Pleural effusion

Davidson

 Accumulation of serous fluid within the pleural space. Accumulation of frank pus is
termed empyema, that of blood is hemothorax, and that of chyle  chylothorax. A
pleural fluid accumulates as a result of either increased HP or decreased
OP(transudative effusion, as seen in cardiac, liver or renal failure. Or from increased
microvascular pressure.
 Clinical assessment: symptoms  pain on inspiration and coughing.
 Signs: 1. inspection  tachypnea. 2. Palpation  low expansion + trachea and apex
may be moved to other side. 3. Percussion  stony dull. 4. Auscultation  absent
breath sounds and absent vocal resonance + bronchial breathing or crackles heard
above effusion.
 Investigation: chest film is of curved shadow at the lung base, blunting the costophrenic
angle. Fluid track up the lateral chest wall. Around 200mL of fluid is required in order for
it to be detectible of PA chest X-ray. US is more accurate for determining the presence of
fluid. Presence of sepetation suggests an evolving empyema or resolving hemothorax.
 Pleural aspiration and biopsy: simple aspiration provides info on the color and texture of
fluid and these alone may immediately suggest an empyema or chylothorax. The
presence of blood is consistent with pulmonary infarction or malignancy but may result
from a traumatic tap. A low pH suggest infection but may also be seen in rheumatoid
arthritis, ruptured esophagus or advanced malignancy.
 Empyema: this is a collection of pus in the pleural space. Microscopically, neutrophil
leukocytes are present in large numbers. It is usually Unilateral. It is always 2ry to
infection of nearby organ such as the lung, most commonly due to the bacterial
pneumonias and TB. Over 40% of patients with CAP develop as associate pleural effusion
(Para-pneumonic effusion). Other causes are infection of a hemothorax following
trauma or surgery, esophageal rupture and rupture of a sub-phrenic abscess through the
diaphragm. CLINICAL ASSESSMENT: should be suspected in patients with pulmonary
infection if there is severe pleuritic chest pain or persisting or recurrent pyrexia, despite
appropriate antibiotic treatment. Once empyema has developed, systemic features are
prominent. INVESTIGATION: chest X-ray appearance may be indistinguishable from
pleural effusion but can form a D- shaped shadow. US or CT is used to identify the
optimal site for aspiration using a wide bore needle. Other features suggesting
empyema  1. fluid glucose < 3.3mmol/L (60mg/dL). 2. LDH > 1000 U/L. 3. pH < 7.0. pus
measurements should be avoided if pus is thick.