15 - Approach To Pleural Effusion

Approach to Pleural Effusion
SYED Khadim Hussain

PGR 
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
The precise pathophysiology of fluid accumulation varies 
.according to underlying aetiologies
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
Transudates
 Less Common causes
 Hypoalbuminaemia
 Peritoneal dialysis
 Hypothyroidism
 Nephrotic syndrome
 Mitral Stenosis
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
Exudates
 Rare causes
 Yellow nail syndrome (and other lymphatic
disorders
 Drugs
 Fungal infections
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.
 Less than a third of the hemithorax
 Dyspnoea is often out of proportion to the
size of the effusion
History
 The drug history is important. Although uncommon, a
number of medications have been reported to cause
exudative pleural effusions. (mesotruxate,
Amiodarone Phenytoin, Nitrofurantoin and Beta-
blockers )>100 cases reported globally
 An occupational history including details about known
or suspected asbestos exposure and potential
secondary exposure via parents or spouses should
be documented.
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
CXR
Diagnostic Imaging
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
Pleural aspiration
 A diagnostic tap, with a fine bore (21G) needle

and a 50mL syringe
 Bedside ultrasound guidance is recommended
for all diagnostic aspirations
 Send for protein, LDH, pH, Gram stain, cytology
and microbiological culture.
 Up to 50ml pleural fluid should be sent for
cytological examination.
Pleural aspiration
 A green needle (21G) . Aspirated fluid should

immediately be drawn into a blood gas syringe
 Biochemical (2-5 ml)
 Gram-stained is necessary for all fluids and
particularly when pleural infection is suspected
(microbiology 5ml)
 50ml for cytological examination
Pleural effusion
 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
-
Appearance
 Milky fluid
 Empyaema
 Chylothorax
 PesudChylothoraxI
 Centrifuging turbid or milky pleural fluid will
distinguish between empyema and lipid
effusions.
 If the supernatant is clear then the turbid fluid
was due to empyema
 If it is still turbid
-chylothorax OR
- pseudochylothorax
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
Fluid Suspected disease
 Putrid odour Anaerobic empyema

 Food particles Oesophageal rupture
 Bile stained Cholothorax (biliary fistula)
 Milky Chylothorax/Pseudochylothorax
 ‘Anchovy sauce’ like fluid Ruptured amoebic
abscess
Differentiating between a pleural
fluid exudate and transudate
 Protein of > 30g/l an exudate

 Protein of <30 g/l a transudate.
 When
protein is close to 30g/l (25-30)
Light's criteria
 Exudates if one or more of the following:

 Pleural fluid protein divided by serum protein
is greater than 0.5
 Pleural fluid LDH divided by serum LDH is
greater than 0.6
 Pleural fluid LDH > 2/3 the upper limits of
laboratory normal value for serum LDH.
? How accurate is Light’s criteria
 In CCF diuretic therapy increases the concentration
of protein, LDH and lipids in pleural fluid
 In this context Light's criteria is recognized to
misclassify a significant proportion of effusions as
exudates .
 Clinical judgment should be used
 Measurement of NT-pro-BNP can be useful.
Other tests
 Glucose < 3.3 mmol/l ? Infection

 PH <7.2 empyaema
 Amylase pancreatic ca ,rupture oesophagus
 Rheumatoid factor RA
 ANA SLE
 Complement level (reduced in SLE,RA,Ca)
Pleural fluid differential cell counts
 Cell proportions are helpful in narrowing the

differential diagnosis but none are disease
specific
 When any effusion becomes long standing it

tends to be populated by lymphocytes (and
neutrophils fade away).
 Pleural malignancy, cardiac failure and
tuberculosis are common specific causes
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.
 Inclusion of air or local anaesthetic in samples

may significantly alter the pH results and should
be avoided.
 In a parapneumonic effusion, a pH <7.2 indicates

the need for tube drainage
PH
 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
 and benign asbestos
 Eosinophils greater than 10% of cells are defined as
eosinophilic effusion
 The most common cause eosinophilia is air or blood
in the pleural space
 Pleural eosinophilia is a fairly non-specific
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
Glucose
 In the absence of pleural pathology, glucose diffuses

freely across the pleural membrane and pleural fluid
glucose concentration is equivalent to blood
 A low pleural fluid glucose level (< 3.4 mmol/l) may
be found in complicated parapneumonic effusions,
 Empyema
 Rheumatoid pleuritis,
 Tuberculosis,
 Malignancy,
 Oesophageal rupture .
Glucose
 The most common causes of a very low pleural fluid
glucose level (< 1.6 mmol/l) are
 rheumatoid arthritis
 and empyema
 Although glucose is usually low in pleural infection
and correlates to pleural fluid pH values,
 it is a significantly less accurate indicator for chest
tube drainage when compared to pH
Cytology
 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.
Tumour markers
 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

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Approach to Pleural Effusion

SYED Khadim Hussain

 Transudates pleural fluid proteins < 30

 Very Common causes

 Through history and physical examination.

 The initial step in assessing a pleural effusion

 Aspiration should not be performed for

 A diagnostic tap, with a fine bore (21G) needle

 A green needle (21G) . Aspirated fluid should

 appearance and odour should be noted.

 Putrid odour Anaerobic empyema

 Protein of > 30g/l an exudate

 Exudates if one or more of the following:

 Glucose < 3.3 mmol/l ? Infection

 Cell proportions are helpful in narrowing the

 When any effusion becomes long standing it

 Pleural fluid pH should be measured in non-

 Inclusion of air or local anaesthetic in samples

 In a parapneumonic effusion, a pH <7.2 indicates

 lymphocytes account for > 50% nucleated

 In the absence of pleural pathology, glucose diffuses

 The diagnostic yield for malignancy depends

 Pleural fluid and serum tumour markers

 Treatment of the cause

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