1. PLEURAL EFFUSION
Outline
• Anatomy/physiology of pleural space;
then the definition of pleural effusion
• Types (transudate & exudate). Lights
criteria
• Causes of each.
• unilateral vs bilateral effusion
• clinical features & imaging
• Pleural fluid analysis**
• Diagnostic and therapeutic drainage
• Treatment

2. Symptoms
• Patients with a small pleural effusion (< 300 mL)
are often asymptomatic.
• Characteristic symptoms
- Dyspnea
- Symptoms of hypoxia
- Pleuritic chest pain (sharp retrosternal pain)
- Dry, nonproductive cough
- Symptoms of the underlying disease
(e.g., fever in empyema, cachexia in cases of
malignancy, symptoms of left-sided heart failure
Clinical features of Pleural Effusion

3. Clinical features of Pleural Effusion
Physical exam findings - SIGNS
• Inspection and palpation
• Asymmetric expansion (may be decreased) and unilateral lagging on
the affected side
• Reduced tactile fremitus due to fluid in the pleural space
• Auscultation
• Diminished or absent breath sounds over the area of effusion
• There may be bronchial breathing above the effusion, where the lung is
compressed
• Pleural friction rub (squeaking sound of inflamed pleural layers rubbing
together during inspiration and expiration)
• Percussion: Stony dull percussion notes; i.e dullness over the area of
effusion
• With large effusions, there may be tracheal deviation away from the
effusion

4. Imaging -Chest X-ray
Indications
• Standard initial imaging modality for detecting
pleural effusion.
• Lateral decubitus view (most sensitive): allows for
detection of fluid collections as small as 5mL
Unilateral Pleural Effusion Bilateral Pleural Effusion
Supportive findings
⚬ Typically unilateral blunting of the
costophrenic angle
⚬ Homogeneous density with a meniscus-
shaped margin (meniscus sign)
• Large effusion
⚬ Complete opacification of the lung
⚬ Mediastinal shift
⚬ Tracheal deviation away from the effusion
(may be due to a space-occupying lesion)

5. Imaging -Chest X-ray

6. Ultrasound
Useful in identifying the presence of pleural fluid
and in guiding diagnostic or therapeutic
aspiration.
Indications
• Quick bedside assessment
• Thoracentesis planning
Supportive findings: hypoechoic or anechoic
collection in the lower margins of the pleural
cavity (costodiaphragmatic recess)
• Very sensitive: can detect fluid amounts as low as
20 mL
• Pleural fluid septations may be present.
• Allows for detection of pleural thickening and
pleural nodules
Thoracic ultrasound is more sensitive than chest X-ray for
diagnosing effusions and estimating effusion size

7. CHEST CT
• Indications: gold standard for small effusions but
use is limited because of radiation and contrast
exposure
• Procedure: chest CT without IV contrast is usually
sufficient
⚬ With IV contrast: allows for the detection of
underlying malignancy (e.g., metastases and/or
primary tumor)
⚬ CT angiogram: helps to identify vascular
pathology (e.g., dissection or AVM)
• Supportive findings
⚬ Can detect > 3–5 mL of fluid
⚬ Fluid density measurement can help
differentiate pleural effusion from empyema and
hemothorax [10]
⚬ Disease-specific signs: See “Pleural empyema.”

8. Primary pleural fluid analysis
Laboratory parameters
Transudative
effusion Exudative effusion
Light criteria
Pleural fluid
protein/serum protein
ratio
≤ 0.5 > 0.5
Pleural fluid LDH/serum
LDH ratio
≤ 0.6 > 0.6
Pleural fluid LDH
< ⅔ the upper limit of
normal serum LDH
Pleural fluid LDH > ⅔ the upper
limit of normal serum LDHVery
high LDH levels, e.g., > 1000 U/L,
suggest empyema, malignancy, or
rheumatoid effusion.
Pleural fluid cholesterol < 45 mg/dL > 55 mg/dL
Pleural fluid LDH < 200 U/L > 200 U/L
Pleural fluid cholesterol: serum cholesterol ratio < 0.3 > 0.3

9. Adjunctive pleural fluid analysis
Pleural fluid parameter
Suggests transudative
effusion
Suggests exudative effusion
• Physical appearance
Clear fluid, Does not froth or
form clots
Cloudy or straw-colored fluid (may
be hemorrhagic in rare
cases) Froths when shaken and
forms clots when left standing
• Specific gravity ≤ 1.016 > 1.016
• pHNormal pH ∼ 7.6 7.4–7.55 < 7.3–7.45
• Glucose ≥ 60 mg/dL < 60 mg/dL
• Total protein gradient(i.e., the
difference between pleural
fluid and serum total protein)
> 3.1 g/dL lower than serum total
protein
< 3.1 g/dL lower than serum total
protein
• Albumin gradient
> 1.2 g/dL lower than serum
albumin
< 1.2 g/dL lower than serum
albumin

10. Thoracentesis
• is a procedure that removes pleural fluid for diagnostic and/or therapeutic
purposes. It is used to relieve symptoms (e.g., dyspnea) and/or obtain pleural
fluid for analysis to help determine the underlying cause (e.g., infection,
malignancy)
• Diagnostic thoracentesis: the
sampling(removal of a small amount)
of pleural effusion for pleural fluid
analysis and identification of the
etiology.
• Therapeutic thoracentesis: removal
of pleural fluid to relieve symptoms
(e.g., dyspnea) and treat respiratory
failure

11. Indications - for Diagnostic thoracentesis
• New unilateral effusion of uncertain
etiology
• Bilateral effusions with atypical findings
(e.g., pleuritic chest pain, fever,
disparate effusion sizes)
• Indications for detailed pleural fluid
analysis that impact management (e.g.,
cytology, culture, and sensitivity)
Parapneumonic effusion > 5 cm
Indications for Therapeutic Thoracentesis
• Large symptomatic pleural effusions in
select patients
• Pleural effusions causing respiratory
failure and/or obstructive shock
• Complicated parapneumonic effusion
Chest Tube Drainage
A chest tube is a flexible plastic tube that is
inserted through the chest wall and into the
pleural space. It is used to remove air, fluid,
pleural effusion, blood, chyle or pus from the
intrathoracic space. It is also known as an
intercostal catheter

12. The treatment of pleural effusion depends on
its underlying cause and the severity of
symptoms.
Observation and monitoring: In some
cases, particularly if the pleural effusion is
small and asymptomatic, a watchful
waiting approach may be adopted. Regular
monitoring with imaging tests can help
track the effusion's progression.
Thoracentesis: it involves the removal of
excess fluid from the pleural space using a
needle and syringe.
Pleural drainage: In cases where the
effusion is recurrent, persistent, or
malignant, or if a large volume of fluid
needs to be drained, a chest tube may be
inserted into the pleural space.
TREATMENT
Medications: Depending on the underlying cause,
• Antibiotics are prescribed if the effusion is due to an
infection, such as pneumonia.
• NSAIDs or colchicine may be used to treat effusions
caused by conditions like RA or SLE
• Diuretics (like furosemide, etc) can be helpful in
managing effusions related to heart failure or kidney
disease.
Pleurodesis: It involves the fusion of the two layers of the
pleura using chemicals or irritants. This procedure aims to
create adhesions between the pleural layers, preventing
the accumulation of fluid. Indication -Malignant/non-
malignant Pleural effusion.
Surgical intervention: In certain cases, may involve
procedures like VAT Surgery or open thoracotomy.
Surgery may be required to remove thickened or infected
pleura, repair underlying lung or chest wall abnormalities,
or perform biopsies for diagnosis.