PLEURAL EFFUSSION

DR.Bilal Natiq Nuaman,MD C.A.B.M.,F.I.B.M.S.,D.I.M.

2016-20171

Pleural Effusion

• Accumulation of fluid within the pleural space when there is an imbalance between formation and absorption in various disease states.

• The accumulation of frank pus is termed empyema, that of blood is haemothorax, and that of chyle is a chylothorax.

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Pulmonary embolic disease, cardiac failure, malignant pleural infiltration and pneumonia (including TB). are the four most important conditions, which are responsible for more than 90 per cent of pleural effusions seen in clinical practice.

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Classification

• Transudate- is an ultra filtrate of plasma, resulting from increased hydrostatic pressure or decreased serum oncotic pressure. An effusion with normal pleura.

• Exudate- resembles plasma, and is rich in

proteins. Results from increased capillary permeability. An effusion with diseased pleura.

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Transudative Pleural effusions

• Congestive heart failure • Cirrhosis • Nephrotic syndrome

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Exudative Pleural Effusions

➢ Neoplastic diseases Metastatic disease Mesothelioma

➢Infectious diseases Bacterial infections Tuberculosis

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Exudative Pleural Effusions

➢ Pulmonary embolism

➢ Collagen-vascular diseases Rheumatoid pleuritis Systemic lupus erythematosus Drug-induced lupus

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Clinical features The symptoms associated with the accumulation of fluid in the pleural space depend upon the cause, volume and rate of formation of fluid. Small effusions are often symptomless, and even quite large effusions can cause little disability, provided the fluid has accumulated slowly. Effusions caused by inflammatory disease often present with pleuritic pain, which may be relieved as the fluid accumulates. Large effusions eventually cause symptoms including dry cough, shortness of breath, initially on exercise and later at rest, together with dull, aching discomfort over the affected side of the chest.

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Historical clues • Trauma history suggests hemothorax

• Cancer history suggests malignant effusion

• Chronic hemodialysis suggests heart failure or uremic pleuritis

• Cirrhosis suggests hepatic hydrothorax.

•Dyspnea on exertion,orthopnea,peripheral edema:CHF

• Asbestos exposure suggests mesothelioma.

• HIV infection suggests pneumonia,TB,lymphoma,Kaposi’s sarcoma

• Rheumatoid arthritis suggests rheumatoid pleuritis

• Lupus suggests lupus pleuritis.

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Physical examination The characteristic findings of stony dullness to percussion and distant or absent breath sounds are most prominent at the lung bases.

Bronchial breath sounds or aegophony may be heard directly above an effusion.

Large effusions displace the mediastinum towards the unaffected side unless the underlying lung is fibrosed from previous inflammation (tuberculosis) or collapsed due to a proximal bronchial lesion.

Clues in the physical to the common etiologies• Distended neck veins, an S3 gallop, or peripheral edema

suggests congestive heart failure. • Unilateral leg swelling or thrombophlebitis and sinus

tachycardia suggests pulmonary embolus. • The presence of lymphadenopathy or

hepatosplenomegaly suggests neoplastic disease. • Ascites may suggest a hepatic cause, ovarian cancer. • Signs of consolidation above the level of the fluid in a

febrile patient suggests parapneumonic effusion.

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• Yellowish nails, lymphedema suggest yellow nail syndrome

INVESTIGATIONS Role Of Imaging

– Detection and the differential diagnosis are highly dependent upon imaging of the pleural space.

– conventional radiographic methods used are frontal, lateral, oblique and decubitus radiographs.

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CXR

OBLITERATION OF COSTOPHRENIC ANGLE

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On Lateral decubitus chest x-ray view Minimum volume to diagnose pleural effusion is 50 ml.

On PA view Minimum volume to diagnose pleural effusion is 250 ml.

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500 mL will obscure the diaphragmatic contour on an upright chest radiograph

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1000 ml of effusion reaches the level of the fourth anterior rib

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Massive pleural effusion > 2000 ml

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Malignancy is the most common cause of massive pleural effusions that cause complete opacification of one hemithorax

Role of CT scan – Visualization of underlying lung

parenchymal processes that are obscured on chest radiographs by large pleural effusions

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Diagnostic thoracentesis

• Indicated if the effusion is clinically significant with no known cause.

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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. All unilateral pleural effusions require further investigation, starting with aspiration.

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Appearance of the fluid.

• Bloody- Cancer, PE, Trauma, Pneumonia in that order

• Turbid- either due to cells or debris or a high lipid level.

• Putrid odor- Anaerobic infection.

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Exudates Vs transudates

Light’s criteria • Pleural fluid protein/serum protein >0.5 • Pleural fluid LDH/serum LDH >0.6 • Pleural fluid LDH more than two-thirds

normal upper limit for serum

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Further work up based on…

• Exudate or transudate. • If transudative, rule out a diagnosis of congestive

heart failure, cirrhosis. • If exudative send for total and differential cell

counts, smears and cultures for organisms, measurement of glucose and lactate dehydrogenase levels, cytologic analysis, and testing for a pleural-fluid marker of tuberculosis.

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Total and Differential Cell Counts

• Predominance of neutrophils in the fluid >50% indicates that an acute process is affecting the pleura.

Common causes include – parapneumonic effusions . • Mononuclear cells like small lymphocytes >50%

indicates a chronic process. – cancer or tuberculous pleuritis.

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Glucose Level

low glucose concentration (< 60 mg per dl) indicates a complicated parapneumonic or a malignant effusion, tuberculosis ,or rheumatoid pleuritis.

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Fluid Tests for Cancer– Cytology is a fast, efficient, and minimally invasive

– not routinely warranted in young patients with evidence of acute illness.

– establishes the diagnosis in more than 70 percent . – If cytology is negative – go for needle biopsy and

thoracoscopy

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Markers of Tuberculosis

• warranted if there is pleural fluid lymphocytosis. Including:

– adenosine deaminase (>40 U/L) (99.6% sensitive and 97.1 % specific)) or

– Interferon (>140 pg/ml) comparable to ADA or

– the PCR for mycobacterial DNA – definitive for TB.

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Treatment• Thoracentesis – Not more than 1 lt should be

removed at a sitting because of risk of pulmonary edema.

• then treat underlying disease Uncomplicated pneumonia – antibiotics

TB effusion – anti TB drugs • Hemithorax involved/ empyema –chest tube

thoracostomy • Malignant effusion- chest tube +/- pleurodesis

(sclerosants)

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Thank you

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