Pleural Effusion

PLEURAL
EFFUSION
Overview
• Introduction
• Classification
• Pathogenesis
• Etiology
• Clinical features
• Investigations
• Management
Introduction
• Pleural effusion is defined as abnormal accumulation of fluid in
the pleural space, i.e., the space between parietal and visceral
pleura
• The pleural space contains normally 0.3ml/kg body weight of
pleural fluid1. There is a continuous circulation of this fluid and
the lymphatic vessels can cope with several millilitres of extra
fluid per 24hours
• Fluid accumulates in the pleural cavity due to either altered
hydrostatic and oncotic pressures or altered permeability of the
pleura
Composition of pleural fluid
• Clear ultra filtrate of plasma
• Volume 0.3 mL/kg
• Cells/ mm3 1000 – 5000
• Mesothelial cells 60%
• Monocytes 30%
• Lymphocytes 5%
• PMN’s 5%
• Protein 1-2 g/dL
• LDH <50% plasma level(105-333IU/L)
• Glucose  plasma level(90-120)
•
Classification
• Can be unilateral or bilateral and classified
A)Based on site
 Apical
 Interlobar
 Sub-pulmonic
 Mediastinal
B)Based on mechanism and type of pleural fluid

 Transudative (alteration in hydrostatic and oncotic pressure)
 Exudative (alteration in pleural permeability)
c) Based on mechanism and type of pleural
fluid formed
 Pyogenic
 Chylous
 Haemothorax
 Pseudochylous
 Hydrothorax
Pathogenesis
• Increased vascular permeability allows migration of inflammatory
cells (neutrophils, lymphocytes, and eosinophils) into the pleural
space.
• The process is mediated by a number of cytokines such as
interleukin IL-1, IL-6, IL-8, tumour necrosis factor (TNF)-alpha and
platelet activating factor released by mesothelial cells lining the
pleural space. The result is the exudative stage of a pleural effusion.
This progresses to the fibro-purulent stage due to increased fluid
accumulation and bacterial invasion across the damaged epithelium.
• Neutrophil migration occurs as well as activation of the coagulation
cascade leading to pro-coagulant activity and decreased fibrinolysis.
Deposition of fibrin in the pleural space then leads to septation or
loculation. The pleural fluid pH and glucose level falls while LDH
levels increase.
Etiology
• EXUDATIVE
 Infective: Pneumonia, Bronchiectasis, Pancreatitis, TB, Lung

abscess
 Collagen vascular disease: SLE, Rheumatoid arthritis,
Polyarteritis
 Neoplastic: leukemias and lymphomas
 Uremia
 Drugs: Bromocriptine, amiodarone, nitofurantoin,

dantrolene, INH, PAS
 Postradiation
 Traumatic
• TRANSUDATIVE:
 Renal cause: Nephrotic syndrome
 Cardiac cause: Congestive cardiac failure
 Hepatic cause: Hepatic failure
 Nutritional: Protein energy malnutrition
 Hypothyroidism
• PYOGENIC:
 Lung abscess
 Septicemia
 Chest wall injuries
 Rupture of oesophagus
 Rupture of subphrenic abscess
 Rupture of liver abscess

• CHYLOUS:
 Trauma to thoracic duct
 Tumour (mediastinal lymphoma)
 Tuberculosis
 Lymphatic obstruction
• HEMOTHORAX:
 Chest wall injuries
 Bleeding disorders
 Neoplasms-leukemias, lymphoma,
mesothelioma
 Drugs-anticoagulants
 Pulmonary infarction
• PSEUDOCHYLOUS:
 Rheumatoid pleuritis
 Tuberculosis or paragonimiasis(lung fluke

infection)
• HYDROTHORAX:
 Congestive heart failure
 Hepatic & Renal failure

Clinical features
 Many patients have no symptoms due to the
effusion when
effusion is small.
 Pleuritic chest pain is the usual symptom of

pleural
inflammation.
 Irritation of the pleural surfaces may also result in a

dry,
nonproductive cough.
Physical examination
Inspection:
 Absent or diminished movements of affected side
 Fullness of chest with bulging intercostal spaces
Palpation:
 Diminished breath sounds over the site of the effusion
 Decreased or absent tactile fremitus
Percussion:
 Stony dullness to percussion
Auscultation:
 Absence of breath sounds over the effusion
 Vocal resonance absent
 Signs of pneumonia like bronchial breathing, crackles
etc.
Investigations
 Total and differential leucocyte counts
• Acute phase reactants-white cell count, total

neutrophil count, CRP, ESR, pro-calcitonin
distinguish bacterial from viral causes
 Radiological examination
• X-ray chest PA view done in erect position-a total

of 300mL of fluid is needed to diagnose pleural
effusion clinically and radiologically
• Even 50mL of fluid can be demonstrated
radiologically in lateral decubitus
Findings
• Obliteration of cardiophrenic and costophrenic angles
• Loculated effusions
• Subpulmonic effusion-collection of fluid below the

diaphragm will lead to elevation of diaphragm,
confirmed by X-ray in lateral decubitus
• Lateral decubitus on side of effusion will show a shift
in the fluid level
• Tracheal and mediastinal shifts are seen in massive
effusion
 Ultrasonogram
Useful in differentiating between loculated pleural effusion

and tumour
 CT Scan
Helpful if the effusion is minimal or loculated
 Pleural fluid aspiration (Thoracocentesis)
Diagnostic: Helps to differentiate between exudates and

transudates
Therapeutic: Massive collection or rapid collection of pleural

fluid
Severe respiratory distress
Suspected empyema
Gross appearance
• Straw-coloured
• Blood stained
• Purulent
• Chylous
Transudate & Exudate
Features Transudates Exudates
Appearance Clear/Straw Cloudy, purulent,

coloured opalascent
Protein < 3g/100mL >3g/100mL
pH >7.2 <7.2
Glucose >40mg/dL <40mg/dL
LDH Low, <200IU/L High,>200IU/L
Cells <1000/mm3 >1000/mm3

lIGHT’S CRITERIA:
• Atleast one of the following criteria should be
satisfied to identify exudates:
 Pleural fluid to serum total protein ratio- more
than 0.5
 Pleural fluid to serum LDH ratio- more than
0.6
 Pleural fluid LDH- more than two-third of
serum LDH
None of these criteria should be satisfied in a

transudative effusion
Roth’s criteria
• If serum-pleural fluid albumin

gradient is more than 1.2 it is
transudate, else exudate.
Pleural Fluid Biochemistry
• pH
• Glucose
• Lactate dehydrogenase(LDH)
• Sodium, potassium and calcium conc
• Amylase
• Adenosine deaminase
• Ratio of protein in pleural fluid to serum
• Ratio of LDH values in pleural fluid to serum

PLEURAL FLUID CYTOLOGY
WBC Count
Predominant cell type(neutrophil, lymphocytes,

eosinophils, red blood cells)
Lymphocytosis- if >50% leucocytosis then suspect TB
Malignant cells
PLEURAL FLUID MICROBIOLOGY
Gram stain
Acid fast for AFB
Pleural fluid Culture
AFB Culture
PCR for TB
 Pleural Biopsy
• Can be done at maximum dullness on
percussion or at a maximum thickening of
pleura. Abram’s pleural biopsy needle is used
for biopsy
• Most helpful in evaluating for TB
• Limited utility for CA (40-50% positive)
Repeat cytology x 3
• Sarcoid, fungal: might be helpful
Other investigations
• Suspected TB
• Adenosine deaminase (>
50 IU/L) • Suspected SLE
• Beta2 - microglobulin • Serum Complement
• Lysozyme III (> • Pleural ANA
20mcg/mL) • LE cells
• PCR (Sens 100%, Spec • Suspected
95%) Pneumonia
• AFB (smear 10-20%; cx • pH
25-50%)
• Suspected
• Suspected Rheumatoid Pancreatitis
• Pleural RF • Pleural Amylase
MULTINUCLEATED MACROPHAGES
TUBERCULOUS PLEURITIS
LE CELL
Management
SUPPORTIVE TREATMENT
• Oxygen is necessary if SpO2 <92%
• Fluid therapy if child dehydrated or

unable/unwilling in drinking water
• Initiate IV antibiotics
• Analgesics and antipyretics
• Chest radiography & U/S

Medical
• Treat the cause
Pneumonia- initial blind antibiotic treatment
A) Following community acquired pneumonia

• Cefuroxime
• Co-amoxiclav
• Penicillin & flucloxacillin
• Amoxicillin & flucloxaxillin
• Clindamycin
B) Hospital acquired pneumonia

• Broader spectrum antibiotics that cover aerobic gram negative
rods
• Tuberculosis- Category I treatment
2HRZE+4HRE
Prednisolone 1-2mg/kg orally 4-6weeks

promotes rapid absorption of the pleural fluid
and prevents fibrosis
• Congestive cardiac failure- treat with
diuretics and other anti-failure medications
Surgical
• Pleural fluid aspiration is done by using a wide bore
needle. If the fluid is thick and cannot be drained by
a needle, an intercostal drainage(under water seal)
at the most dependant part should be done.
• Indications
 Empyema
 Presence of causative organisms in the fluid
 Pleural fluid glucose <50mg/dL
 Pleural fluid pH <7.0

• Complications
• Pleural shock
• Introduction of infection
• Pneumothorax
• Pulmonary embolism
• Air embolism
• Acute pulmonary edema
• Injury to neovascular bundles
• Hydropneumothorax
Bibliography
• Nelson textbook of pediatrics 19Th edition
• British Thoracic Society

Pleural Effusion

Uploaded by

Copyright:

Available Formats

Pleural Effusion

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Pleural Effusion

Uploaded by

Copyright:

Available Formats

PLEURAL

B)Based on mechanism and type of pleural fluid

 Infective: Pneumonia, Bronchiectasis, Pancreatitis, TB, Lung

 Drugs: Bromocriptine, amiodarone, nitofurantoin,

 Cardiac cause: Congestive cardiac failure

 Hepatic cause: Hepatic failure

 Nutritional: Protein energy malnutrition

 Chest wall injuries

 Rupture of subphrenic abscess

 Rupture of liver abscess

 Tumour (mediastinal lymphoma)

 Tuberculosis or paragonimiasis(lung fluke

 Hepatic & Renal failure

 Pleuritic chest pain is the usual symptom of

 Irritation of the pleural surfaces may also result in a

• Acute phase reactants-white cell count, total

• X-ray chest PA view done in erect position-a total

• Subpulmonic effusion-collection of fluid below the

Useful in differentiating between loculated pleural effusion

Helpful if the effusion is minimal or loculated

 Pleural fluid aspiration (Thoracocentesis)

Diagnostic: Helps to differentiate between exudates and

Therapeutic: Massive collection or rapid collection of pleural

Severe respiratory distress

Appearance Clear/Straw Cloudy, purulent,

Protein < 3g/100mL >3g/100mL

Glucose >40mg/dL <40mg/dL

LDH Low, <200IU/L High,>200IU/L

Cells <1000/mm3 >1000/mm3

None of these criteria should be satisfied in a

• If serum-pleural fluid albumin

• Sodium, potassium and calcium conc

• Ratio of protein in pleural fluid to serum

• Ratio of LDH values in pleural fluid to serum

Predominant cell type(neutrophil, lymphocytes,

Lymphocytosis- if >50% leucocytosis then suspect TB

PLEURAL FLUID MICROBIOLOGY

Acid fast for AFB

Pleural fluid Culture

• Oxygen is necessary if SpO2 <92%

• Fluid therapy if child dehydrated or

• Analgesics and antipyretics

• Chest radiography & U/S

Pneumonia- initial blind antibiotic treatment

A) Following community acquired pneumonia

• Penicillin & flucloxacillin

• Amoxicillin & flucloxaxillin

B) Hospital acquired pneumonia

Prednisolone 1-2mg/kg orally 4-6weeks

 Presence of causative organisms in the fluid

 Pleural fluid glucose <50mg/dL

 Pleural fluid pH <7.0

• Acute pulmonary edema

• Injury to neovascular bundles

• Nelson textbook of pediatrics 19Th edition

• British Thoracic Society

You might also like