Pleural Effusion


Article Author:
Rachana Krishna


Article Editor:
Mohan Rudrappa


Editors In Chief:
Mohamed Alhajjaj
Richard Sue
Fatima Anjum


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
2/11/2019 9:19:10 PM

Introduction

Pleural effusion is the accumulation of fluid in between the parietal and visceral pleura, called pleural cavity. It can occur by itself or can be the result of surrounding parenchymal disease like infection, malignancy or inflammatory conditions. Pleural effusion is one of the major causes of pulmonary mortality and morbidity. [1][2][3]

Etiology

Pleural fluid is classified as a transudate or exudate based on modified Light’s criteria. Pleural fluid is considered an exudative effusion if at least one of the criteria are met. [4][5]

  1. Pleural fluid protein/serum protein ratio more than 0.5
  2. Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio more than 0.6
  3. Pleural fluid LDH is more than two-thirds of the upper limits of normal laboratory value for serum LDH.

Common causes of transudates include conditions which alter the hydrostatic or oncotic pressures in the pleural space like congestive left heart failure, nephrotic syndrome, liver cirrhosis, hypoalbuminemia leading to malnutrition and with the initiation of peritoneal dialysis.

Common causes of exudates include pulmonary infections like pneumonia or tuberculosis, malignancy, inflammatory disorders like pancreatitis, lupus, rheumatoid arthritis, post-cardiac injury syndrome, chylothorax (due to lymphatic obstruction), hemothorax (blood in pleural space) and benign asbestos pleural effusion.

Some of the less common causes of pleural effusion are a pulmonary embolism which can be exudate or transudate, drug-induced (e.g., methotrexate, amiodarone, phenytoin, dasatinib, usually exudate), post-radiotherapy (exudate), esophageal rupture (exudate) and ovarian hyperstimulation syndrome (exudate).

Epidemiology

Pleural effusion is the most common disease among all the pleural disease and affects 1.5 million patients per year in the United States. A wide variety of diseases can present with pleural effusions like diseases primarily involving the lung like pneumonia, asbestos exposure, primarily systemic diseases like lupus, rheumatoid arthritis, or maybe the pleural manifestation of diseases which primarily affect other organs like congestive heart failure, pancreatitis, or diseases local to the pleura like pleural infections and mesothelioma.[6]

Pathophysiology

In the normal healthy adult, the pleural cavity has minimal fluid which acts a lubricant for the two pleural surfaces. The amount of pleural fluid is around at 0.1 ml/kg to 0.3 ml/kg and is constantly exchanged. Pleural fluid originates from the vasculature of parietal pleura surfaces and is absorbed back by lymphatics in the dependent diaphragmatic and mediastinal surfaces of parietal pleura. Hydrostatic pressure from the systemic vessels that supply the parietal pleura is thought to drive the interstitial fluid into the pleural space and hence has a lower protein content than serum. Accumulation of excess fluid can occur if there is excessive production or decreased absorption or both overwhelming the normal homeostatic mechanism. If pleural effusion is mainly due to Mechanisms that lead to pleural effusion mainly due to increased hydrostatic pressure are usually transudative, and leading to pleural effusion have altered the balance between hydrostatic and oncotic pressures (usually transudates), increased mesothelial and capillary permeability (usually exudates) or impaired lymphatic drainage.[7][8]

History and Physical

A patient with pleural effusion can be asymptomatic or can present with exertional breathlessness depending on the impairment of thoracic excursion. Patient with active pleural inflammation called pleurisy complains of sharp, severe, localized crescendo/ decrescendo pain with breathing or a cough. When the effusion develops, pain can subside, falsely implying an improvement in condition. Constant pain is also a hallmark of malignant diseases like mesothelioma. Depending on the cause of effusion, the patient can also complain of a cough, fever and systemic symptoms.

Physical examination can be subtle. In large effusion, there will be the fullness of intercostal spaces, and dullness on percussion on that side. Auscultation reveals decreased breath sounds and decreased tactile and vocal fremitus. Pleural rub, often mistaken for coarse crackles can be heard during active pleurisy without any effusion.

As pleural effusion is the result of varied disease, history and physical examination should also be focused on the underlying pulmonary or systemic cause of the effusion. For example, in congestive heart failure (CHF), examine for jugular venous distension and pedal edema, in cirrhosis leading to hepatic hydrothorax, look for ascites and other stigmata of liver disease.

Evaluation

Chest radiographs are useful to confirm the presence of effusion. The findings of effusion vary with amount of effusion. On an upright posteroanterior (PA) view, minimum 200ml of fluid is required to  obliterate the costophrenic angle, called the meniscus sign of a pleural effusion. However, in a lateral view, 50 ml of fluid can be diagnosed with this sign. Ultrasound of chest is more sensitive and useful for diagnosis of pleural effusion and also helps in planning thoracentesis. All unilateral effusion in adults need thoracentesis to determine the cause of pleural fluid. This is also known to improve the patient's symptoms and facilitate recovery.[9][10][11]

Determining whether the fluid is an exudate or transudate narrows the differential. However, Light’s criteria should be interpreted in the clinical context since it misdiagnoses 20% of transudates as exudative. An example would be a patient who has been chronically diuresed for heart failure can increase the pleural fluid protein level and can be classified as an exudate.

Commonly performed tests on the pleural fluid to determine etiology are a measurement of fluid pH, fluid protein, albumin and LDH, fluid glucose, fluid triglyceride, fluid cell count differential, fluid gram stain and culture, and fluid cytology. Exudates are characterized by elevated protein, elevated LDH and decreased glucose. Pleural fluid LDH greater than 1000 U/L may be seen in tuberculosis, lymphoma, and empyema. Low pH (pH less than 7.2) indicates complex pleural effusion in the setting of pneumonia, and almost always requires chest tube insertion for drainage. Other causes for low pH may be an esophageal rupture and rheumatoid arthritis.

Fluid cell counts in transudates show predominantly mesothelial cells. In parapneumonic effusions, lupus pleuritis, and acute pancreatitis, there is neutrophilic predominance in cell counts. Some causes of lymphocyte predominant effusions include malignancy, lymphoma, tuberculosis, sarcoid, chronic rheumatoid pleural effusion, and malignancy. Eosinophilia in pleural effusion is rare and usually in the presence of air (pneumothorax), blood (hemothorax), a parasitic disease, or drug-induced effusion.

The presence of organisms by gram stains or culture leads to a diagnosis of empyema and necessitates a chest tube for drainage of pus. Cytology is necessary for determining the presence of malignant cells in the pleural fluid. The sensitivity of pleural fluid cytology in the presence of malignant effusion in the first thoracentesis is around 60%, and the yield increases with further attempts, approaching 95% by three samples on different days.  However, if a malignant effusion is strongly suspected and cytology is negative, then medical thoracoscopy with pleural biopsy can be performed after two to three thoracenteses to obtain a diagnosis.

Other tests that can be performed on the pleural fluid to determine etiology include adenosine deaminase (ADA) which, when elevated is suspicious for tuberculosis in areas of high prevalence of tuberculosis. In esophageal rupture, the presence of amylase in pleural fluid is diagnostic. In heart failure, an elevated NT-proBNP level may be seen in pleural fluid. The presence of more than 110 mg/dL of triglycerides in the pleural fluid indicates a chylothorax. Pleural fluid is usually straw colored, and if it is milky white, then a chylothorax should be suspected. Diagnosis of hemothorax can be made if the pleural fluid hematocrit is more than 0.5 times that of serum hematocrit.

Treatment / Management

Once the etiology of pleural effusion is determined, management involves addressing the underlying cause. In cases of complex parapneumonic effusions or empyema, (pleural fluid pH less than 7.2 or presence of organisms) chest tube drainage is usually indicated along with antibiotics. Small-bore drains (10 G to 14 G) are equally effective as large bore drains for this purpose. If patients do not respond to appropriate antibiotics and adequate drainage, then thoracoscopic decortication or debridement may be necessary. Instillation of intrapleural fibrinolytics and DNAse may be used to improve drainage and in those who do not respond to sufficient antibiotic therapy and those who are not candidates for surgical intervention.

If a patient with malignant pleural effusion is not symptomatic, drainage is not always indicated unless an underlying infection is suspected. For malignant pleural effusions that require frequent drainage, options for management are pleurodesis (where the pleural space is obliterated either mechanically or chemically by inducing irritants into the pleural space) and tunneled pleural catheter placement.[12][13]

Differential Diagnosis

  • Congestive heart failure
  • Injury to the diaphragm
  • Diaphragmatic paralysis
  • Malignant mesothelioma
  • Pneumonia
  • Atelectasis

Consultations

  • Pulmonologist
  • Thoracic Surgeon

 

Pearls and Other Issues

If a large pleural effusion is drained quickly and volumes of more than 1.5 L are removed, the rapid re-expansion of the collapsed lung may occasionally lead to re-expansion pulmonary edema. Pleural manometry and monitoring pleural pressure during drainage of large volumes and terminating further drainage once the pleural pressure drops below -20 cm water or terminating with the onset of chest pain may prevent re-expansion pulmonary edema.

Enhancing Healthcare Team Outcomes

The management of a pleural effusion is multidisciplinary. Irrespective of the cause, if the fluid is aspirated or a chest tube is inserted, the nurse has to look after the patient. Once a chest tube is inserted, the nurse is responsible for recording the drainage, ensuring proper seal of the connections and assessing the patient's respiratory status. Some patients with a chest tube or a pleural effusion may require oxygen and chest physical therapy. For those with chylous ascites, a dietary consult is necessary to help lower the amount of drainage. Limiting fat intake may benefit some patients. Regular chest x-rays are done in patients with chest tubes, and thus the radiologist has to evaluate the chest tube position and site of drainage ports. Pain is a significant problem when chest tubes are inserted, and hence, anesthesia may be contacted for a pain pump or a thoracic epidural.[14][15]

Outcomes

The outcome of patients with pleural effusions depends on the cause, severity and patient comorbidity. In general, people who do not seek therapy have a poor outcome compared to those who are treated. Overall, patients with malignant pleural effusions tend to have a poor outcome. Most patients are dead within 12-24 months, irrespective of the cause of the malignant pleural effusion. When pleural effusions are inadequately treated, this can result in an empyema, sepsis and even a trapped lung. [9][10](Level V)


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Pleural Effusion - Questions

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Which of the following about pleural effusions is incorrect?



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Which of the following conditions is not associated with a transudative pleural effusion?



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Which of the following would prompt immediate thoracostomy tube placement for drainage of a pleural effusion?



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What is the minimal volume of pleural fluid required to be visible on an upright posteroanterior chest radiograph?



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What is the major difference between a transudate and an exudate?



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Which of the following regarding pleural effusion is true?



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What is the most probable diagnosis in the case of a patient who is found on pulmonary exam to have poor excursion, decreased breath sounds and flatness to percussion on the right with a leftward deviated trachea?



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Which of the following is not a cause of a transudative pleural effusion?



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Which of the following findings help distinguish an uncomplicated right lower lobe pneumonia from an uncomplicated large right pleural effusion?



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Which is true of pleural effusions?



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In a patient with a left pleural effusion, which of the following is an unlikely finding?



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Which of the following is NOT TRUE about pleural effusions?



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A patient is found on pulmonary exam to have poor excursion, decreased breath sounds, and dullness to percussion on the right with a leftward deviated trachea. Which of the following is the most likely cause?



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Which of the following is NOT a cause of a transudative pleural effusion?



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In which of the following pulmonary conditions is the trachea deviated towards the unaffected side?



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What is the most common cause of transudative effusions?



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How does a patient with a large pleural effusion often present?



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Which physical finding is most indicative of a pleural effusion?



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What is the best method to image a loculated pleural effusion?



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Which of the following is not a physical finding with pleural effusions?



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Which of the following is not consistent with an exudative pleural effusion?



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What is the most common cause of pleural effusions?



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A 75-year-old female with a 50-pack-year history of tobacco use presents with a 2-week history of worsening dyspnea on exertion. She has had a dry cough but no fever, night sweats, or chills. Her neck shows no jugular venous distention. Heart tones are distant but regular without murmurs. A lung exam reveals right lower lung dullness to percussion and decreased breath sounds. A chest radiograph shows a pleural effusion but no infiltrates or lymphadenopathy. Laboratories are normal. What is the appropriate management?



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Which of the following occurs with dullness on percussion of the chest?



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What is the most appropriate evaluation in a patient with a newly diagnosed pleural effusion?



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Which of the following is a tool to help differentiate exudative versus transudative pleural effusions?



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Which of the following is not an etiology of transudative pleural effusions?



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Which of the following mechanisms contribute to the formation of a pleural effusion?



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A pleural effusion that is a transudate has a pleural fluid to serum LDH ratio of:



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What is the pleural fluid to serum protein ratio of an effusion that is an exudate?



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What is a pleural effusion?



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Regarding pleural exudates and transudates:



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What does costophrenic angle blunting on a plain film typically indicate?



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Which is not consistent with a diagnosis of pleural effusion?



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An 85-year-old man presents with increasing dyspnea and cough. He was a plumber with exposure to asbestos, smoked his whole life, and has a positive PPD. A pleural effusion is found and thoracentesis is performed. Specific gravity is 1.011 and protein is 1.3 g/L. There are a few macrophages but no other cells. Select the most likely diagnosis.



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Which is not a physical finding of pleural effusion?



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What is the most common incidental abnormality of the pleura?



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In distinguishing benign and malignant pleural thickening, which of the following findings does not favor malignancy?



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What is the approximate minimal volume of pleural effusion that becomes visible on a frontal chest radiograph in adult patients?



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A patient without underlying lung disease develops a right pleural effusion. Which of the following might not be present on the right side?



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In the emergency room is a 59-year old with chest pain and shortness of breath. She just had her appendix removed 8 days ago. Chest examination reveals dullness to percussion on the right side, decreased tactile fremitus, and asymmetrical chest expansion on the right side. Which one of the following is most likely?



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A 64-year-old male presents to the emergency department for cough, difficulty breathing, and pleuritic chest pain. He recently emigrated from Nigeria, and he has had no health care to date, takes no medications, and denies any past hospitalizations. The patient has a 30 pack year smoking history and works in construction. The patient denies any current or recent illness, fever, chills, nausea, dizziness, or loss of consciousness. On physical exam, the patient appears tired, distressed, and lung sounds are faint bilaterally. His temperature is 37.2 C, pulse is 92/minute, blood pressure is 158/96 mmHg, and respirations are 19 per minute. Imaging indicates a bilateral pleural effusion, what is the best next step in treating this patient?



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A 70-year-old man presents to the emergency department for evaluation of shortness of breath, nonproductive cough, and left-sided pleuritic chest pain. He has a history of hypertension, diabetes mellitus type two, and chronic obstructive pulmonary disease. He reports that he has a 30-pack-year smoking history but quit two years ago. His blood pressure is 126/80 mmHg, heart rate is 86 bpm, respirations are 20 breaths per minute, and he has a temperature of 100.6 degrees F. Chest x-ray shows a moderate left-sided pleural effusion. A diagnostic thoracentesis is performed, and pleural fluid results are as follows: total protein: 5.4 g/dL, lactate dehydrogenase: 360 U/L, serum total protein is 6.1 g/dL, and serum lactate dehydrogenase is 140 U/L. Which of the following is the most likely etiology of this patient’s pleural effusion?



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Pleural Effusion - References

References

Kugasia IR,Kumar A,Khatri A,Saeed F,Islam H,Epelbaum O, Primary Effusion Lymphoma of the Pleural Space: Report of a Rare Complication of Cardiac Transplant with Review of the Literature. Transplant infectious disease : an official journal of the Transplantation Society. 2018 Oct 1     [PubMed]
Karki A,Riley L,Mehta HJ,Ataya A, Abdominal etiologies of pleural effusion. Disease-a-month : DM. 2018 Sep 28     [PubMed]
Riley L,Karki A,Mehta HJ,Ataya A, Obstetric and gynecologic causes of pleural effusions. Disease-a-month : DM. 2018 Sep 28     [PubMed]
Lepus CM,Vivero M, Updates in Effusion Cytology. Surgical pathology clinics. 2018 Sep     [PubMed]
Bedawi EO,Hassan M,Rahman NM, Recent developments in the management of pleural infection: A comprehensive review. The clinical respiratory journal. 2018 Aug     [PubMed]
Dancel R,Schnobrich D,Puri N,Franco-Sadud R,Cho J,Grikis L,Lucas BP,El-Barbary M,Soni NJ, Recommendations on the Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the Society of Hospital Medicine. Journal of hospital medicine. 2018 Feb     [PubMed]
Guinde J,Georges S,Bourinet V,Laroumagne S,Dutau H,Astoul P, Recent developments in pleurodesis for malignant pleural disease. The clinical respiratory journal. 2018 Sep 25     [PubMed]
Arnold DT,De Fonseka D,Perry S,Morley A,Harvey JE,Medford A,Brett M,Maskell NA, Investigating Unilateral Pleural Effusions: The role of cytology. The European respiratory journal. 2018 Sep 27     [PubMed]
Feller-Kopman DJ,Reddy CB,DeCamp MM,Diekemper RL,Gould MK,Henry T,Iyer NP,Lee YCG,Lewis SZ,Maskell NA,Rahman NM,Sterman DH,Wahidi MM,Balekian AA, Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. American journal of respiratory and critical care medicine. 2018 Oct 1     [PubMed]
Iyer NP,Reddy CB,Wahidi MM,Lewis SZ,Diekemper RL,Feller-Kopman D,Gould MK,Balekian AA, Indwelling Pleural Catheter versus Pleurodesis for Malignant Pleural Effusions: A Systematic Review and Meta-Analysis. Annals of the American Thoracic Society. 2018 Oct 1     [PubMed]
Arenas-Jiménez JJ,García-Garrigós E,Escudero-Fresneda C,Sirera-Matilla M,García-Pastor I,Quirce-Vázquez A,Planells-Alduvin M, Early and delayed phases of contrast-enhanced CT for evaluating patients with malignant pleural effusion. Results of pairwise comparison by multiple observers. The British journal of radiology. 2018 Sep     [PubMed]
Chambers DM,Abaid B,Gauhar U, Indwelling Pleural Catheters for Nonmalignant Effusions: Evidence-Based Answers to Clinical Concerns. The American journal of the medical sciences. 2017 Sep     [PubMed]
Bueno Fischer G,Teresinha Mocelin H,Feijó Andrade C,Sarria EE, When should parapneumonic pleural effusions be drained in children? Paediatric respiratory reviews. 2018 Mar     [PubMed]
Shu M,Wang BY,Zhang J,Guo CY,Wang XH, Analysis of specialized nursing on respiratory functions in thoracotomy patients. Journal of biological regulators and homeostatic agents. 2017 Oct-Dec     [PubMed]
Lu C,Jin YH,Gao W,Shi YX,Xia X,Sun WX,Tang Q,Wang Y,Li G,Si J, Variation in nurse self-reported practice of managing chest tubes: A cross-sectional study. Journal of clinical nursing. 2018 Mar     [PubMed]

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