1. Explain the pathogenesis of the pleural effusion.
 Decreased serum oncotic pressure, such as cirrhosis & nephrotic
“Pleural” refers to the space between the chest cavity and the lungs.
“Effusion” refers to a collection of fluid.
 So a pleural effusion is when a disease process causes fluid to
start to collect in the pleural space, which can sometimes restrict
lung expansion.
 The pleural space lies between the lung and the chest wall and
normally contains a very thin layer of fluid, which acts as
lubrication to allow the lungs to slide back and forth as they
expand and contract.
The normal pleural space contains approximately 15 mL of fluid,
representing the balance between:
1. hydrostatic and oncotic forces in the visceral and parietal pleural
capillaries and
2. persistent sulcal lymphatic drainage.
Pleural effusions may result from disruption of this natural balance.
A pleural effusion results from either a transudative or exudative
effusion because too much fluid is produces by the body or the
lymphatics can’t effectively drain away the fluid called a lymphatic
effusion.
Presence of a pleural effusion heralds an underlying disease process that
may be pulmonary or non-pulmonary in origin and, furthermore, that
may be acute or chronic.
Many diseases can cause pleural effusions.
 Elevated pleural capillary pressure, such as congestive heart failure,
pericardial disease & increased blood volume.
↑ Hydrostatic Pressure (Pushing Force) the force that blood exerts
on the walls
 A common cause of this is a Heart Failure, just because when
the heart cant effectively pump blood to the body, it backs
up to the pulmonary vessels and causes the blood pressure in
those vessels to rise.
 The high pressure forces fluid out of the capillaries and into
the pleural space
syndrome
Oncotic pressure— results from the inability of solutes like large
proteins like albumin to move across through the capillary.
 By the process of osmosis, fluid moves from areas of low
solute concentration to high solute concentration.
 Fluid therefore flows out of capillaries and leaks into the
pleural space when there is ↓oncotic pressure in the blood
vessels.
 Two causes of low oncotic pressure are Cirrhosis where the
liver makes fewer proteins and Nephrotic Syndrome, where
proteins are lost through the urine.
 Elevated pleural permeability, such as pleural inflammation,
neoplastic pleural disease (metastatic disease or mesotheliomas),
pulmonary emboli, systemic lupus erythematosus (SLE)
 The larger spaces between endothelial cells allow fluid,
immune cells and large proteins(like LDH) which is found in
all cells to leak out of the capillaries.
 The causes of this include Trauma, Malignancy, inflammatory
conditions like SLE and infections like Pneumonia.
 If the underlying reason is an infection, like bacterial or
mycobacterial infection, the it’s also possible for that
infection to spread into the pleural space which is a walled
off space—a bit like an enormous abscess.
 Just like an abscess, the infected pleural space can develop
fibrinous walls and have loculations.
 Dysfunction of parietal pleura lymphatics drainage.
Finally, there can be lymphatic pleural effusion, called Chylothorax.
 In a chylothorax, the thoracic duct is disrupted, and
lymphatic fluid accumulates in the pleural space.
 The most common cause of chylothorax is when the thoracic
duct accidentally gets damaged during a thoracic surgery,
but it can also be caused by tumors in the mediastinum that
press up the thoracic duct and compress it shut.