper limit
for serum
If a patient has an exudative PE glucose level, differential cell
count, microbiologic studies, and cytology

9. Hemothorax
• Cause: trauma ,blood vessel rupture ,tumor
• Hematocret >50% peripheral blood
• Observation
• Drain existing blood and clot
• Quantify the amount of bleeding
• Reduce the risk of fibrothorax
• Permit apposition of pleural surface

10. Diagnostic Algorithm

11. Diagnostic Algorithm...
Any following meet?
PF protein/serum protein >0.5
PFLDH/serum LDH >0.6
PF LDH > 2/3 normal upper limit for serum
Exudates
Further diagnostic procedures
Measure PF
glucose level, Amylase cytology. differential cell count,
Cluture stain PF PF marker for TB
Transudates
Treat CHF, cirrhosis nephrosis
Yes No

12. Diagnostic Algorithm...
Measure PF
glucose level, Amylase cytology. differential
cell count, Cluture stain PF PF marker for TB
Serum Amylase elevated
Consider Esophageal rupture,
pancreatic PE and malegnancy
No Diagnosis
Glucose < 60 mg/dl
Consider Malegnancy,
bacterial infection
Rheumatoid pleurites

13. Diagnostic Algorithm...
No
Diagnosis
Consider pulmonary embolus (spiral CT or lung scan)
Treat PE PF Marker for TB
Treat TB
Symptom Improving
Observe
Consider thoracoscopy
Or open plural biopsy
Yes No
Yes No
Yes No

14. Causes
Transudative Pleural Effusions
1. Congestive heart failure
2. Cirrhosis
3. Pulmonary embolization
4. Nephrotic syndrome
5. Peritoneal dialysis
6. Superior vena cava obstruction
7. Myxedema
8. Urinothorax

15. Causes...
Exudative Pleural Effusions
1. Neoplastic diseases
2. Infectious diseases
3. Pulmonary embolizm
4. Gastrointestinal disease
5. Collagen vascular diseases
6. Post-coronary artery bypass surgery
7. Asbestosis
8. Sarcoidosis
9. Uremia

16. Causes...
Exudative Pleural Effusions …
10. Meigs' syndrome
11. Yellow nail syndrome
12. Drug-induced pleural disease
13. Trapped lung
14. Post-cardiac injury syndrome
15. Hemothorax
16. Ovarian hyperstimulation syndrome
17. Pericardial disease
18. Chylothorax

17. Clinical Findings
Symtoms and Signs
Dyspnea
Cough
Chest pain
o Symptoms are more common in a patient of
cardiopulmonary disease
o Small PE are less likely to be symptomatic than Large
effusion.

18. Clinical Findings
Physical findings
Inspection:
• bulging of the intercostal spaces massive effusions
Palpation:
• Displacement of Trachea to apposite site.
• decreased tactile fremitus over the area of the effusion
Percussion:
• Dullness
Auscultation
• Decrease of breath sounds
• Compressive atelectasis bronchial breath sounds

19. Clinical Findings
Imaging Studies:
Conventional Radiography:
• 5 mL of pleural fluid can detect using lateral decubitus
position chest
• At least 50–75 mL of fluid must accumulate before
blunting of the posterior costophrenic angle
• > 175–200 mL must be present to cause visible blunting
of the lateral costophrenic angles on the PA view
• Thickening of the major and minor fissures, indicative of
superior tracking fluid

22. Clinical Findings
Ultrasound:
1. Dx and sampling of loculated fluid collections
2. guided sampling of small effusions or those difficult to tap
(failing two or three attempts
Computed Tomography
• Free flowing fluid appears as a sickle-shaped opacity
• loculations appear as lenticular or rounded opacities
• CT is also helpful in distinguishing PF from parenchymal
and extrapleural disease due to distinguish anatomic
compartments
• CT donot definitively discriminate among parenchymal
lesions, solid pleural masses, and pleural collections of
serous fluid, blood, or pus.

24. Thoracentesis (Pleural Tap)
Indications:
– All pleural effusions > 1 cm in decubitus views.
– In CHF, 75% resolves with diuresis within 48 hrs
– Thus, Asymmetry, fever, chest pain or failure to
resolve → pleural tap!
Complications;
– Pneumothorax 5-10%
– Hemothorax 1 %
– Re-expansion pulmonary edema (if > 1.5 L removed).
– Spleen/liver laceration
– Post-tap CXR not routinely needed.

25. Clinical Findings...
Gross Appearance
Color of fluid
Pale yellow (straw) Transudate, some exudates
Red (bloody)
Malignancy, benign asbestos pleural effusion,
postcardiac injury syndrome, or pulmonary infarction
in absence of trauma
White (milky) Chylothorax or cholesterol effusion
Brown
Long-standing bloody effusion; rupture of amebic liver
abscess
Black Aspergillus
Yellow-green Rheumatoid pleurisy
Dark green Biliothorax

26. Clinical Findings...
Character of fluid
Pus Empyema
Viscous Mesothelioma
Debris Rheumatoid pleurisy
Turbid
Inflammatory exudates or lipid
effusion
Anchovy paste Amebic liver abscess
Odour of fluid
Putrid Anaerobic empyema
Ammonia Urinothorax

27. Clinical Findings...
Laboratory findings
Transudative pleural
effusions
Exudative pleural effusions
PF protein/serum protein <0.5 PF protein/serum protein >0.5
PF LDH/serum LDH <0.6 PF LDH/serum LDH >0.6
PF LDH less than two-thirds
normal upper limit for serum
PF LDH more than two-thirds
normal upper limit for serum
PF Cholesterol < 45mg/dl PF Cholesterol > 45 mg/dl
Serum Albumin –PF gradient
> 1.2 g/dl
Serum Albumin –PF gradient
< 1,2 g/dl

28. Clinical Findings...
Laboratory findings
 Frank pus indicates a pleural space infection, or empyema
 A fluid hematocrit >50% of the measured peripheral blood
hematocrit is diagnostic of hemothorax
fluid hematocrit 1–50% of the peripheral blood typically in
cancer
An elevated hematocrit also occur with pulmonary
embolism, trauma, or even pneumonia
Clear yellow PF, particularly with an odor of urine, in
urinary obstruction with urinothorax

29. Clinical Findings...
Laboratory findings…
Special Tests:
Cell Differential:
• Neutrophils > 50%
• Implies acute process
• Parapneumonic, PE, pancreatitis
• Lymphocytes > 50%
• Implies chronic process
• Cancer, TB, rheumatologic
• Eosinophils > 10%
• ⅔ due to blood or air in pleural space
• Drug reaction
• Asbestos, paragonimiasis,, PE

30. Clinical Findings...
Laboratory findings…
Special Tests:
Glucose:
• low fluid glucose (<60 mg/dL) include complicated
parapneumonic effusion/empyema, cancer, TB pleuritis, and
rheumatoid disease
• Elevated PFglucose due to peritoneal dialysis with high
glucose dialysate
Amylase:
Elevated fluid amylase levels (> the upper limit of normal
serum) occur in
• Esophageal perforation (salivary)

31. Clinical Findings...
Laboratory findings…
Amylase…
• Acute pancreatitis (pancreatic), chronic pancreatitis with
fistula (pancreatic; >4000 IU/mL),
• About 10% of malignant effusions (salivary)
Fluid pH:
• Usually occurs in same situations as low fluid glucose.
• Often implies empyema (esp. if pH < 7.0)
• Lowest pH found in esophageal rupture pH 6.0
• The lower the pH, the worse the prognosis with malignant
effusions

32. Clinical Findings...
Laboratory findings…
Special Tests:
Gram's stain and culture on all exudative effusions for two
important reasons
1) culture positive for organisms is diagnostic of empyema
2) stain and culture are necessary to exclude pleural space
infection in the setting of existing (and often confounding)
pleural disease
such as for rheumatoid pleuritis in which the fluid glucose and
pH are typically low even in the absence of infection

33. Clinical Findings...
Laboratory findings…
Special Tests:
For TB pleuritis
• fluid adenosine-deaminase (ADA),
• interferon- levels,
• PCR to detect mycobacterial DNA
Lipids and Cholesterol:
• Chylothorax is diagnosed
• when fluid TG is >110 mg/dL, fluid TG/serum TG is >1,
• fluid cholesterol/serum cholesterol is <1.
• Fluid TG <50 mg/dL effectively rules out the Dx of chylothorax,
• pseudochylothorax
• fluid cholesterol >250 mg/dL
• Fluid TG of 50–110 mg/dL (or >110 in the setting of a fluid/serum
cholesterol ratio >1)

34. Treatment
• PE with effusion should be treated as PE
• bloody effusion does not contraindicate anticoagulation
• TB pleuritis typically resolves after 6 weeks of standard
treatment of (TB)
• Acute effusion following CABG usually resolves
spontaneously
• rheumatoid effusion most often spontaneously resolves
within 3 months
• chronic effusions may require therapeutic thoracentesis (one
or two times) with or without (NSAIDs)

35. Treatment...
• In Malignant Effusion
 therapeutic thoracentesis and
pleurodesis 4–5 g talc in 50 mL saline
 placement of a pleuroperitoneal shunt
chronic thoracostomy drainage catheter and bag.
• In Hepatic Hydrothorax
controlling the patient's ascites through the use of Na restriction and
diuretics
Transjugular intrahepatic portosystemic shunt (TIPS)
liver transplantation
Bacterial infection of hepatic hydrothorax
antibiotics (or empiric coverage appropriate for SBP), without need for chest
tube thoracostomy.

36. Treatment ...
• In Chylothorax and Pseudochylothorax the Dx of the
underlying cause
• traumatic/surgical and nontraumatic with talc pleurodesis,
pleuroperitoneal shunt implantation, or surgical ligation of
the thoracic duct.
• AIDS, with more than half of these being parapneumonic
causes of effusion TB, Kaposi's sarcoma (KS), renal
failure, and hypoalbuminemia

37. Treatment ...
Indications for Pleural Drainage
• Frank pus
• Positive GS/culture
• Pleural pH <7.20
• Pleural glucose < 40 mg/dL (< 2.2 mmol/L)
• Pleural LDH > 1000
• Loculated effusion

38. Treatment ...
Indications for Thoracotomy
• To control hemorage
• To remove clot
• To treat complication such as broncho pleural fistula
formation.

39. References
1. Guyton, A.C 2007 Textbook of Medical physiology (11th
edition), Emedicina Forum
2. J.Stephen ,2012 Current Medical Diagnosis & Treatment
(51st edition) The McGraw-Hill Companies, Inc.
3. Harrison Tinsley R Harrison, 2012 Principles of internal
Medicine (18th edition), The McGraw-Hill Companies,
Inc.